Headache resident survival guide: Difference between revisions
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==Overview== | ==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 | 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== | ==Causes== | ||
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|- | |- | ||
| rowspan="7" |Intracranial disorders | | rowspan="7" |Intracranial disorders | ||
|Brain space occupying lesion | |Brain space-occupying lesion | ||
|- | |- | ||
|Chiari Type 1 malformation | |Chiari Type 1 malformation | ||
|- | |- | ||
|CSF leak with low pressure headache | |CSF leak with low-pressure headache | ||
|- | |- | ||
|Hemorrhage | |Hemorrhage | ||
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|} | |} | ||
'''Life-threatening causes''': | '''Life-threatening causes''': | ||
Life-threatening causes include conditions | Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. | ||
*[[Brain abscess]] | *[[Brain abscess]] | ||
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==Diagnosis== | ==Diagnosis== | ||
{{Family tree/start}} | {{Family tree/start}} | ||
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==Treatment== | ==Treatment== | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | | | | | B01 | | | | | | B01= Patient with headache }} | {{Family tree | | | | | | | | B01 | | | | | | B01= Patient with headache }} | ||
| Line 151: | Line 151: | ||
{{Family tree | | C01 | | | C01= manage as sever migraine }} | {{Family tree | | C01 | | | C01= manage as sever migraine }} | ||
==Do's== | == Do's == | ||
*Be aware of patients who describe a sudden severe [[thunderclap headache]], described as the worst [[headache]] of their lives. Perform a non-contrasted [[CT scan]] of the [[head]] to rule out [[subarachnoid hemorrhage]]; if negative, perform a [[lumbar puncture]].<ref name="pmid30083630">{{cite journal |vauthors=Montemayor ET, Long B, Pfaff JA, Moore GP |title=Patient with a Subarachnoid Headache |journal=Clin Pract Cases Emerg Med |volume=2 |issue=3 |pages=193–196 |date=August 2018 |pmid=30083630 |pmc=6075496 |doi=10.5811/cpcem.2018.5.38417 |url=}}</ref> | |||
*Distinguish [[migraine]] from [[meningitis]] if in addition of [[Photophobia|photophobi]]<nowiki/>a and [[phonophobia]], [[Neck stiffness|neck stiffnes]]<nowiki/>s and fever coexist.<ref name="urlMigraine and Meningitis | JAMA Neurology | JAMA Network">{{cite web |url=https://jamanetwork.com/journals/jamaneurology/article-abstract/579362 |title=Migraine and Meningitis | JAMA Neurology | JAMA Network |format= |work= |accessdate=}}</ref> | |||
*Perform an [[MRI]] or [[CT scan]] of the [[head]], if [[intracranial hypertension]] is suspected. Morning predominant headache accompanied by [[vomiting]] supports the [[diagnosis]] of [[Brain tumor|intracranial tumors]].<ref name="pmid29071043">{{cite journal |vauthors=Sina F, Razmeh S, Habibzadeh N, Zavari A, Nabovvati M |title=Migraine headache in patients with idiopathic intracranial hypertension |journal=Neurol Int |volume=9 |issue=3 |pages=7280 |date=August 2017 |pmid=29071043 |pmc=5641834 |doi=10.4081/or.2017.7280 |url=}}</ref> | |||
<br /> | |||
==Don'ts== | ==Don'ts== | ||
*Do not administer [[Drospirenone and Ethinyl estradiol]] or [[Norelgestromin and Ethinyl Estradiol]] in patients older than 35.<ref name="urlEthinyl estradiol and norelgestromin (transdermal) Uses, Side Effects & Warnings - Drugs.com">{{cite web |url=https://www.drugs.com/mtm/ethinyl-estradiol-and-norelgestromin-transdermal.html |title=Ethinyl estradiol and norelgestromin (transdermal) Uses, Side Effects & Warnings - Drugs.com |format= |work= |accessdate=}}</ref> | |||
*Do not administer [[Non-steroidal anti-inflammatory drug|NSAIDs]] more than 15 days straight do to possible [[rebound headache]].<ref name="pmid29262094">{{cite journal |vauthors=Aleksenko D, Maini K, Sánchez-Manso JC |title= |journal= |volume= |issue= |pages= |date= |pmid=29262094 |doi= |url=}}</ref> | |||
<br /> | |||
==References== | ==References== | ||
{{Reflist|2}} | |||
[[Category: | [[Category:Primary care]] | ||
[[Category: | [[Category:Up-To-Date]] | ||
Revision as of 23:56, 1 December 2020
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
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 withdrawl | ||
| 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.
- Brain abscess
- Cerebral aneurysm
- Encephalitis
- Hydrocephalus
- Hypertensive encephalopathy
- Increased intracranial pressure
- Intracerebral hemorrhage
- Meningitis
- Subarachnoid hemorrhage
- Subdural hemorrhage
FIRE
Diagnosis
| 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
Do's
- Be aware of patients who describe a sudden severe thunderclap headache, described as the worst headache of their lives. Perform a non-contrasted CT scan of the head to rule out subarachnoid hemorrhage; if negative, perform a lumbar puncture.[1]
- Distinguish migraine from meningitis if in addition of photophobia and phonophobia, neck stiffness and fever coexist.[2]
- Perform an MRI or CT scan of the head, if intracranial hypertension is suspected. Morning predominant headache accompanied by vomiting supports the diagnosis of intracranial tumors.[3]
Don'ts
- Do not administer Drospirenone and Ethinyl estradiol or Norelgestromin and Ethinyl Estradiol in patients older than 35.[4]
- Do not administer NSAIDs more than 15 days straight do to possible rebound headache.[5]
References
- ↑ 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.
- ↑ "Migraine and Meningitis | JAMA Neurology | JAMA Network".
- ↑ 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.
- ↑ "Ethinyl estradiol and norelgestromin (transdermal) Uses, Side Effects & Warnings - Drugs.com".
- ↑ Aleksenko D, Maini K, Sánchez-Manso JC. PMID 29262094. Missing or empty
|title=(help)
| 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 | |||||||||||||||||||||||||||||||||