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HEADACHES
DIFFERENTIAL DIAGNOSIS
- Chronic headache syndromes
- Classic migraine (migraine with aura)
- Common migraine (migraine without aura)
- Migraine variants
(hemiplegic, familial, retinal, ophthalmoplegic)
- Tension headache
- Cluster headache
- Cluster headache variants
- Mixed headaches
- Post-traumatic headache
- Meningitis or encephalitis
- Subarachnoid hemorrhage
- Cerebral vascular accident
- Post-dural-puncture
- Altitude
- Coital
- Alcohol or food intake (hangover, ice
cream, hot dog, Chinese
restaurant syndrome)
- Arterial hypertension
- Brain tumor
- Post-endarterectomy
- Giant cell arteritis
- Headache due to other diseases
- Abstinence ( narcotics, coffee, tea,
cigarettes)
- Diseases of nose and sinuses
- Diseases of the eye
- Reflex headache (bowel obstruction, distension of G.I. tract, impaction,
etc.)
HISTORY
- Targeted Headache History
- Where is the patient when seen (emergency room, hospital, office)?
- What is the problem? Allow the patient to describe the headache
- Where located
- Are there other type
headaches
- Frequency of headache
(increase or decrease in intervals between)
- Is the headache becoming more severe, with each
episode)
- Have you ever had this type headache
before? When? Has it changes?
- What is the pattern of occurrence? Every
day or frequently? Is it the same? Different?
- What is the location? (front, back, side, all over the head)
- What is the character of headache? (steady, pounding, etc.)
- What is the time from onset to peak
severity?
- Vascular (thirty minutes to an
hour)
- Common headache (muscle contraction or tension two to four
hours)
- Awaken from sleep (cluster headache)
- What time of day does headache occur? (morning, noon, night)
- Are there other phenomena related to headache? (intolerance to light,
sound, spots before the eyes, stiff neck)
- Is there an Aura? (strange smell, taste, vision)
- What makes the headache worse? (alcohol, food, stress or neck position, or exertion)
- What makes headache better? (hot or cold compresses, sleep, oxygen)
- Is there a family history of headache?
- Where there childhood headaches? Motion sickness?, Cyclical vomiting? Unexplained fever?
- Prior diagnostic tests and results?
- Type of previous headache medication? What was the result?
- Other medical illnesses? (heart disease, polymyalgia
rheumatica, rheumatoid arthritis, immunosuppressive disease, cervical spine
disease, cancer with metastases) Drug therapy?
- Is there any psychiatric illness? (history of drug or substance abuse,
quality of patient's life?)
- On a scale where 0 is no pain and 10 is the worst imaginable pain,
how bad is the headache?
CLINICAL FINDINGS
- Neurologic examination (emphasis on cranial and cervical
nerves)
- Blood pressure in both arms
- Examination of the head (previous surgical scars; local infection; occult tumor;
hardened and tender temporal arteries;
sinus tenderness; tenderness of occipital nerves; myofacial trigger points; trigger areas of trigeminale and
glossopharyngeal neuralgia; dental and periodontal disease; ocular disease;
tempbromandibular joint abnormalities; auscultation for bruits)
- Physical examination
TESTS
- Routine laboratory tests (complete blood count, chemistry panel,
sedimentation rate, P.T., P.T.T. urinalysis, and drug screen) when
indicated
- Electrocardiogram (ECG) (all patients on beta blockers,
calcium channel blockers, tricyclic antidepressants, hypertension, heart
disease)
- Lumbar puncture (if infection, meningitis/encephalitis, hemorrhage or if
meningeal cancer) is suspected
- Radiological examination
- Skull X-rays
- Computed tomogaraphy (in acute bleed, mass effect, or neurologic deficit)
- Magnetic resonance imaging (soft tissue and posterior fossa
defects)
- Chest X-ray if malignance is suspected
- Electroencephalogram (encephalitis, epileptic headache )
- Sleep study if sleep apnea or other abnormality is suspected
- Intraocular pressure
MANAGEMENT
- Proper diet (eliminate tyramine, MSG, aspartame), adequate vitamin
and mineral supplement.
