Jose Paciano Jose Paciano B.B.T. Reyes, MDT. Reyes, MD, , FPNAFPNA

HeadacheHeadache:: Determining Determining tthe he Appropriate Diagnostic Appropriate Diagnostic && Treatment ApproachTreatment Approach

What is hWhat is headacheeadache??

• CephalalgiaCephalalgia

• Diffuse pain in the various parts of Diffuse pain in the various parts of the head the head

• Not confined to the area of Not confined to the area of distribution of a nervedistribution of a nerve

Prevalence of different typesPrevalence of different types

Headache TypeHeadache Type PrevalencePrevalence

Tension Tension ttypeype 69%69%

Headache from systemic infectionHeadache from systemic infection 63%63%

MigraineMigraine 16%16%

Headache after head injuryHeadache after head injury 4%4%

Idiopathic stabbing headacheIdiopathic stabbing headache 2%2%

Exertional headacheExertional headache 1%1%

Vascular disordersVascular disorders 1%1%

Subarachnoid hemorrhageSubarachnoid hemorrhage <1%<1%

Brain tumorsBrain tumors 0.1%0.1%

Types of Types of HeadachesHeadaches

• Primary headaches Primary headaches

• BenignBenign

• RecurrentRecurrent

• No organic disease as their causeNo organic disease as their cause

• Secondary headachesSecondary headaches• Underlying organic diseaseUnderlying organic disease

Primary Headache DisordersPrimary Headache Disorders

• More commonMore common• Migraine, Migraine, with with

or without auraor without aura

• Tension typeTension type

• ClusterCluster

• Less commonLess common• Paroxysmal hemicraniaParoxysmal hemicrania

• Idiopathic stabbingIdiopathic stabbing

• Cold-stimulusCold-stimulus

• Benign coughBenign cough

• Benign exertionalBenign exertional

• Associated with sexual Associated with sexual activityactivity

Secondary Headache DisordersSecondary Headache Disorders

• Associated with non-Associated with non-vascular intracranial vascular intracranial disorderdisorder• Benign intracranial Benign intracranial

hypertensionhypertension• Intracranial infectionIntracranial infection• Low CSF pressureLow CSF pressure

• Associated with Associated with noncepalic infectionnoncepalic infection• Viral infectionViral infection• Bacterial infectionBacterial infection

• Associated with vascular Associated with vascular disordersdisorders• Subarachnoid Subarachnoid

hemorrhagehemorrhage• Acute ischemic Acute ischemic

cerebrovascular disordercerebrovascular disorder• Unruptured vascular Unruptured vascular

malformationmalformation• ArteritisArteritis• Carotid or vertebral artery Carotid or vertebral artery

painpain• Venous thrombosisVenous thrombosis• Arterial hypertensionArterial hypertension

Secondary Headache DisordersSecondary Headache Disorders

• Associated with Associated with head traumahead trauma• Acute post-traumatic Acute post-traumatic

headacheheadache

• Associated with Associated with substance use or substance use or withdrawalwithdrawal• Acute use or Acute use or

exposureexposure• Chronic use or Chronic use or

exposureexposure

• Associated with Associated with metabolic disordersmetabolic disorders• HypoxiaHypoxia

• HypercapniaHypercapnia

• Mixed hypoxia & Mixed hypoxia & hypercapniahypercapnia

• DialysisDialysis

Secondary Headache DisordersSecondary Headache Disorders

• Associated with head traumaAssociated with head trauma• Acute post-traumatic headacheAcute post-traumatic headache

• Headache of facial pain associated with Headache of facial pain associated with disorder of cranium, neck, eyes, ears, nose, disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial sinuses, teeth, mouth or other facial or cranial structuresstructures

• Cranial neuralgias, nerve trunk pain and Cranial neuralgias, nerve trunk pain and deafferentation paindeafferentation pain

Headache HistoryHeadache History

• Is this your first or worst headache? Is this your first or worst headache? How bad is your pain on a scale of 1-10? Do you How bad is your pain on a scale of 1-10? Do you

have headaches on a regular basis? Is this have headaches on a regular basis? Is this headache like the ones you usually have?headache like the ones you usually have?

• What symptoms do you have before of What symptoms do you have before of during the headache? What symptoms do during the headache? What symptoms do you have now?you have now?

• When did this headache begin? How did it When did this headache begin? How did it start start (gradually, suddenly)(gradually, suddenly)??

