CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – HEADACHE

Far Eastern University – Nicanor Reyes Medical Foundation HEADACHE OUTLINE

CD B PD LEC: HEADACHE - Definition
Dr. Barja MD - Approach to diagnosis
HEADACHE o anatomy
o pain sensitive cranial structures
o history and neuro exam
- Algorithm: 1st onset headache
- Algorithm: chronic headache
- Differential diagnosis
- Primary headaches: diagnostic criteria migraine
o tension
o cluster
- Treatment
- Secondary headaches: case

PAIN
- An unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms
of such damage

HEADACHE
- Pain located above the orbitomeatal line
- All aches and pains located in the head
- Discomfort in the region of the cranial vault
- Face and scalp are more richly supplied with pain receptors
- Many are due to medical rather than neurologic diseases
- Always a question if there is an underlying intracranial disease
- Most common reason for seeking medical help

PAIN SENSITIVE CRANIAL STRUCTURES

- Intracranial venous sinuses and tributaries (pericavernous)
- Parts of dura at base of brain, arteries within dura and
pia- arachnoid
- Middle meningeal, superficial temporal arteries
- Cranial nerves II, III, V, IX, X and cervical nerves I-III
- Skin, Subcutaneous tissue, muscles, extracranial
arteries, periosteum of the skull

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – HEADACHE
- Delicate structures of eye, ear, nasal cavities, paranasal Intracranial lesions posterior Occipitonuchal
sinuses fossa
*pain arises in walls of small blood vessels containing pain fibers
Supratentorial Fronto-temporal
PAIN INSENSITIVE CRANIAL STRUCTURES approximating site of lesion
- 1.Brain parenchyma Non-specific
- 2.Ependyma
- 3.Choroid plexus Glaucoma, sinusitis, Frontal region pain
- 4.Pia matter thrombosis of VA,
- 5.Arachnoid BA pressure on tentorium,
- 6.Dura over convexity of skull Increased ICP
(Dura around vascular sinuses and vessels is sensitive to pain)
Ear disease Ear pain
APPROACH: HISTORY Disease of throat, cervical
- Precipitating /palliative spine, post fossa
o Relationship of HA to certain biologic events Peri-orbital, supraorbital
o Relationship to aggravating or relieving factors Eye dissease, dissection of
cervical ICA
PRECIPITATING Sphenoid/ethmoid sinus Vertex, bi-parietal
Premenstrual period Premenstrual disease, thrombosis of
tension headache migraine superior sagittal sinus
Intense pain after periods of Cervical spine disease
inactivity, 1st movements are APPROACH: QUALITY
stiff / painful - Most headaches are dull, aching, not sharply
Upon awakening, midmorning, Nasal sinusitis localized (regardless of type)
worse on stooping, - Tightness, Pressure, bursting
Changes in atmospheric QUALITY
pressure Pricking or stinging Skin
Prolonged eye use, peering into Eyestrain HA Throbbing Vascular source
glaring lights
HA made worse on Intracranial (distention of Pulsatile/throbbing especially
sudden movement or by vessels) if hemicranial is MIGRAINE
coughing / straining, exertion REFERRED PAIN
Induced by anger, excitement, Migraine - Pain from Supratentorial structures referred to Territory of
worry CN V
Stroking of hair Temporal arteritis o (1st and 2nd division)
- Pain from Infratentorial structures referred to vertex,
Extreme rise in BP Pheochromocytoma, o back of head and neck
malignant hypertension
APPROACH: SEVERITY
APPROACH: LOCATION - Interpret with caution
- What may be painful to one might not be painful to another
- Index of severity: degree to which HA has incapacitated the
patient
o affects ADL’s
o awakens from sleep
o prevents sleep
o most intense pain:
▪ deadly-meningitis, subarachnoid hemorrhage
LOCATION ▪ benign-migraine, cluster, tic doloreaux
Inflammation of Localized to site
extracranial artery
Paranasal sinus HA, or HA Not sharply localized but occur in
from teeth, eyes, upper specific regions: forehead, maxilla,
cervical vertebra around the eyes

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – HEADACHE
- Diplopia with internal squint (lateral rectus palsy)
- Deterioration in the level of consciousness
- hydrocephalus

APPROACH: MENINGEAL IRRITATION

- Headache
- Vomiting
- Nuchal rigidity
- Brudzinski
- Kernig’s

APPROACH: FOCAL NEUROLOGIC DEFICITS

- Mental Status
- Cranial Nerves
- Motor
- Cerebellar
- Sensory
TEMPORAL PROFILE
- Mode of onset
- Time-intensity curve
- Duration

