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Concurrent use of triptans, many possibly serious drug interactions; heart disease or angina, hypertension, peripheral vascular disease, pregnancy, renal insufficiency, breastfeeding.

Family Medicine 18: 24-year-old female with headaches User: YULAK LANDA Email: landayrn17@stu.southuniversity.edu Date: February 8, 2021 10:36PM

Learning Objectives

The student should be able to:

Identify the typical presenting signs and symptoms of common as well as serious causes of headache (tension, cluster, brain tumor, intracranial hemorrhage, medication use). Obtain an appropriately focused history on a patient who presents with headache. Perform a reliable focused neurologic exam on a patient who presents with headache. Identify appropriate indications for ordering imaging tests on a patient who presents with headache. Counsel a patient who presents with headache on the appropriate prevention and treatment of the headache. Discuss the importance of continuity of care when treating a patient who presents with chronic headache. Demonstrate the use of point-of-care technology when uncertainty regarding diagnosis, appropriate evaluation, and/or treatment of a patient arises during the course of an office visit.

Knowledge

Causes of Headache

Common types of headache seen in the outpatient setting:

1. Tension-type 2. Migraine 3. Medication overuse 4. Cluster headache

Serious causes of headache:

1. Meningitis 2. Brain tumor 3. Intracranial hemorrhage 4. Traumatic brain injury (concussion)

Causes of Serious Secondary Headaches

Etiology of secondary headache

Findings

Meningitis Headache with fever, mental status changes, or stiff neck.

Intracranial hemorrhage Sudden onset of headache, severe headache, recent trauma, elevated blood pressure.

Brain tumor Cognitive impairment, weight loss or other systemic symptoms, abnormal neurologic examination.

Traumatic brain injury (concussion)

Head injury with subsequent confusion and amnesia. Loss of consciousness sometimes occurs. Subsequent headache, dizziness, and nausea and vomiting. Over hours and days: mood and cognitive disturbances, sensitivity to light and noise, and sleep disturbances.

Common Etiologies of Secondary Headaches

1. Headache due to depression or anxiety

Features

Similar to tension-type headache: Bilateral, pressing, and/or tight

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Last from 30 minutes to seven days Some experts feel that depression or anxiety can trigger tension-type headaches. In those cases tension-type headaches are considered secondary, not primary headaches. 2. Medication overuse headache (also called analgesic rebound headache) Chronic use of any analgesic can cause this type of headache. Features

Mild to moderate in severity Diffuse, bilateral headaches that occur almost daily and are often present on first waking up in the morning. Often aggravated by mild physical or mental exertion. Can be associated with restlessness, nausea, forgetfulness, and depression. Headaches may improve slightly with analgesics but worsen when the medication wears off. Tolerance develops to abortive medications and there is decreased responsiveness to preventive medications. Medication overuse headache can occur at varying doses for different types of medication; it may occur with as low as an average of 18 doses of triptans per month, but may require as high as an average of 114 doses of analgesics per month.

Diagnostic criteria

More than 15 headaches per month. Regular overuse of an analgesic for more than three months. Development or worsening of a headache during medication overuse. Headache resolves or reverts to its previous pattern within 2 months after discontinuation of overused medication.

Treatment

Stop the overused medication.

Important Physical Exam Findings with Headache

Signs of increased intracranial pressure:

Papilledema Altered mental status

Other important findings to look for:

Signs of meningeal irritation such as Kernig’s sign or Brudzinski’s sign Focal neurologic deficits such as unilateral loss of sensation, unilateral weakness, or unilateral hyperreflexia.

Triggers for Tension & Migraine Headaches

Physical or environmental triggers:

1. Intense or strenuous exercise 2. Sleep disturbance 3. Menses 4. Ovulation 5. Pregnancy (though for many women, headaches actually improve during pregnancy) 6. Acute illness 7. Fasting 8. Bright or flickering lights 9. Emotional stress

Medications or substances that act as triggers:

1. Estrogen (birth control/hormone replacement) 2. Tobacco, caffeine or alcohol 3. Aspartame and phenylalanine (from diet soda)

When to Initiate Prevention of Migraines

The American Migraine Prevalance and Prevention Study outlines recommendations as to when daily pharmacological treatment should be initiated:

At least six headache days per month At least four headache days with at least some impairment At least three headache days with severe impairment or requiring bed rest.

Prevention should be considered: Four to five migraine days per month with normal functioning Two to three migraine days per month with some impairment Two migraine days with severe impairment.

