Headache resident survival guide
For Headache resident survival guide click here.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];
| Headache Resident Survival Guide Microchapters |
|---|
| Overview |
| Causes |
| FIRE |
| Diagnosis |
| Treatment |
| Do's |
| Don'ts |
Overview
A headache is pain or discomfort in the head, scalp, or neck.
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 withdrawl | ||
| Hormones (estrogen) | ||
| Toxins | Carbonmonoxide | |
| Nitrates | ||
Life-threatening causes: Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Brain abscess
- Cerebral aneurysm
- Encephalitis
- Hydrocephalus
- Hypertensive encephalopathy
- Increased intracranial pressure
- Intracerebral hemorrhage
- Meningitis
- Subarachnoid hemorrhage
- Subdural hemorrhage
FIRE
Diagnosis
| Red flags Emergent(immediately action) •Thunderclap onset •Fever and meningismus •Papilledema with focal signs of reduced LOC •Acute glaucoma Urgent ( with hours to days) •Temporal arteritis •Papilledema without focal signs of LOC •Relevant systemic illness •Elderly patient with new headache and cognitive change | 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 | |||||||||||||||||||||||||||||||||||||||