TEMPORAL PROFILE
Abrupt, maximal severity in Subarachnoid hemorrhage
seconds/minutes
Gradually over hours / days meningitis
Onset in early am/daytime, peak Classic migraine
over 30 minutes, lasts 4-72 hrs
unless treated, terminated by sleep
HA at any time, interrupts sleep, Tumors
vary in intensity,
few minutes/hours
Worse on awakening Posterior fossa tumor
* HA that have recurred regularly for many years prove to be
VASCULAR or tension type

APPROACH: NEURO EXAMINATION

- Signs and symptoms of increased intracranial pressure
- Signs and symptoms of meningeal irritation
- Focal neurologic deficits

APPROACH: INCREASE ICP

- Headache
- Vomiting
- Papilledema

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – HEADACHE
DIFFERENTIAL DIAGNOSIS o 2.Migraine with aura
- Eye Problem? ▪ (transient focal neurological symptoms that usually
- Sinus? precede or sometimes accompany the headache)
- Premonitory and resolution symptoms
HEADACHE AND EYE DISORDERS o hyperactivity, hypoactivity depression
- Eye Disorders Known To Be Associated With Headache o cravings for particular foods repetitive yawning
Or Ocular Pain o fatigue
- Acute Glaucoma o neck stiffness / pain
- Uveitis
- Optic Neuritis MIGRAINE WITHOUT AURA: DIAGNOSTIC CRITERIA
•Ophthalmologists Are The 3rd Most Often Consulted Specialists - A .At least five attacks fulfilling criteria B–D
For Acute Headaches - B. Headache attacks lasting 4-72 hours (untreated or
unsuccessfully treated)
PHYSICAL EXAMINATION: SINUSITIS - C. Headache has at least two of the following four
- Transillumination of frontal and Maxillary Sinuses characteristics:
o 1.unilateral location
o 2.pulsating quality
o 3.moderate or severe pain intensity
o 4.aggravation by or causing avoidance of routine physical
- D .During headache at least one of the following:
o 1.nausea and/or vomiting
o 2.photophobia and phonophobia
- Tenderness on percussion or compression over the frontal - E. Not better accounted for by another ICHD-3 diagnosis
and maxillary sinuses and mastoid processes
MIGRAINE WITHOUT AURA
- often bilateral in children and adolescents (< 18 y/o)
- unilateral in late adolescence or early adult life
- Usually frontotemporal
- some have facial location of pain, which is called ‘facial
migraine’
- often has a menstrual relationship
- 1.Sitting patient leans forward with the trunk on the legs and
- the disease most prone to accelerate with frequent use of
head down
symptomatic medication (medication overuse HA)
- 2.have the patient perform a Valsalva maneuver increases
sinus pain, which will then have a pounding character
AURA
corresponding with the pulse
- complex of neurological symptoms that occurs usually before
- increased venous pressure acting on the swollen mucosa
the HA ---may begin after the pain phase has commenced
- Visual aura
PRIMARY HEADACHES
o most common type of aura
o > 90% of patients aura
- sensory disturbances
o pins and needles affecting one side of the body, face
and/or tongue
o Numbness
- speech disturbances, usually aphasic
- motor weakness -Hemiplegic migraine, may last for weeks

MIGRAINE HEADACHE SCINTILLATING SCOTOMA/FORTIFICATION SPECTRUM

- 3rd most prevalent disorder and seventh-highest specific
cause of disability worldwide
- Headache associated symptoms of migraine
o symptoms before the headache begins
o symptoms associated with the headache
o symptoms after the HA resolves
- two major subtypes
o 1.Migraine without aura
- also called visual migraine is the most common visual aura
preceding migraine
- precedes a migraine headache
- can also occur acephalgically (without headache)
- As the scotoma area expands, some people perceive only a
bright flickering area that obstructs normal vision, while
others describe seeing various patterns.

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- Some describe seeing one or more shimmering arcs of white
or colored flashing lights.
- An arc of light may gradually enlarge, become more obvious,
and may take the form of a definite zigzag pattern, sometimes
called a fortification spectrum (i.e. teichopsia)
CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – HEADACHE
o has very little impact on the individual, requires no
medical attention
- Frequent episodic tension-type headache
o associated with considerable disability,
o sometimes warrants treatment with expensive drugs