DSM-5 Substance Use Disorder

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The DSM-5 substance use disorder criteria combine the DSM-4 criteria for dependence, addiction, and tolerance. There is now one term, “substance use disorder,” that encompasses a continuum of problems with substances from mild to severe. Each specific substance use disorder is diagnosed in similar fashion, using a list of 11 symptoms to determine the severity of illness. For opioid use disorder, the 11 symptoms are:

opioids taken in larger amounts than intended unsuccessful efforts to control use significant time spent in opioid-related activities craving use results in unmet obligations at work, school, or home continued use despite significant interpersonal problems related to use other activities neglected due to use use in physically hazardous situations continued use despite physical or psychological problems related to use tolerance withdrawal

Note: The last two symptoms do not apply to patients taking opioids solely under appropriate medical supervision.

Clinical Skills

How to Perform a Neurological Exam

Test cranial nerves II through XII:

Cranial Nerves Test

II and III Pupils are equal, round, and reactive to light.

II

Test visual fields with confrontation.

Confrontation: Ask the patient to look with both eyes into your eyes. While returning her gaze, place your hands about 2 feet apart, lateral to her ears, and instruct her to point to your fingers as soon as they are seen. Then slowly move your wiggling fingers on both hands along an imaginary bowl encircling her head toward the line of gaze until she identifies them. Do this in the upper and lower temporal quadrants.

III, IV, and VI

Extraocular eye movements are intact.

Convergence intact.

Extraocular eye movements:

Ask the patient to refrain from moving her head while following your finger movements with her eyes, and make a wide H in the air, leading her gaze:

(1) To her extreme right

(2) To the right and upward

(3) Down on the right

(4) Then, without pausing in the middle, to the extreme left

(5) To the left and upward

(6) Down on the left

Convergence:

Ask her to follow your fingertip with her eye as you move it towards the bridge of her nose.

V Ask the patient to close her eyes and then ask if the two stimuli feel the same when you lightly touch her right, then leftforehead; right, then left cheek; right, then left chin.

VII

Observe for facial asymmetry while the patient is talking or performing the following maneuvers:

1. Raise her eyebrows.

2. Frown.

3. Close both eyes tightly while you try to open them.

4. Show both upper and lower teeth.

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5. Smile.

6. Puff out both cheeks.

VIII Rub your fingers near each ear.

XI Ask the patient to elevate her shoulders against resistance.

IX, X, and XII Note if speech is clear and tongue and palate are midline.

Management

Patient Management of Migraine and Tension-Type Headaches

1. Headache diary

Make note each day of whether or not you have a headache. Keep track of the severity of the headaches and which treatments are effective. Identify and avoid headache triggers. Use a list of things that trigger headaches, and monitor which of these triggers worsen your headaches.

2. Caffeine

Caffeine can help headaches but an excess can make them worse, especially when coming off of it abruptly. Slowly decrease the use of diet sodas. The caffeine worsens both migraines and tension-type headaches, but coming off of caffeine too quickly may make things worse in the short term. 3. Sleep

Try to get more sleep. Aim for eight hours each night and establish a regular sleep routine, meaning try to go to sleep at the same time each night.

Examples of Effective Stress Relievers

Meditation or a scheduled moment of stillness Listening to a relaxation audio program Setting limits on other people’s expectations Talking with trusted family and friends Getting moderate, regular exercise Getting at least eight hours of restful sleep each night

Migraine Medications

Migraine- specific treatments:

Treatment Generic name(trade name) Contraindications Side effects

triptans

sumatriptan (Imitrex, Imigran), naratriptan (Amerge, Naramig), rizatriptan (Maxalt), zolmitriptan (Zomig), frovatriptan (Frova, Migard), almotriptan (Axert), eletriptan (Relpax)

Concurrent use of ergotamine, MAOIs; history of hemiplegic or basilar migraine; significant cardiovascular, cerebrovascular, or peripheral vascular disease; severe hypertension; pregnancy; in combination with SSRI’s, may cause serotonin syndrome.

Dizziness, sleepiness, nausea, fatigue, paresthesia, throat tightness/closure, chest pressure.

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ergot alkaloids

ergotamine (Ergostat), ergotamine/caffeine (Cafergot), dihydroergotamine (DHE)

Concurrent use of triptans, many possibly serious drug interactions; heart disease or angina, hypertension, peripheral vascular disease, pregnancy, renal insufficiency, breastfeeding.

Severe reactions possible. MI, ventricular tachyarrhythmias, stroke, hypertension, nausea, vomiting, diarrhea, dry mouth, rash.

Non-specific treatments (effective for any pain disorder):

Treatment Generic name(trade name) Contraindications Side effects

acetaminophen/aspirin/caffeine (Excedrin) Pregnancy; sensitivity to aspirin.

Nausea; GI bleed; hypertension.

Older medications no longer recommended because of increased risk of overuse:

Treatment Generic name(trade name) Contraindications Side effects

aspirin/butalbital/caffeine (Fiorinal)

Risk of chronic daily use or dependence higher; history of porphyria or peptic ulcers; bleeding risk; pregnancy.

