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Chapter 16 - Headache

1) Headaches can be either primary, meaning the headache itself is the disorder, or secondary, caused by an underlying condition. 2) A thorough neurological exam and imaging studies like CT or MRI are important for evaluating new or changing headaches to identify potential causes like tumors, hemorrhages, or meningitis. 3) Specific secondary headache conditions discussed include meningitis, intracranial hemorrhage, brain tumors, and giant cell arteritis. Giant cell arteritis commonly affects those over 70 and can lead to blindness if not treated promptly with glucocorticoids.

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0% found this document useful (0 votes)
76 views7 pages

Chapter 16 - Headache

1) Headaches can be either primary, meaning the headache itself is the disorder, or secondary, caused by an underlying condition. 2) A thorough neurological exam and imaging studies like CT or MRI are important for evaluating new or changing headaches to identify potential causes like tumors, hemorrhages, or meningitis. 3) Specific secondary headache conditions discussed include meningitis, intracranial hemorrhage, brain tumors, and giant cell arteritis. Giant cell arteritis commonly affects those over 70 and can lead to blindness if not treated promptly with glucocorticoids.

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Serious Leo
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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HARRISON’S PRINCIPLE OF INTERNAL MEDICINE

Chapter 16: Headache

I. HEADACHE
• Primary headaches • Autonomic symptoms reflect activation of cranial
Headache and its associated features are the parasympathetic pathways, and functional imaging
disorder itself. studies indicate that vascular changes in migraine and
• Secondary headaches cluster headache.
Caused by exogenous disorders (Headache • Migraine and other primary headache types are not
Classification Committee of the International “vascular headaches”
Headache Society, 2018). These disorders do not reliably manifest vascular
changes, and treatment outcomes cannot be
predicted by vascular effects.

B. CLINICAL EVALUATION OF ACUTE, NEW-ONSET


HEADACHE
• Careful neurologic examination is an essential first
step in the evaluation.
• In most cases, patients with an abnormal examination
or a history of recent-onset headache should be
evaluated by a computed tomography (CT) or
magnetic resonance imaging (MRI) study of the
A. ANATOMY AND PHYSIOLOGY OF HEADACHE brain, which are equally sensitive as an initial
• Pain usually occurs when peripheral nociceptors. screening procedure for intracranial pathology.
• Pain can also result when pain-producing pathways • In some circumstances, a lumbar puncture (LP) is
of the peripheral or central nervous system (CNS) also required, unless a benign etiology can be
are damaged or activated inappropriately. otherwise established.
• Relatively few cranial structures are pain-producing • Investigation of cardiovascular and renal status by
Scalp blood pressure monitoring and urine examination.
Meningeal arteries • Eyes by fundoscopy, intraocular pressure
Dural sinuses measurement, and refraction.
Falx cerebri • Psychological state of the patient should also be
Proximal segments of the large pial arteries evaluated because a relationship exists between head
pain, depression, and anxiety.
• Key structures involved in primary headache appear to
It is notable that medicines with antidepressant
be the following:
The large intracranial vessels and dura mater and actions are also effective in the preventive
treatment of both tension-type headache and
the peripheral terminals of the Trigeminal Nerve
migraine, each symptom must be treated optimally.
that innervate these structures (trigeminovascular
• Underlying recurrent headache disorders may be
system)
activated by pain that follows otologic or endodontic
The caudal portion of the trigeminal nucleus, which
surgical procedures.
extends into the dorsal horns of the upper cervical
Treatment of the headache is largely ineffective
spinal cord and receives input from the first and
until the cause of the primary problem is
second cervical nerve roots (the
addressed.
trigeminocervical complex)
• Brain tumor is a rare cause of headache and even less
Rostral pain-processing regions, such as the
commonly a cause of severe pain.
ventroposteromedial thalamus and the cortex
• The vast majority of patients presenting with severe
The pain-modulatory systems in the brain that
headache has a benign cause.
modulate input from trigeminal nociceptors at all
levels of the pain-processing pathways and
influence vegetative functions, such as
hypothalamus and brainstem structures