Headache HistoryHeadache History

• Where is your pain? Where is your pain? Does the pain spread to any other area? Where?Does the pain spread to any other area? Where?

• What kind of pain do you have What kind of pain do you have (throbbing, (throbbing, stabbing, dull, others)stabbing, dull, others)??

• Do you have other medical problems?Do you have other medical problems?• Do you take medicines?Do you take medicines?• Have you recently hurt your head or had a Have you recently hurt your head or had a

medical or dental procedure?medical or dental procedure?

Blue Flag HeadachesBlue Flag Headaches

Red Flag HeadachesRed Flag Headaches

Other Red Flag HeadachesOther Red Flag Headaches

• Associated with rashAssociated with rash• May indicate Lyme disease or meningococcemiaMay indicate Lyme disease or meningococcemia

• Non-migraine headache in pregnanacy or post-partumNon-migraine headache in pregnanacy or post-partum• May indicate cerebral thrombosisMay indicate cerebral thrombosis

• Associated with changes in postureAssociated with changes in posture• May indicate low CSF pressure due to spontaneous CSF May indicate low CSF pressure due to spontaneous CSF

leakleak

• Associated with pressing visual disturbancesAssociated with pressing visual disturbances• May be due to glaucoma or optic neuritisMay be due to glaucoma or optic neuritis

Headache Red Flags: S-N-O-O-P-SHeadache Red Flags: S-N-O-O-P-S

• SSystemic symptoms: ystemic symptoms: fever, weight lossfever, weight loss

• NNeurological symptoms or abnormal signs: eurological symptoms or abnormal signs: confusion, impaired alertness or consciousnessconfusion, impaired alertness or consciousness

• OOnset: nset: suddent, abrupt or split-secondsuddent, abrupt or split-second

• OOlder: lder: new onset or progressive headache, new onset or progressive headache, specially in patients > 50 yospecially in patients > 50 yo

• PPrevious headache history: revious headache history: first o new or first o new or different headachedifferent headache

• SSecondary risk factors: econdary risk factors: systemic cancers, HIVsystemic cancers, HIVDavid Dodick, MD

Mayo Clinic, Scottsdale

Diagnostic Criteria for Diagnostic Criteria for Episodic Tension Type HeadacheEpisodic Tension Type Headache

Diagnostic Criteria for Diagnostic Criteria for Cluster HeadacheCluster Headache

Diagnostic Tests for Diagnostic Tests for HeadacheHeadache

• NeuroimagingNeuroimaging

• Indications:Indications:• To rule out a structural disorderTo rule out a structural disorder

• To assure anxious patient or his relativesTo assure anxious patient or his relatives

Diagnostic testing for the evaluation Diagnostic testing for the evaluation of headachesof headaches

Yield of neuroimaging in the evaluation of patients with Yield of neuroimaging in the evaluation of patients with headache and a normal neurologic examination is headache and a normal neurologic examination is quite lowquite low ( (N = 3026 scansN = 3026 scans))

Brain tumorsBrain tumors 0.8%0.8%

AVMsAVMs 0.2%0.2%

HydrocephalusHydrocephalus 0.2%0.2%

AneurysmAneurysm 0.1%0.1%

Subdural hematomaSubdural hematoma 0.2%0.2%

StrokesStrokes 1.2%1.2%

Neurol ClinNeurol Clin 1996 Feb; 14(1):1-26 1996 Feb; 14(1):1-26

Neuroimaging recommendations for non-acute headacheConsider neuroimaging in: • Patients with an unexplained abnormal finding on the

neurologic examination (Grade B)• Patients with atypical headache features or headaches

that do not fulfill the strict definition of migraine or other primary headache disorder (or have some additional risk factor, such as immune deficiency), when a lower threshold for neuroimaging may be applied (Grade C)

• Neuroimaging is not usually warranted in patients with migraine and a normal neurologic examination (Grade B)

AAN Sept 2000

Neuroimaging algorithm for headache of Neuroimaging algorithm for headache of >4 weeks & normal neurologic exam>4 weeks & normal neurologic exam

Tension-type headache?

Migraine-type headache?

Any atypical features?

Neuroimaging unlikely to show abnormality

See other pathway

NO

NO

NO

YES

YES

YES CONSIDER BRAIN IMAGING

Neuroimaging algorithm for headache of Neuroimaging algorithm for headache of >>4 weeks4 weeks

Worse with Valsalva?

Wakes patient from sleep?

New headache in older patient?

