Best Practices for Diagnosis Sadly, I have no conflicts of interest - PDF document

Disclosures Best Practices for Diagnosis • Sadly, I have no conflicts of interest to disclose and Treatment of Headache • Thanks to Dr. Morris Levin, Director of the John Engstrom, M.D. Headache Program at UCSF April 2019 • Thanks to Dr. Amy Gelfand, Pediatric Headache Program Medical Chart Quotes Medical Chart Quotes “The patient was in his usual “The patient lives at home state of good health until his with his mother, father, and airplane ran out of gas and pet turtle, who is presently crashed.” enrolled in day care three times a week” 1

Headache Challenges Medical Chart Quotes • HA training in the GME setting is lacking • If all neurologists only saw headache “The patient has been depressed patients, only a small proportion of ever since she began seeing me in headache patients would be treated 2013.” • Primary care providers provide the majority of headache care and will do so in the future • If you would benefit from a headache template, see “30 Questions” in syllabus Old Headaches vs. New Headache (HA) Topics Headaches • HAs requiring timely medical intervention • Primary Headache Clinical Diagnosis • Severity of headaches only occasionally helpful with diagnosis • Secondary Headaches • Historical risk factors: • Management primary headache types – New-onset – elderly, immunosuppressed – Altering the environment-prevention – Focal neurologic signs – Acute management – Postural – supine or standing – Chronic management-prophylaxis – Fever, incr HR, rash, stiff neck-meningitis • Medication Overuse Headache – Sudden onset over 1-2 seconds-hemorrhage 2

Postural Headaches and Q1: Which Statement Regarding Intracranial Pressure (ICP) Postural Headaches is False? • Low ICP-headache worse with standing and 1) Due to low or high intracranial pressure resolves with supine position but not meds 2) Common after an LP – Post-LP (risk about 5-10%) 3) May require brain imaging to see if CSF pathways are obstructed – Spontaneous/traumatic leaks • Elevated ICP-Headache worse when supine 4) Usually require a follow-up LP 5) Low ICP headache may require a search – Mass lesions that obstruct flow CSF pathways for the anatomic source of the leak – Infection (meningitis), hemorrhage, cancer – Nocturnal-CO 2 retention with vasodilatation Low ICP Headache-Management High ICP Headache-Management • Post LP – Bed rest for 5-7 days, generous caffeine • Neurologic exam and medical history – Persistent-anesthesiology/radiology for epidural • Ophthal eval for papilledema + visual fields blood patch • Brain MRI with MR venogram • Not post-LP • MRI negative, LP-opening pressure (OP) – Neurologic exam and medical history • IIH (Idiopathic Intracranial Hypertension) – Brain/spine MRI for sagging brain/spinal block – CSF to measure opening pressure – Preserve vision and relieve symptoms – CT/MR myelogram-source of leak – Diamox, Lasix, steroids 3

Q2: Which one of the following Primary Headaches (HA) is not a primary headache type? • Migraine without aura 1) Cluster HA • Migraine with aura 2) Cervicogenic HA • Tension-type headache 3) Migraine with aura • Cluster headache 4) Migraine without aura 5) Tension HA • Together, these make up 98% of the headaches you will see Migraine Without Aura Migraine with Aura • HA attacks last 4-72 h (untreated or refractory to treatment) • Prefer > one aura symptom-visual, sensory, • Prodrome in 75%-irrit, depression, euphoria speech or language, motor, brainstem • HA Features-unilateral and pulsating • Aura spreads gradually over more than 5 – Worse with usual physical activity (climbing minutes (not a sensory seizure over 1-5 stairs, walking) seconds) and lasts 5-60 minutes – Accompanied by nausea or emesis, • Aura accompanied or followed by headache photophobia or phonophobia in < 60 minutes – Patient feels better in a dark room 4