- Daily exercise up to 20 minutes (calisthenics, walking, cycling, swimming)
- Good sleep habits (early to bed and early to rise)
- Stop smoking
- Keep a headache diary, record symptoms associated with headache
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- Prodrome
- Aura
- Headache location
- Quality of Pain
- Associated symptoms (nausea/vomiting, sensitivity to light/sound, muscle
tenderness, relationship to activity, duration, treatment, effectiveness, side effects disability)
- How you feel after the headache
- Other health problems
- Medications taken, including
over-the-counter drugs, herbs, and
vitamins
- Drugs to treat tension-type headache
- Analgesics, usually adequate to relieve mild to moderate pain
include, aspirin, acetaminophen, ibuprofen and naproxen
- Combination analgesics, use of these drugs is limited, as overuse can worsen the headache or become habit forming, they
often contain butalbital or narcotics.
- Drugs used to prevent tension type headaches
- Tricyclic antidepressants (amitriptyline or
doxepin)
- Beta-blockers (propranolol, metopropolol,
nadolol)
- Divalproex sodium, is
effective for adults with chronic daily headaches)
Tension headache, a nonvascular headache, also known as muscle contraction headache, is
usually bilateral. It is a band like nonpulsatile ache or tightens in the frontal, temporal and
occipital regions. There is frequently associated neck symptoms, it evolves over a period
of hours or days and then remains constant. There is no aura but sleep
disturbance may be present. The headaches frequently occur between 4 and 8 A.M. and 4 and 8 P.M. The
triggering factor is invariably either physical or psychological stress.
- Drugs used to treat migraine headache
- Midrin
- Stadal NS. (nasal spry)
- Indomethacin (Indocin) (rectal suppositories)
- Cafergot (contraindicated in hypertensive and those with
coronary heart disease)
- Sumatriptan Succinate (Imitrex) prefilled syringe
- Rizatriptan
(Maxalt)
- Zolmitriptan
(Zomig)
- Metoclopromide (Reglan) taken at onset of headache to reduce
nausea and vomiting
- Drugs used to prevent migraine headache
- Beta Blockers
(atenolol, metoprolol, propranolol, timolol,
nadolol)
- Methysergide Maleate
(Sansert)
- Amitriptyline HCL
(Elavil)
- Verapamil HCL
(Isoptin)
- Triggering factors in migraine
- Fatigue
- Bright light/glare
- Loud noses
- Strong odors
- Weather change
- Vacations (first day)
- Weekends
- Altitude
- Tyramine containing foods
- Chocolate
- Alcoholic beverages
- Excessive caffeine consumption
- Over sleeping
- Irregular sleep/wake cycles
- Skipping meals
- Stress.
Migraine headache is a periodic unilateral headache that usually begins in childhood but in
any case before the age of 30. Attacks may occur every few days or only every 5 to 6
months. The headache can become generalized as it progresses. The pain is usually
throbbing or pounding and may predominantly be behind one eye. There are usually
systemic symptoms of nausea and vomiting, photophobia;
sonophobia; alteration in mood and appetite. There may on occasion be focal neurological problems. Migraine attacks
usually last more than 4 hours and frequently for 24 hours or longer. Females suffer 60 to
70% of migraines and frequently report a history of the disease in the
family.
- Drugs and modalities to treat cluster headache
- Oxygen inhalation
- Dihydroergotamine mesylate
- Lidocaine 4% nasal drops on side of headache
- Drugs to prevent cluster headache
- Methysergide
- Ergotamine tartrate
- Phenobarbital
- Belladonna alkaloids
- Prednisone
- Indomethacin
- Verapamil
- Lithium carbonate.
Cluster headache is so
named because the headaches occur in clusters, headaches
occurring in daily attacks (often during the night) for 4 to 12 weeks, followed by total
remission (no headache) often for 6 to 18 months. Cluster headaches are more common in
men ratio 5:1 and may be confused with migraine. There are,
however, several differences:
- develop in the 30s, 10 years later than migraine
- do not appear to be familial
- no prodrome or aura
- attacks most like to occur 90 minutes after patient falls asleep
- the clusters seem to coincide with the seasonal change in length of day, frequently increasing in spring and fall
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