MIGRAINE WITH AURA: BRAIN SYMPTOMS CLUSTER HEADACHE

- 1.dysarthria - Acute attacks involve activation in the region of the posterior
- 2.vertigo hypothalamic grey matter
- 3.tinnitus - Age at onset is usually 20–40 y/o
- 4.hypacusis - 3x more in men
- 5.diplopia - may be autosomal dominant in about 5% of cases
- 6.ataxia - may be provoked by alcohol, histamine or nitroglycerin
- 7.decreased level of consciousness
CLUSTER HEADACHE: DIAGNOSTIC CRITERIA
Many patients who have migraine attacks with aura also have - A. At least five attacks fulfilling criteria B–D
attacks without aura - B. Severe or very severe unilateral orbital, supraorbital and/or
migraine aura may occur without headache temporal pain lasting 5–180 minutes (when untreated)
- C. Either or both of the ff:
Diagnostic criteria: o 1.at least one of the following symptoms or signs,
- At least two attacks fulfilling criteria B and C ipsilateral to the HA
- One or more of the following fully reversible aura symptoms: ▪ a) conjunctival injection and/or lacrimation
o visual ▪ b) nasal congestion and/or rhinorrhoea
o sensory
▪ c) eyelid oedema
o speech and/or language
▪ d) forehead and facial sweating
o motor
o brainstem ▪ e) forehead and facial flushing
o retinal ▪ f) sensation of fullness in the ear
- At least two of the following four characteristics: ▪ g) miosis and/or ptosis
o at least one aura symptom spreads gradually over ≥5 o 2. a sense of restlessness or agitation
min, and/or two or more symptoms occur in succession
o each individual aura symptom lasts 5-60 min 1 MIGRAINE: TREATMENT
o at least one aura symptom is unilateral 2 - Acute treatment: to stop pain and prevent progression
o the aura is accompanied, or followed within 60 minutes, - Preemptive treatment: avoidance of known headache
by headache
triggers
- Not better accounted for by another ICHD-3 diagnosis.
- Preventive treatment: maintenance meds x months-years to
TRANSIENT ISCHEMIC ATTACK? reduce attack frequency, severity, duration
- When aura occurs for the first time after age 40
- when symptoms are exclusively negative (e.g. ACUTE MIGRAINE TREATMENT GENERAL PRINCIPLES
hemianopia) when aura is prolonged or very short - 1.Treat as early as possible to reduce intensity and duration of
attack
- Headache occurring on 15 or more days per month for > 3
months, - GOAL: free of migraine within 2 hrs, no recurrence for at least
24 hrs
- which has the features of migraine headache on at least 8 days
- 2. Tailor the treatment to the patient and the migraine attack
per month

TENSION HEADACHE
- very common
- lifetime prevalence in the general population 30-78%
- very high socio-economic impact
- typically bilateral, pressing or tightening, mild to
moderate severity
- lasting 30 min to 7 days
- does not worsen with routine physical activity
- not associated with nausea
When given during an aura, triptans do not show consistent efficacy
- photophobia or phonophobia may be present
in aborting or preventing the migraine
- Infrequent episodic tension-type headache
o occurs in almost the entire population

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TREATMENT FOR ACUTE MIGRAINE MD ACUTE TREATMENT PREVENTIVE
- Non-specific pain medicines IV NSAIDs (ketoprofen) Anti-convulsants
o NSAIDs 1 RTC oral NSAID x 2-3 mos up to 6 mos
o Combination analgesics +/- RTC tramadol/paracetamol
o Opioids NSAIDs Topiramate
o Neuroleptics / anti emetics 2 opioids Triptans Valproate
o Corticosteroids
Topiramate
- Specific pain medicines
3 NSAIDs Valproate Flunarizine
o Triptans
(Sibelium)
o Ergotamine / DHE
NSAIDs Topiramate
PRINCIPLES FOR PROPHYLACTIC TREATMENT 4 Tramadol / paracetamol triptans Valproate
- Frequency of attack >/= 2 per month Flunarizine (Sibelium)
- Symptoms significantly interferes with ADLs even w/ acute Orphenadrine + paracetamol Topiramate
treatment lasting > /=3 days/ month 5 Sumatriptan / Valproate
- Failure, A/E and c/i of acute therapies zolmitriptan tramadol Flunarizine (Sibelium)
- Overuse of acute therapy ie >/= 2x per week NSAIDs Anti-convulsants
- Patient preference 6 Tramadol / paracetamol Triptans Anti-depressants
- Choice of drug: co-morbidities, A/E, interactions
- Considered successful if >/= 50% decreased frequency of CLUSTER HEADACHE: TREATMENT
attack per month w/in 3 months - Acute treatment
- Continued for 4-6 months then taper over 2-3 weeks o SC sumatriptan (6 mg) fastest,
o intranasal sumatriptan (20 mg), zolmitriptan (5mg)
o intranasal lidocaine 4%
o O2 inhalation (10-15 LPM) x 15 minutes
Prescription analgesics or opioids not effective and may lead to
medication overuse HA
- Transitional treatment (1-2 weeks)
o Prednisone 60 mg qd x 3 days, then taper by 10 mg q 3
days
o Ergotamine
o occipital nerve blockade
- Maintenance (duration of cluster period, usually 2-3 mos)
o verapamil 80 mg TID or 240 mg SR up to 720 mg/day
o valproic acid 500-2000 mg/d
o topiramate 50-150 mg/d