Chronic migraine Tension type HA • Meets diagnostic criteria for migraine on • More than 2 of the following 4 traits: 15+ days per month for more than 3 months – bilateral location – pressing or tightening (non-pulsating) quality • More than 5 attacks over 3 months – mild or moderate intensity • Affected more than 8 days/mo x 3 months – not aggravated by routine physical activity • Both of the following: • Frequent HAs compromise daily functions – no nausea or vomiting • HA responsive to ergot or triptan – no more than one: photophobia or phonophobia • Does not meet criteria other HA diagnosis Cluster HA-I Cluster HA-At Least one ipsilateral symptom or sign • Severe/very severe unilateral orbital, supraorbital and/or temporal pain lasting • Conjunctival injection and/or lacrimation 15-180 min • Nasal congestion and/or rhinorrhea • Frequency from 1-2/d to 8/d for > half the • Eyelid edema time when active • Forehead and facial sweating or flushing • Either or both of the following: • Sensation of ear fullness – A sense of restlessness or agitation • Pupillary miosis or eyelid ptosis (Horner’s – At least one ipsilateral symptom or sign syndrome)-temporary or permanent 5

Secondary Headaches-Associated Diagnosis of Primary Headaches with Medical Comorbidities • Trauma or injury to the head or neck Migraine - unilateral, throbbing, nausea, wants to • CNS disease (e.g.-vascular, trauma) lay down in a dark room, +/- aura • Use or withdrawal of a substance Tension-type HA - milder, bilateral band around • Headache/facial pain attributed to disorder head, no nausea, no aura of cranium, neck, eyes, ears, nose, sinuses, Cluster - Unilateral, supraorbital/orbital, brief, teeth, mouth, other facial/cranial structure cyclic, other symptoms affecting the eye, restless • Psychiatric disorder and wants to move around Post-Traumatic Headache Cervicogenic Headache • Key component persistent post-concussive • HA due to pathology in C-spine or neck syndrome • Need to prove cause and effect (2 required): • Can resemble other headache types including migraine – HA onset temporally related to structural lesion • Resistant to treatment-Nortriptyline 30-50 – Cervical ROM reduced and HA worse with exam maneuvers mg/night – HA resolves with diagnostic block of the lesion • Categorized by cause or severity of head injury or nerve supply of the lesion – HA improves with resolution of the pathology 6

Cough Headache Headaches from Vascular Disease • Intracranial vessels are pain-sensitive • Immediate and transient headache pain with coughing or sneezing • Stroke-hemorrhagic, thrombotic, embolic • Can be a sign of structural disease at the • Vascular anomalies-AVM, aneurysm foramen magnum • Arteritis – Arnold Chiari malformation-cerebellar tonsils • Carotid or other arterial dissection protrude thorugh the foramen magnum and • Cerebral venous thrombosis compress the brainstem or spinal cord • Post-endarterectomy – May be associated with neurologic exam signs Clinical Approach to HA Patient Headache Disorders-Other Hx • Diurnal periodicity • Exclude urgent headaches (e.g.-infection, neoplasm, vascular dz, High ICP, low ICP) – Divide day into quarters MN to 6 AM; 6 AM to noon; noon to 6 PM; 6 PM to MN), • Exclude other secondary causes of headache – Number HA out of 10 that begin in one quarter by exploring comorbidities (med dz, drugs) • Triggers-foods, alcohol, sleep deprivation • Does clinical presentation fit primary HA • Current meds and substances-especially if syndrome (migraine, tension, cluster)? new or prior to onset of headache • Consider all three management strategies- • Family history prevention, acute treatment, prophylaxis 7

Headache– Labs to Consider Headache Disorders - Exam • Blood tests – Consider CBC, lytes, Ca, Mg, BUN, Cr, liver enz, thyroid, ESR, HIV • General - Vital signs • C-spine X-ray, sinus X-rays • Head and Neck - trauma, carotids, C-spine, TMJ, paranasal/other sinuses, greater • MRI/CT - if new HA/risks for structural dz occipital/supraorbital nerve, funduscopic exam, • LP-suspect subarachnoid hemorrhage, otoscopic exam high/low ICP, or meningitis/encephalitis • Neurological - Screening neurologic exam on • Consider MRA, MRV, CTA, or cerebral first visit: will be normal 95-98% of time angiography Personalized Primary Headache Care Q3: Predictable timing of HA aura/onset informs when to Rx. • Tailor management to the patient’s life circumstances • Goal: Not cure; reduce frequency/severity 1) True of headaches and improve daily function • How does the headache interfere with daily 2) False life (employment, family life, diet, sleep)? • What are the 3 most intrusive/bothersome consequences of HA for the patient? 8