Headache resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo, M.D. Niloofarsadaat Eshaghhosseiny, MD[2]

Synonyms and Keywords: Approach to headache, Headache management, Headache workup

Main article: Headache

Headache Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

The first step in headache diagnosis is to determine what kind of headache the patient has, primary or secondary headache disorder. Primary headaches such as migraine,tension-type, cluster are not caused by another underlying disease, despite secondary headaches are caused by another underlying disorder such as trauma, tumors. For differentiating these two types of headache, history and physical examination are necessary, although neuroimaging and other tests may be needed as well.

Causes

Primary Migraine
Tension- type headache
Cluster headache
Secondary Extracranial disorders Carotid or vertebral artery dissection
Temporomandibular joint dysfunction
Glaucoma
Sinusitis
Intracranial disorders Brain space-occupying lesion
Chiari Type 1 malformation
CSF leak with low-pressure headache
Hemorrhage
Meningitis
Vascular malformations
Venous sinus thrombosis
Systemic disorders Acute severe hypertension
Pheochromocytoma
Fever
Vasculitis
Viral infections
Hypercapnia
Drugs Analgesic overdose
Proton pump inhibitors
Caffeine withdrawal
Hormones (estrogen)
Toxins Carbonmonoxide
Nitrates

Life-threatening causes: Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

FIRE

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Headache according the American Academy of Neurology guidelines:[1][2]

 
 
 
Red flags
•Headache beginning after 50 years old
•Increased severity and frequency of headaches
•Sudden onset of headache
•New onset of headache in cancer and HIV patients
•Headache with sign of systemic illness(fever,rash,neck stiffness)
•Focal neurological symptoms
•Papilledema
•Headache subsequent to head trauma
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer and investigate
 
 
 
 
 
Possible indicators of secondary headache
•Unexplained focal signs
•Atypical headaches
•Unusual headache precipitatnts
•Unusual aura symptoms
•Onset after after age 50
•Agravatting by neck movement: abnormal neck examination findings (consider cervicogenic headache)
Jaw symptoms (consider temporomandibular joint dysfunction)
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
Migraine
•Acute medications
•Monitor for medication overuse
Prophylactic medication if:
-Headache >3 d/mo and acute medications are not effective
OR
-Headache >8 d/mo (risk of overuse)
OR
-Disability despite acute medication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Headache with >2 of the following:
Nausea
Light sensitivity
•Interference with activities
Practice points:
Migraine has been historically underdiagnosed
•Considere migraine diagnosis for recurring "sinus" headaches
 
Yes
Migraine
 
Medication overuse
Assess
Ergots, triptans, combination analgesics, or codeine or other opioids >10 d/mo
OR
Acetaminophen or NSAIDs >15 d/mo
Manage
•Educate patient
•Considere prophylactic medication
•Provide an effective acute medication for severe attacks with limitations on frequency of use
•Gradual withdrawal of opioids if used, or combination analgesic with opioid or barbiturate
•Abrupt (or gradual) withdrawal of acetaminophen, NSAIDs or triptans
 
 
 
 
Behavioral management
•Keep headache diary: intensity, triggers, frequency, medications
•Adjust lifestyle factors: reduce caffeine, ensure regular exercise, avoid irregular or inadecuate sleep or meals
•Develope stress management strategies: relaxation training, CBI, pacing activity, biofeedback
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
Tension type headache
•Acute medications
•Monitor for medication overuse
Prophylactic medication disability despite medication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Headache with no nausea but >2 of the following:
Bilateral headache
•Nonpulsating pain
•Not worsened by activity
 
Yes
Tension type headache
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uncommon headache syndromes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
All of the following:
•Frequent headache
•Severe
•Brief <3 h per attack)
•Unilateral (always same side)
Ipsilateral eye redness, tearing or restleness during attacks
 
 
 
All of the following:
•Unilateral (always same side)
•Continuous
•Dramatically responsive to indomethacin
 
 
 
Headache continuous side onset
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
Yes
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cluster headache or another trigeminal autonomic cephalalgia
•Management primarly pharmacologic
•Acute medication
Prophylactic medication
•Early specialist referral recommended
 
 
 
Hemicrania continua
•Specialist referral
 
 
 
New daily persistent headache
•Specialist referral

Treatment

Shown below is an algorithm summarizing the treatment of headache:[2]

 
 
 
 
 
 
 
Patient with headache
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule about secondary causes and emergency conditions
 
Treat secondary causes and emergency conditions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient education and assessment of severity
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild to moderate
 
 
 
Associated with nausea, vomiting, and diarrhea
 
 
 
Severe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Simple analgesics: NSAIDs, acetaminophen
 
 
 
Add an antiemetic
 
 
 
Triptans, DHE nasal spray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Combination of analgesics and caffeine
 
 
 
Inadequate response
 
 
 
Opioid analgesics
Butorphanol
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inadequate response
 
 
 
Considere preventive therapy
 
 
 
Corticosteroids
IV valproate
 
 
 
 
 
 
 
Manage as sever migraine
 
 

Do's


Don'ts


References

  1. Becker WJ, Gladstone JP, Aubé M (November 2007). "Migraine prevalence, diagnosis, and disability". Can J Neurol Sci. 34 (4): S3–9. PMID 18064751.
  2. 2.0 2.1 Latinovic R, Gulliford M, Ridsdale L (March 2006). "Headache and migraine in primary care: consultation, prescription, and referral rates in a large population". J Neurol Neurosurg Psychiatry. 77 (3): 385–7. doi:10.1136/jnnp.2005.073221. PMC 2077680. PMID 16484650.
  3. Montemayor ET, Long B, Pfaff JA, Moore GP (August 2018). "Patient with a Subarachnoid Headache". Clin Pract Cases Emerg Med. 2 (3): 193–196. doi:10.5811/cpcem.2018.5.38417. PMC 6075496. PMID 30083630.
  4. 4.0 4.1 Becker WJ, Findlay T, Moga C, Scott NA, Harstall C, Taenzer P (August 2015). "Guideline for primary care management of headache in adults". Can Fam Physician. 61 (8): 670–9. PMC 4541429. PMID 26273080.
  5. "Migraine and Meningitis | JAMA Neurology | JAMA Network".
  6. Sina F, Razmeh S, Habibzadeh N, Zavari A, Nabovvati M (August 2017). "Migraine headache in patients with idiopathic intracranial hypertension". Neurol Int. 9 (3): 7280. doi:10.4081/or.2017.7280. PMC 5641834. PMID 29071043.
  7. "Ethinyl estradiol and norelgestromin (transdermal) Uses, Side Effects & Warnings - Drugs.com".
  8. Aleksenko D, Maini K, Sánchez-Manso JC. PMID 29262094. Missing or empty |title= (help)