HEADACHE

 

Etiology:

We will report most, but not all of the causes of headache. We will subsequently discuss in details some of them and others will be discussed elsewhere in this guide.   

We will classify HA into "benign" and "potentially serious". As a general guideline, chronic HA w/o other associated S & S are benign. New HA, on the other hand, are potentially serious. Three worrisome symptoms are: 1) "thunderclap" HA, 2) HA + Fever, 3) HA + neural signs.

 

Classification:

 

A.  Benign Causes of  HA:

  1. Migraine
  2. Cluster HA
  3. Tension HA
  4. Post-ictal (see "Seizure")
  5. BIH or NPH- BIH - Benign Intracranial Hypertension (Pseudotumor
    Cerebri), NPH (Normal pressure Hydrocephalus)
  6. Primary headache - i.e. not attributed to any  pathology

 

 

B.  Potentially Serious Causes of HA

  1. HTN - see elsewhere
  2. CVA - see elsewhere
  3. IC hemorrhage (SAH from AV malformation or aneurysm, SDH, EDH) - see elsewhere
  4. Head trauma - see elsewhere for details.
  5. Vascular/Rheumatic -Venous or  Cavernous Sinus Thrombosis (VST), Temporal Arteritis, SLE, PN, aneurysm, Carotid or Vertebral Artery Dissection (CAT and VAT), AV malformation
  6. Referred (see elsewhere)- ocular (glaucoma, iritis), dental pathology, sinusitis, trigeminal neuralgia, muscular pain, spinal (cervical) pain, premenstrual, Herpes Zoster
  7. Intoxications/Drugs (see elsewhere) - CO poisoning, Nitroglycerin, WD from coffee, MSG, ETOH (abuse or hangover), lead, cyanide, antihypertensives. The list of  toxins and drugs that can give headache is  endless
  8. Post lumbar puncture (see "LP" in  section "Procedures in the ER" )
  9. Intracranial Tumor/Mass/NPH (Normal Pressure Hydrocephalus - presents
    with triad of Dementia-Ataxia-Incontinence)
  10. Infection (see elsewhere) - meningitis, encephalitis, abscess, sinusitis, infected tooth.
  11. Metabolic process - fever, hypoglycemia, thyrotoxicosis, CO2 retention

 

S & S, DX and TREATMENT of specific causes of  Headache

 

  1. BIH ( Benign Intracranial Hypertension or Pseudotumor cerebri)
    1. More common in females
       
    2. Patient is often obese and has history of irregular menses
       
    3. HA, nausea, visual changes (diplopia, blind spots, < visual field later on, fleeting visual "blackouts" i.e. few seconds of blindness) are common complaints. Neuro exam is normal. Patient may report worsening of the HA with eye movement.
       
    4. Dx is established by exam that reveals papilledema, CT (narrow ventricles) and LP (CSF pressure  > 250mmHg and no   increase  in cells or proteins)
       
    5. Treatment c/o CSF removal, diuretics, steroids.
       
  2. CAT and VAT (Carotid and Vertebral Artery Dissection).
    This is  an example of why all NEW  HAs must be investigated.
     
    1. Common cause of the dissection in above arteries is a strain applied to them while stretching  the neck during exercise, neck manipulation, wrestling, trauma to neck, watching skyscraper, nose blowing. Other causes are HTN, Marfan.
       
    2. Patient may c/o subtle or dramatic symptoms.

S&S of CAD:

    1. Ipsilateral facial pain and HA in 50-70%  of cases
      .
    2. Ipsilateral partial Horner's (ptosis, miosis without sweating) in 40% of cases.
       
    3. Carotid bruit in 40-50% of cases.
       
    4. Contralateral Cranial Nerve  palsy (in order of occurrence XII, X, IX, V, VII) occurs only in < 10% of cases while signs of Cerebral Ischemia (CVA or TIA), i.e. weakness to upper and/or lower extremities, although delayed, are present in 40-80%.
       
    5. Other non specific S&S are amaurosis fugax, syncope.

S&S of VAD:

    1. HA in posterior nucal area in 50% of cases.
       
    2. Facial numbness and pain 75%
       
    3. Neuro deficit attributed to brainstem (CN 9-10) and cerebellum (vertigo, ataxia, vomiting) is present in 80%
      .
    4. Horner is present in 25%.

DX of CAD and VAD:

    1. Doppler US and MRI/MRA
       
    2. Angiogram is a gold standard (in the books)
       
    3. CT may be needed to r/o intracranial bleed. CT is also a prerequisite for anticoagulation.

Treatment of CAD and VAD:

    1. Anticoagulation. This treatment modality is chosen since the major consequence of dissection is emboli and thrombi formation. Anticoagulation shouldn't be initiated without r/o by CT presence of IC bleed.