Consider Brain Imaging (CT or MRI)

Brain Imaging Not Necessary

NO

NO

NOYES

YES

YES

Headache progressively worsening? YES

NO

Other RED FLAGS?

YES NO

•Exertion induced•Maximum severity at onset•Seizures•Systemic illness•Worst headache ever•Strong patient or family concerns•Family history of tumors or aneurysms

Abnormal neuro findings?

NO YES

Computed Tomographic ScanningComputed Tomographic Scanning

AdvantagesAdvantages

• Procedure of choice Procedure of choice for acute for acute hemorrhage and hemorrhage and skull fracturesskull fractures

• Cheaper than MRICheaper than MRI

• Faster testing timeFaster testing time

• CT angiographyCT angiography

DisadvantagesDisadvantages• False negative results for False negative results for

small lesionssmall lesions• Radiation exposureRadiation exposure• Allergic reaction to Allergic reaction to

contrast dyecontrast dye• Contraindicated in Contraindicated in

pregnancypregnancy• Monitor creatinine levels in Monitor creatinine levels in

elderly and renal diseaseelderly and renal disease

Magnetic Resonance ImagingMagnetic Resonance Imaging

AdvantagesAdvantages• Better images, Better images,

brainstem lesionsbrainstem lesions• Detect vascular Detect vascular

anatomy for anatomy for suspected aneurysms suspected aneurysms and vasculitisand vasculitis

• Detect small Detect small aneurysmsaneurysms

• No radiationNo radiation

DisadvantagesDisadvantages• Metal implants Metal implants

contraindicatedcontraindicated• Pregnancy up to 2Pregnancy up to 2ndnd

trimester trimester contraindicatedcontraindicated

• CostlyCostly• AvailabilityAvailability• Long testing time Long testing time

ElectroencephalographyElectroencephalography

IndicationsIndications• Loss of consciousnessLoss of consciousness

• Depressed sensorium or alertnessDepressed sensorium or alertness

• SeizuresSeizures

• Suspected metabolic encephalopathySuspected metabolic encephalopathy

Electroencephalography in headacheElectroencephalography in headache

…not useful in the routine evaluation of patients with headache. This does not exclude the use of EEG to evaluate headache patients with associated symptoms suggesting a seizure disorder, such as atypical migrainous aura or episodic loss of consciousness. Assuming head-imaging capabilities are readily available, EEG is not recommended to exclude a structural cause for headache.

•Practice Guideline, AAN, 1995

Other DiagnosticOther Diagnostic Tests Tests

• Lumbar punctureLumbar puncture• CNS infectionCNS infection

• MSMS

• Increased or decreased CSF pressureIncreased or decreased CSF pressure

• Blood examinationBlood examination

Symptomatic TherapySymptomatic Therapy

• As abortive therapyAs abortive therapy• Goal: to abort, reduce or stop a headache, Goal: to abort, reduce or stop a headache,

head pain or symptoms accompanying a head pain or symptoms accompanying a headacheheadache

• Purpose: Purpose: • for acute attacks that are infrequentfor acute attacks that are infrequent• for breakthrough attacks while on preventive for breakthrough attacks while on preventive

therapytherapy

Symptomatic TherapySymptomatic Therapy

• Notes:Notes:• Better used at onset of headacheBetter used at onset of headache

• Frequently combined with preventive Frequently combined with preventive therapytherapy

• Can cause rebound headachesCan cause rebound headaches

• Should not exceed 3 days/weekShould not exceed 3 days/week

Preventive TherapyPreventive Therapy

• As prophylaxis or prevention of recurrenceAs prophylaxis or prevention of recurrence• Goal: reduce frequency, severity and duration Goal: reduce frequency, severity and duration

of attacksof attacks

• Purpose: Purpose: • FFor frequent attacks of headache or frequent attacks of headache • For moderate to severe headachesFor moderate to severe headaches• For those on excessive use of symptomatic For those on excessive use of symptomatic

medication without reliefmedication without relief

Preventive TherapyPreventive Therapy

• Notes:Notes:• Given daily for at least 3-6 monthsGiven daily for at least 3-6 months• Begin at lower dose with upward titrationBegin at lower dose with upward titration• Reassess every 6 monthsReassess every 6 months• Some medications need tapering before Some medications need tapering before

discontinuationdiscontinuation• Encourage effective birth control in fertile Encourage effective birth control in fertile

women while on preventive therapywomen while on preventive therapy

Thank You!