1 / 28

Approach to Headaches

Approach to Headaches. AIMGP Seminar April 2004 Gloria Rambaldini. Case 1. A 28 y.o. woman is referred to you for management of her headaches Headaches are described as right-sided pounding, with associated nausea and photophobia Aggravated by activity

markku
Télécharger la présentation

Approach to Headaches

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Approach to Headaches AIMGP Seminar April 2004 Gloria Rambaldini

  2. Case 1 • A 28 y.o. woman is referred to you for management of her headaches • Headaches are described as right-sided pounding, with associated nausea and photophobia • Aggravated by activity • ASA and Tylenol have not provided relief • What next?

  3. Case 2 • A 72 y.o. woman presents with a four month history of a bitemporal headache with aching and morning stiffness of her shoulders • She has noted a low grade fever and some weight loss • What next?

  4. Case 3 • A 62 y.o. man is referred for new onset headaches • For the last 4 weeks he has awoken with a diffuse headache and nausea • What next?

  5. Objectives • To learn about the major types of headaches • To understand the difference between primary and secondary headaches • Be familiar with the ‘RED FLAGS’ • Treatment and prophylaxis of primary headaches

  6. Extra-cranial pain sensitive structures: Sinuses Eyes/orbits Ears Teeth TMJ Blood vessels Intra-cranial pain sensitive structures: Arteries Veins Meninges Dura Origins of Pain in the Head

  7. PRIMARY - NO structural or metabolic abnormality: Tension Migraine Cluster SECONDARY – structural or metabolic abnormality: Extracranial: sinusitis, otitis media, glaucoma, TMJ ds Inracranial: SAH, vasculitis, dissection, central vein thrombosis, tumor, abscess, meningitis Metabolic disorders: CO2 retention, CO poisoing Classification of Headaches

  8. HISTORY • Headache Characteristics: • Temporal profile: acute vs chronic, frequency • Location and radiation • Quality • Alleviating and exacerbating factors • Associated symptoms • Constitutional symptoms • PMH: HTN, DM, hyperlipidemia, smoking

  9. RED Flags

  10. RED Flags • New onset headache in a patient >50 y.o. • Sudden, worst headache of one’s life • Morning headache associated with N/V • Fever, weight loss • Worsens with valsalva maneuvers • Focal neurologic deficits, jaw claudication • Altered LOC • Hx of trauma, cancer or HIV

  11. Physical Exam • Blood pressure • Fundoscopy • Auscultation for bruits in H/N • Temporal artery inspection and palpation • Meningismus • Neurologic exam: motor, sensory, coordination and gait

  12. MIGRAINE Headaches • Affects 15% of the general population • Female > Males • Family History present in 70% • Pathophysiology: vascular vs neurologic • Precipitants: caffeine, chocolate, alcohol, cheese, BCP/HRT, menses, stress

  13. MIGRAINE Headaches • Diagnostic criteria: 1. 5 attacks in 6 months 2. Headaches lasting 4-72 h with >/= 2: - unilateral - pulsatile - moderate to severe in intensity - aggravated by activity 3. Associated with >/= 1: - nausea/vomiting - photophobia/phonophobia

  14. MIGRAINE Headaches • Subtypes: • Auras – visual or sensory • Scintillating scotoma • Fortification spectra • Ophthalmoplegic • CN III palsy • Vertbrobasilar • hemiplegic

  15. Visual Auras: Patient drawings Scintillating Scotomas Progression of a typical aura over 30 minutes BMJ 2002; 325:881-6

  16. MIGRAINE: Acute Treatment • Mild attacks: NSAIDS +/- dopamine antagonists • eg. ASA 650-1300 mg q4h + metoclopromide 10 mg PO/IV • Moderate attacks: • NSAIDS (ibuprofen 400-800 mg PO q2-6h) • 5-HT1 receptor agonists • Selective – sumatriptan 50-100 mg PO • Nonselective – ergot 1-2 mg PO q1h x 3 CMAJ 1997; 156: 1273-87

  17. MIGRAINE: Acute Treatment • Severe & Ultra-severe attacks: • First line: • DHE 0.5-1 mg q1h IM/SC/IV • sumatriptan 50-100 mg PO or 6 mg SC • Second line: • chlorpromazine 50 mg IM • Prochlorperazine 5-10 mg IV/IM • dexamethasone 12-20 mg IV CMAJ 1997; 156: 1273-87

  18. MIGRAINE: Prophylaxis • Consider if >/3 attacks/month, impaired quality of life: • B-blockers • Calcium channel blockers • TCA (amitriptyline) • NSAIDS • Valproic acid • 5HT2 Antagonists (methysergide, pizotyline) CMAJ 1997; 156: 1273-87

  19. TENSION Headaches • Most common type, typically brought on by stress, lasting 30 min to 7 d • Diagnostic Criteria >/= 2: • Pressing/tightening, non-pulsating • Mild-moderate • Bilateral • Not worsened by ADLs • Photo or phonophobia (not coincident) • Not associated with N/V • Treatment: reassurance, NSAIDS

  20. CLUSTER Headaches • Age of onset 25-50 y.o., M>F • Features: • Attacks clustered in time (>5) • Severe unilateral, orbital or temporal pain • Lasting 15 min – 3 h • Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead/facial swelling, miosis, ptosis • Treatment: • Acute: O2, 5HT1 antagonists, DHE • Prophylaxis: Calcium Channel Blockers, ergots, Li

  21. Medication Induced Headaches • Rebound headaches due to overuse of analgesics or prophylactic meds • 25% of patients referred to neurologists for ‘intractable’ headaches have medication-overuse or medication-induced headaches

  22. Giant Cell Arteritis • Chronic granulomatous vasculitis affecting the arteries originating from the aortic arch • 18/100 000 persons >50 y.o. • Features: • Headache 2/3 of patients (LR 1.2) • Fever, weight loss, malaise • Scalp tenderness • Jaw claudication (LR 4.2) • Diplopia (LR 3.4) • PMR related Sx (50% of GCA patients have PMR)

  23. Giant Cell Arteritis • Physical Exam: • BP and pulse deficits in arms • Fundoscopy • Temporal Artery: beaded (LR 4.6), prominent (LR 4.3), tender (LR 2.6) • H/N and subclavian bruits • MSK exam • Investigations: • Normocytic normochromic anemia • ESR (typically > 50) • TA biopsy JAMA 2002; 287(1): 92-101

  24. Giant Cell Arteritis • Diagnostic Criteria – 3/5 (Sn 94%, Sp 91%) • Age > 50 y.o. • New onset headache • TA tender +/- decreased pulse • ESR > 50 • Bx: necrotizing granulomatous arteritis

  25. Giant Cell Arteritis • Treatment: • Prednisone 40-80 mg PO od until symptoms resolve and ESR normalizes • Once in remission decrease dose by 10% q1-2w • Osteoporosis prevention: vitamin D and calcium +/- bisphosphonate AIM 2003; 139:505-515

  26. Case 1 • A 28 y.o. woman is referred to you for management of her headaches • Headaches are described as right-sided pounding, with associated nausea and photophobia • Aggravated by activity • ASA and Tylenol have not provided relief • What next?

  27. Case 2 • A 72 y.o. woman presents with a four month history of a bitemporal headache with aching and morning stiffness of her shoulders • She has noted a low grade fever and some weight loss • What next?

  28. Case 3 • A 62 y.o. man is referred for new onset headaches • For the last 4 weeks he has awoken with a diffuse headache and nausea • What next?

More Related