 

3. Intracranial Tumor

S&S:

    1. Patient will present with HA, new onset seizure, symptoms c/w CVA i.e. focal signs such asintracranial nerve deficit paresis or speech defect, N/V. Patient's HA is progressive and may be worse in the morning.  Pt almost never has HA alone.

DX:

    1. Established by CT that may show lesion with or without mass effect and with presence or absence of bleed.

Treatment:

    1. Neuro or Neurosurgical consult is appropriate.
       
    2. Patients long-term treatment will be dictated by biopsy.
       
    3. In ER, seizure prophylaxis with Phenytoin, control of high BP (if needed) and  administration of  osmotic diuretic (if mass effect is present) are among common modalities available.

 

4. Migraine

S&S:

    1. Periodic HA attacks, more common in women. HA is often unilateral,  often throbbing. N/V, photophobia/phonophobia are frequent.
       
    2. Aura is described as a prodromal symptom.
       
    3. Different types of Migraine:
       
      • Classic migraine - occurs only in 15% of cases. Onset is usually within 1 hour. Aura, throbbing HA, N/V, photophobia are present but visual complaints such as scotomas, hemianopsia, visual field deficit are the most common S&S.
                                 
      • Common  migraine - occurs in 80% of cases. No neurological S&S are present. Prodromal symptoms are not specific and may be present for hr. or days. Patient c/o unilateral HA, throbbing, N/V, photophobia.
         
      • Ophthalmic migraine - HA and ipsilateral CN III involvement. This dx can't be made  without excluding expanding aneurysm compressing III CN.
      • Hemiplegic migraine - HA and contralateral hemiplegia. This dx can't be made without excluding  TIA, focal SZ,  CAD/VAD (see above)

DX:

    1. Based on history and, if needed, by excluding other causes of HA.

Treatment:

    1. Prochlorperazine, promethazine or metoclopramide are used as first line.
       
    2. If above didn't provide relief  Sumatriptan 6 mg SQ or DHE 1mg IM or IV are alternatives. Contraindications are HTN, CAD, pregnancy, MAOi.
       
    3. Patient may benefit from O2 and dark, quiet room.

 

5. Cluster

    1. HA of days to weeks followed by HA-free period. Usually at the same time of the day and year (alarm clock headache).
       
    2. Common among men. Precipitated by use of ETOH, histamine containing products, stress.
       
    3. Severe retro-orbital unilateral HA of 30 min-2 hr, nasal congestion, conjunctivitis and ipsilateral Horner (in 25% of cases)  are described.
       
    4. Treated with 100% O2 x 15 min, NSAIDs and/or DHE or Sumatriptan.

 

6. Tension

    1. Patient c/o bilateral HA.
       
    2. On exam muscle tension in trapezius and neck muscles may be apparent.
       
    3. Treatment c/o NSAIDs.

7. Temporal Arteritis

    1. Is a vasculitis of temporal artery characterized by giant cell formation.
       
    2. More common in women > 50 y.o. Association with polymyalgia rheumatica (PMR) is described in 20%.
       
    3. Patient c/o HA and/or pain over temporal area. HA generally is severe and is in temporal area only in 30-50% of cases.
       
    4. Constitutional S&S may be described in 20-60%. These are: low grade fever, anorexia, weight  loss.
       
    5. Non specific visual complaints such as scotoma,  visual acuity are described in 40%.
       
    6. Some patients describe jaw claudication.
       
    7. Diagnosis in ER established by ESR > 50 mm/hr, palpation of tender  temporal artery and   constellation  of  above S&S i.e. new HA in pt > 50 y.o. Definitive diagnosis is achieved with biopsy.
       
    8. Patients are started in ER on Prednisone 60 mg. If this therapy is not instituted ASAP patient may lose vision.
       
    9. Patient must be referred to rheumatologist for biopsy and confirmation of the suspected diagnosis. If  biopsy not done within 5 days of treatment initiation, biopsy may lose specificity.

 

8. Trigeminal Neuralgia

    1. Facial pain in 3 branches of  trigeminal  nerve distribution. Most commonly it is on the border of two branches.
       
    2. Pain is commonly associated  with eating and triggered by even light touch, chewing etc.
       
    3. Treatment is provided with carbamazepine (Tegretol).

 

9. VST (Venous Sinus Thrombosis or CVT=Cerebral Venous Thrombosis)

    1. Thrombosis in any  of the intracranial sinuses 2ry to infections ( sinuses, ear, dental ), hypercoagulability, nasal fracture, head trauma.
    2. Patient may c/o headache and exam will reveal papilledema, hemiplegia, seizure and deficit to specific CN depending on sinus involved. Most commonly cavernous sinus is involved and ocular cranial nerves (CN III, IV,VI) are affected.
    3. DX is supported by  ESR, abnormal CSF ( proteins,  cell count) and abnormal EEG. CT is abnormal but not specific. MRI is the diagnostic tool of choice.
    4. Treatment c/o anticoagulation

[BACK]