Anaphylaxis, toxic epidermal necrolysis, Stevens-Johnson syndrome, myelosuppression/thrombocytopenia, GI bleed.

acetaminophen/butalbital/caffeine (Esgic, Fioricet, Phrenilin (lacks caffeine))

History of porphyria; pregnancy; caution in drug abuse.

Dizziness, drowsiness, dyspnea, nausea, vomiting, abdominal pain, agranulocytosis, thrombocytopenia, respiratory depression, Stevens- Johnson syndrome.

acetaminophen/dichloralphenazone (Midrin (discontinued in the U.S.))

Hepatorenal insufficiency; diabetes; hypertension; glaucoma; heart disease; MAOI use.

Hypertension, dizziness, rash.

Opioid/Butalbital Last Resort Migraine Therapy

Note: Don’t use opioid or butalbital treatment for migraine except as a last resort.

Opioid and butalbital treatment for migraine should be avoided because more effective, migraine-specific treatments are available. Frequent use of opioid and butalbital treatment can worsen headaches. Opioids should be reserved for those with medical conditions precluding the use of migraine-specific treatments or for those who fail these treatments. See Choosing Wisely – American Academy of Neurology.

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Migraine prophylaxis

Patients who have migraines more frequently than twice weekly are at risk for medication overuse headache. Migraine prophylaxis should be considered in these patients if the lifestyle changes aren’t effective .

Drugs used (daily dose range)

FDA Approved? Efficacy/cost

Contraindications / Cautions Side effects

Beta-blockers

First line:

Metoprolol (47.5- 200 mg)

Propranolol (20- 160mg)

Timolol (10-30mg)

Second line:

Atenolol

Nadolol

Yes Good-excellent/cheap Asthma, depression, severe COPD, DM requiring insulin, Raynaud’s disease

Fatigue, bronchospasm, lightheadedness, insomnia, bradycardia, depression, sexual dysfunction

Tricyclic Antidepressants

First line:

Amitriptyline (10- 150mg)

No (off- label)

Excellent/cheap and also work for fibromyalgia and tension-type headache

Cardiac conduction defects, MAOI

Drowsiness, weight gain, dry mouth

Neurostabilizers

Second line:

Divalproex sodium (500-1500mg); Topiramate (25- 200mg

Yes Good/expensive

Pregnancy/risk of pregnancy

Divalproex: hepatic disease

Divalproex: birth defects, weight gain, alopecia, pancreatitis, ovarian cysts

Topiramate: abdominal pain, change in tastes, renal stones, weight loss

Goals of Headache Treatment

The American Migraine Prevalance and Prevention Study outlined recommendations as to when daily pharmacological treatment should be initiated: Prevention should be initiated:

at least six headache days per month at least four headache days with at least some impairment at least three headache days with severe impairment or requiring bed rest.

Prevention should be considered: four to five migraine days per month with normal functioning two to three migraine days per month with some impairment two migraine days with severe impairment.

The goals of treatment: The 2000 US Headache Consortium defined the following goals for preventive treatment: (1) decrease attack frequency by 50% and decrease intensity and duration; (2) improve responsiveness to acute therapy; (3) improve function and decrease disability; and (4) prevent the occurrence of a medication overuse headache (MOH) and chronic daily headache.

Studies

Indications for Brain Imaging in the Evaluation of Headache

Don’t do imaging for uncomplicated headache. Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well- being. For more information, see the “Choosing Wisely” campaign of the American Board of Internal Medicine Foundation. The American Academy of Neurology and the U.S. Headache Consortium guidelines recommend neuroimaging only if:

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2. The patient is at higher risk of a significant abnormality 3. The results of the study would alter the management of the headache

Symptoms that increase the odds of positive neuroimaging results include:

Rapidly increasing frequency of headache Abrupt onset of severe headache Marked change in headache pattern A history of poor coordination, focal neurologic signs or symptoms, and a headache that awakens the patient from sleep. A headache that is worsened with use of Valsalva’s maneuver Persistent headache following head trauma New onset of headache in a person age 35 or over History of cancer or HIV

Clinical Reasoning

Defining Characteristics of Primary Headaches

Migraine Tension type Cluster

Severity of pain Moderate to severe. Mild to moderate. Severe.

Associated symptoms

Often occur with nausea and vomiting, photophobia, or hyperacusis. May occur with aura.

May occur with photophobia or hyperacusis.

Associated with rhinorrhea, lacrimation, facial sweating, miosis, eyelid edema, conjunctival injection, and ptosis.

Quality of pain Pulsating and can be unilateral.

Pressing, tightening, and bilateral.

Severe unilateral orbital, periorbital, supraorbital, or temporal pain.

Aggravating factors Worsened with physical activity.

Typically not worsened with physical activity.

Duration of symptoms Last from 4-72 hours.

Last from 30 minutes to 7 days. Last 15-180 minutes.