TENSION HEADACHE
- Non-pharmacologic therapy
o Relaxation
Valproate ER 500- Topiramate 50-200 mg o Stress reduction
1000 mg o Biofeedback
Average Decreased 1.8x Decreased 3x - Pharmacologic
migraine o TCA anti depressants
frequency
HA intensity Decreased 3.7 x Decreased 3.6 x SECONDARY HEADACHES
HA duration Decreased by 13.4 Decreased 11.9 hrs - Symptoms suggesting systemic illness
hours - Neurological s/sx, focal or non-focal
Side effects Weight gain ( 34%) , weight loss (23%) - Most severe headache ever experienced
hair loss paresthesias (9%), - Maximal severity at onset
(3%), somnolence somnolence, - Persistent or progressive worsening of headache
(3%) GI intolerance - Change in usual headache pattern awakening of patient from
sleep
- New onset HA in > 50 y/0
- Valsalva maneuver precipitates HA
- Seizures

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – HEADACHE
CASE: o ciprofloxacin dexamethasone
- 78M, hypertensive on maintenance medicines o fungal culture (+) after 1 month
- Sudden severe headache, pain score: 10/1 - Advised amphotericin, but initially refused Consult with
- Vomiting, altered sensorium another neurologist, IDS
- Emergency room - On the 6th month
o BP 200/110 E3V5M o Still with moderate to severe headache (+) weakness of
o No focal deficits (+) nuchal rigidity right hand
- DX: Subarachnoid hemorrhage 2 to ruptured aneurysm - Consult:
o CSF analysis: high pressure
CASE: o (+) CALAS, (+) india ink
- 78F, hypertensive, diabetic controlled with meds - Amphotericin started (+) seizure
- 4 days PTA- After sneezing, (+) severe pain on the left temple, - (+) deterioration in sensorium
with partial relief from analgesics - Repeat cranial CT scan: stroke 2 to arte died
- 3 days PTA- (+)diplopia
- 2 days PTA- (+) ptosis left eye RARE PRIMARY HEADACHE
- Admission - Primary headache associated with sexual activity
- Physical Exam - Men > women
o (+) bruit -left eye - Pain intensity may increase with increasing sexual excitement
o left carotid - Abrupt explosion of intensity just before or with orgasm
o Left eye - Can last 1 min to 24 hr
▪ ptosis - Previously classified as : pre-orgasmic and orgasmic
▪ mydriasis - More prone to have abnormalities in cerebral
▪ (+) palsy of superior/inferior recti, medial rectus venous circulation (venous stenosis)
muscle - Triptans, Propranolol and indomethacin effective
- DX: CAROTICO-CAVERNOUS FISTULA as prophylaxis

FACTITIOUS DISORDER
- condition in which a person acts as if they have an illness by
deliberately producing, feigning, or exaggerating symptoms

TRIGEMINAL NEURALGIA (TIC DOLOREAUX)

- 3x more common in women
- >/= 50 y/o
- Paroxysms of intense, stabbing pain
- patient winces involuntarily
CASE: - V2 and V3 division of CN V
- 52M, hypertensive - Rarely lasts more than a few seconds frequently x several
- On and off mild-moderate-severe HA x 3 months Progressing weeks at a time
severity and duration - Initiation of pain by stimulation trigger points in the face,
- Partial relief from analgesics lips, gums
- Progressive Left sided hemiparesis x 1 week (+) vomiting - Compression of trigeminal roots by a tortous blood vessel
- DX: TUMOR - TREATMENT:
o Carbamazepine
CASE: o Gabapentin
- 37M o valproic acid
- Moderate to severe headache, 8-10/10 pain score x 2 months o phenytoin
- Partial relief from analgesics
- Cranial CT scan: normal
- CSF analysis: opening pressure > 500 mm H2
- (+) pleocytosis, lymphocytic, low (-) TB PCR, (-) CALAS
- Treated with quadruple anti-Koch’s
- After 1 month, still with 8-10/10 HA
- CSF analysis: opening pressure > 500 mm H2O
o (+) pleocytosis, lymphocytic, low sugar (-) TB PCR, (-)
CALAS, (-) india ink
- Treated for MDR TB meningitis: quadruple anti-Koch’s Notes from Lecture PPT only

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