DISORDERS ASSOCIATED WITH HEADACHE

DISORDERS  ASSOCIATED  WITH HEADACHE

Headache

A 32-year-old woman comes to the office complaining of a headache that started 2 days ago. She locates her headache at the right side of her head and describes it as throbbing in quality. The headache is worsened by walking up stairs or around the block. She experiences nausea but denies vomiting. She also states that loud noise and bright light exacerbate her pain.

Definition. Headache is defined as pain located in the head, neck, or jaw.

Note

Any patient who presents with headache and the following should be considered to

have a secondary headache syndrome:

• “Worst headache of my life”

• Worsening symptoms over

days to weeks

• Abnormal neurologic exam

• Fever

• Vomiting preceding the

headache

• Headache induced by coughing, bending, lifting; or onset age >55

Etiology. There are many causes of headache that can be divided into primary or secondary headache syndromes. Primary headache syndromes include migraine, cluster, and tension headache. Secondary causes of headache include intracranial hemorrhage, brain tumor, meningitis, temporal arteritis, and glaucoma. Migrane affects 15% of the general population.

Clinical Presentation. The single most important question that has to be answered in any patient who presents complaining of a headache is whether there exists a serious underlying cause for the symptoms. By taking a thorough history and performing an adequate physical examination, it is possible to make this differentiation. An essential point in the history is to determine whether this is the first episode of headache that the patient has experienced. A his- tory of recurrent symptoms makes the diagnosis of a primary headache disorder more likely. A history of a first-time headache, especially when severe and rapidly peaking, speaks strongly for serious underlying pathology.

Headache with fever and nuchal rigidity suggests meningitis as the underlying cause. Conversely, a headache that is described as “the worst headache of my life” and/or “thunder- clap” at onset, and is accompanied by nuchal rigidity without fever, suggests an intracranial hemorrhage as the underlying cause. Patients with brain tumors will present complaining of headache that is described as a deep, dull, aching pain that disturbs sleep. The history of vomiting that precedes the onset of headache by a number of weeks, or a history of headache induced by coughing, lifting, or bending, is typical of posterior fossa brain tumors. Patients with temporal arteritis complain of a unilateral pounding headache associated with visual changes, described as dull and boring with superimposed lancinating pain. Patients will also complain of polymyalgia rheumatica, jaw claudication, fever, weight loss, and scalp tender- ness (difficulty combing hair or lying on a pillow). The scalp tenderness is from pain over the temporal artery. Temporal arteritis is a disorder of the elderly, generally presenting in patients age >50. Temporal arteritis gives an elevated sedimentation rate and is diagnosed with biopsy of the temporal artery. Do not wait for the biopsy results to initiate therapy with steroids. Patients with glaucoma will usually give a history of eye pain preceding the onset of the headache.

Once serious underlying pathology is excluded by history and physical examination, primary headache syndromes should be considered. The main primary headache syndromes are migraine, cluster, and tension headache.

 Migraine headaches are defined as a benign and recurrent syndrome of headache, nausea/ vomiting, and other varying neurologic dysfunctions. Patients will describe the headache    as pulsatile, throbbing, unilateral, and aggravated by minor movement. Other associated features include photophobia, phonophobia, and the time to maximal pain (4 to 72 hours). Migraine is a likely diagnosis when a typical trigger can be identified. Typical triggers include alcohol, certain foods (such as chocolate, various cheeses, monosodium glutamate), hunger, or irregular sleep patterns.

• Migraine without aura is a migraine without a preceding focal neurologic deficit.

• Migraine with aura (classic migraine) is a migraine accompanied by a preceding aura that consists of motor, sensory, or visual symptoms. Focal neurologic symp- toms usually occur during the headache rather than as a prodrome. The pathogno- monic aura for classic migraine is the scintillating scotoma. Only 20% of migraine headaches are accompanied by an aura. Visual auras are also described as stars, sparks, and flashes of light. Migraine equivalent is defined as focal neurologic symp- toms without the classic complaints of headache, nausea, and vomiting.

• Complicated migraine is migraine with severe neurologic deficits which persist after

the resolution of pain.

• Basilar migraine is migraine associated with symptoms consistent with brain-stem

involvement (vertigo, diplopia, ataxia, or dysarthria).

Tension-type headaches are described as tight, band-like headaches that occur bilaterally. Patients may also describe their headache as “vise-like,” and these headaches may be associ- ated with tightness of the posterior neck muscles. Patients will describe their pain as one that builds slowly, and the pain may persist for several days with or without fluctuations. Movement will not generally exacerbate the headache.

Cluster headaches, common in men, begin without warning and are typically described as excruciating, unilateral, periorbital, and peaking in intensity within 5 minutes of onset. They are rarely described as pulsatile in nature. The attacks last from 30 minutes to 3 hours and occur 1–3× day for a 4-to-8-week period. Symptoms associated with cluster headaches include rhinorrhea, reddening of the eye, lacrimation, nasal stuffiness, nausea, and sensitivity to alcohol. Horner syndrome is sometimes found. Emotion and food rarely will trigger a cluster headache.

Diagnosis. Patients with severe, sudden onset of a first-time headache accompanied by strong evidence for an underlying cause on history or physical examination should have a CT scan of the head to rule out any secondary causes.

Treatment. Always begin with an attempt to identify probable triggers for the patient and to modify lifestyle by avoiding those triggers. Most patients will require pharmacotherapy as well.

Pharmacologic treatment for migraine headaches can be divided into management of an acute episode and prophylaxis. Initially, for a mild migraine—which is defined as headache in the absence of nausea or vomiting—NSAIDs may be used.

Acutely, abortive therapy consists of sumatriptan, which acts as a serotonin receptor agonist. Dihydroergotamine is the alternative to the triptans. Ergotamine can be used in combina- tion with caffeine. The triptans are contraindicated in patients with known cardiovascular disease, uncontrolled hypertension, or pregnancy. In addition to sumatriptan, there is almotriptan, naratriptan, zolmitriptan, and eletriptan. These medications can be given orally, intranasally, or even subcutaneously, depending on the severity of the headache. Alternatively, ergotamine can be given for acute abortive therapy. Dopamine antagonists

such as metoclopramide can be given acutely as oral formulations to aid in the absorption of other abortive medications. When given parenterally, dopamine antagonists can provide relief acutely for migraine headaches.

Prophylactic treatment for migraine therapy should be initiated when patients have acute migraine headaches >3–4/month. The best prophylactic medication is a beta blocker. Propranolol, valproic acid, and topiramate are all considered first-line therapy for migraine prophylaxis. Verapamil and tricyclics can also be used. These medications take 2 to 6 weeks to have an effect and can be discontinued gradually over 6 months once clinical stabilization has occurred. Methysergide is not used because of the serious side effects associated with prolonged use (valvular and retroperitoneal fibrosis). SSRIs such as sertraline and fluoxetine can also be used for prophylaxis.

Opioid analgesics are not routinely recommended for the treatment of migraine headaches because of the possibility of developing addiction. They are used only in patients with severe, infrequent migraines that are unresponsive to other therapy. Other therapies for migraine headaches are acetaminophen and NSAIDs such as ibuprofen.

Treatment for tension headaches consists of relaxation. Patients should be encouraged to find activities that are relaxing for them. Initial pharmacotherapy consists of acetaminophen and NSAIDs. If the headache remains refractory to these medications, a muscle relaxant can be added to the regimen.

Cluster headaches are treated with a triptan or 100% oxygen. Prophylaxis of cluster headaches is best done with a calcium channel blocker. Prednisone and lithium are sometimes used.