Number of episodes 5 episodes needed for diagnosis.

10 episodes needed for diagnosis. 5 episodes needed for diagnosis.

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing; 2013.

Andress-Rothrock D1, King W, Rothrock J. An analysis of migraine triggers in a clinic-based population. Headache. 2010 Sep;50(8):1366-70.

Aukerman G, Knutson D, Miser WF; Department of Family Medicine, Ohio State University College of Medicine and Public Health, Columbus, Ohio. Management of the acute migraine headache. Am Fam Physician. 2002 Dec 1;66(11):2123-30.

Bickley LS. Bates Guide to Physical Examination and History Taking. 10th edition. Philadelphia: Wolters Kluwer/Lippincott Williams & Williams; 2009.

D’Andrea G, Colavito D, Carbonare MD, Leon. Migraine with aura: conventional and non-conventional treatments. Neurol Sci. 2011; 32 (Suppl 1):S121-S129.

Diener HC, Holle D, Dodick D. Treatment of chronic migraine. Curr Pain Headache Rep. 2011 Feb;15(1):64-9. doi: 10.1007/s11916-010- 0159-x.

Dowell D, Haegerich TM, Chou R. CDC. Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep 2016;65 (No. RR-1):1-49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

Estemalik E, Tepper S. Preventive treatment in migraine and the new US guidelines. Neuropsychiatric Disease and Treatment. 2013;9:709-720. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663475/. Accessed May 1, 2019.

Hainer BL, Matheson EM. Approach to acute headache in adults. Am Fam Physician. 2013 May 15;87(10):682-7.

Headache, Diagnosis and Treatment of. ICSI. Revised 2013. https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_neurological_guidelines/headache/

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Accessed May 1, 2019.

International Headache Society. IHS Classification ICHD-3. Migraine. https://ichd-3.org/1-migraine/. Accessed August 27, 2019.

International Headache Society. IHS Classification ICHD-3. Tension-type headache. https://ichd-3.org/2-tension-type-headache/. Accessed August 27, 2019.

International Headache Society. IHS Classification ICHD-3. https://ichd-3.org/8-headache-attributed-to-a-substance-or-its-withdrawal/. Accessed October 15, 2019.

Jackman RP, Purvis JM, Mallett BS. Chronic nonmalignant pain in primary care. Am Fam Physician. 2008 Nov 15;78(10):1155-62.

Jordan JE, for the Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria: Headache. Am J Neuroradiol 28:1824-26. http://www.ajnr.org/content/28/9/1824.full.pdf+html

Kavan MG, Elsasser G, Barone EJ. Generalized anxiety disorder: practical assessment and management. Am Fam Physician. 2009 May 1;79(9):785-91.

Kristoffersen ES, Lundgvist C. Medication-overuse headache: a review. J Pain Res.. June 2014;7:367-8.

Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003 Nov;41(11):1284-92.

Maurer DM, Raymond, TJ, Davis BN. Depression: screening and diagnosis. Am Fam Physician. October 2018;98(8):508-515.

Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies. Am Fam Physician. February 2018;97(4):243-1.

Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies. Am Fam Physician. February 2018;97(4):243-51.

Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician. 2006 Jan 1;73(1):72-8.

Neuropsychiatr Dis Treat. 2013; 9: 709–720. Published online 2013 May 17. doi: 10.2147/NDT.S33769.

Silberstein, SD et al. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1337-45.

Stress: How to Cope with Life’s Challenges. Am Fam Physician. 2006 Oct 15;74(8):1385-1386. http://www.aafp.org/afp/2006/1015/p1385.html. Accessed May 1, 2019.

Work Group on Substance Use Disorders, Kleber HD, Weiss RD, Anton RF, Rounsaville BJ, George TP, et. al. Treatment of patients with substance use disorders, second edition. American Psychiatic Association. Am J Psychiatry. 2006 Aug;163(8 Suppl):5-82.

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  • Family Medicine 18: 24-year-old female with headaches
    • Learning Objectives
    • Knowledge
      • Causes of Headache
      • Causes of Serious Secondary Headaches
      • Common Etiologies of Secondary Headaches
      • Important Physical Exam Findings with Headache
      • Triggers for Tension & Migraine Headaches
      • When to Initiate Prevention of Migraines
      • DSM-5 Substance Use Disorder
    • Clinical Skills
      • How to Perform a Neurological Exam
    • Management
      • Patient Management of Migraine and Tension-Type Headaches
      • Examples of Effective Stress Relievers
      • Migraine Medications
      • Opioid/Butalbital Last Resort Migraine Therapy
      • Migraine prophylaxis
      • Goals of Headache Treatment
    • Studies
      • Indications for Brain Imaging in the Evaluation of Headache
    • Clinical Reasoning
      • Defining Characteristics of Primary Headaches
    • References