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II. SECONDARY HEADACHE

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A. MENINGITIS • Inflammatory disorder of arteries that frequently
• Acute, severe headache with stiff neck and fever involves the extracranial carotid circulation.
suggests meningitis. • Average age of onset is 70 years, and women account
• LUMBAR PUNCTURE is mandatory. for 65% of cases.
• Often there is striking accentuation of pain with eye • About half of patients with untreated temporal arteritis
movement. develop blindness due to involvement of the
OPHTHALMIC ARTERY and its branches.
B. INTRACRANIAL HEMORRHAGE • Ischemic optic neuropathy induced by giant cell
• Acute, maximal in <5 min, severe headache lasting arteritis is the major cause of rapidly developing
>5 min with stiff neck but without fever suggests bilateral blindness in patients >60 years.
SUBARACHNOID HEMORRHAGE. • Because treatment with glucocorticoids is effective in
• A ruptured aneurysm, arteriovenous malformation, or preventing this complication, prompt recognition of the
intraparenchymal hemorrhage may also present with disorder is important.
headache alone. • Typical presenting symptoms include headache,
• Rarely, if the hemorrhage is small or below the foramen polymyalgia rheumatica, jaw claudication, fever,
magnum, the head CT scan can be normal. and weight loss.
Therefore, LP may be required to diagnose • Headache is the dominant symptom and appears in
definitively subarachnoid hemorrhage. association with malaise and muscle aches.
Head pain may be unilateral or bilateral and is
C. BRAIN TUMOR located temporally in 50% of patients but may
• ~30% of patients with brain tumors consider headache
involve any and all aspects of the cranium.
to be their chief complaint.
• Pain appears gradually over a few hours before peak
• The head pain is usually nondescript—an intermittent
intensity is reached; occasionally, it is explosive in
deep, dull aching of moderate intensity, which may
onset.
worsen with exertion or change in position and may
Quality of pain is infrequently throbbing; it is
be associated with nausea and vomiting.
almost invariably described as dull and boring,
• Headache of brain tumor disturbs sleep in about 10%
with superimposed episodic stabbing pains similar
of patients.
to the sharp pains that appear in migraine.
• A history of amenorrhea or galactorrhea should lead
• Most patients can recognize that the origin of their
one to question whether a prolactin-secreting
head pain is superficial, external to the skull, rather
pituitary adenoma (or the polycystic ovary syndrome)
than originating deep within the cranium.
is the source of headache.
• Scalp tenderness is present, often to a marked
• Headache arising de novo in a patient with known
degree; brushing the hair or resting the head on a
malignancy suggests either cerebral metastases or
pillow may be impossible because of pain.
carcinomatous meningitis, or both.
• Headache is usually worse at night and often
• Head pain appearing abruptly after bending, lifting, or
aggravated by exposure to cold.
coughing can be due to a posterior fossa mass, a
• Additional findings may include reddened, tender
Chiari malformation, or low cerebrospinal fluid (CSF)
nodules or red streaking of the skin overlying the
volume.
temporal arteries, and tenderness of the temporal or,
less commonly, the occipital arteries.
• Erythrocyte sedimentation rate (ESR) is often, although
not always, elevated.
A normal ESR does not exclude giant cell arteritis.
• A temporal artery biopsy followed by immediate
treatment with prednisone 80 mg daily for the first
4–6 weeks should be initiated when clinical suspicion
is high.

E. GLAUCOMA
• May present with a prostrating headache associated
with nausea and vomiting.
• Headache often starts with severe eye pain.
• On physical examination, the eye is often red with a
fixed, moderately dilated pupil.
D. TEMPORAL ARTERITIS III. PRIMARY HEADACHE DISORDERS

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• Headache and associated features occur in the • Secondary to overuse of ANALGESICS.
absence of any exogenous cause.
• The most common are migraine, tension-type Outpatient management
headache, and the TACs, notably cluster headache. • Analgesic use be reduced and eliminated.
Reduce the medication dose by 10% every 1–2
A. CHRONIC DAILY OR NEAR-DAILY HEADACHE weeks.
• Patient experiences headache on 15 days or more • Small dose of a nonsteroidal anti-inflammatory drug
per month. (NSAID) such as NAPROXEN 500 mg bid, if tolerated,
will help relieve residual pain as analgesic use is
IV. APPROACH TO THE PATIENT reduced.
A. CHRONIC DAILY HEADACHE • For some patients, discontinuing analgesics is very
difficult; often the best approach is to inform the patient
that some degree of pain is inevitable during this initial
period.

Inpatient management
• Some patients will require hospitalization for
detoxification.
• Antiemetics and fluids are administered as required.
• Clonidine is used for opioid withdrawal symptoms.
• For acute intolerable pain during the waking hours,
Aspirin, 1 g IV, is useful.
• IM CHLORPROMAZINE can be helpful at night;
patients must be adequately hydrated.
• 3-5 days into the admission, as the effect of the
withdrawn substance wears off, a course of IV
DIHYDROERGOTAMINE (DHE) can be used.
DHE, administered every 8 h for 5 consecutive
days, can induce a significant remission that allows
• For migraine or tension-type headache a preventive treatment to be established.
Tricyclics: AMITRIPTYLINE or NORTRIPTYLINE Serotonin 5-HT3 receptor antagonists, such as
at doses up to 1 mg/kg ondansetron or granisetron, or the neurokinin
─ Started in low doses (10–25 mg) daily and may receptor antagonist, aprepitant, may be required
be given 12 h before the expected time of with DHE to prevent significant nausea, and
awakening in order to avoid excess morning domperidone (not approved in the United States)
sleepiness orally or by suppository can be very helpful.
Avoiding sedating or otherwise side effect–prone
MANAGEMENT OF MEDICALLY INTRACTABLE antiemetics is helpful.
DISABLING PRIMARY CHRONIC DAILY HEADACHE
•…

MEDICATION-OVERUSE HEADACHE B. NEW DAILY PERSISTENT HEADACHE

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• Headache usually begins abruptly, but onset may be • Initial treatment for low CSF volume headache is
more gradual. bed rest.
Evolution over 3 days has been proposed as the For patients with persistent pain, IV caffeine (500
upper limit for this syndrome. mg in 500 mL of saline administered over 2 h) can
• Patients typically recall the exact day and be very effective.
circumstances of the onset of headache; the new, ─ An electrocardiogram (ECG) to screen for
persistent head pain does not remit. arrhythmia should be performed before
administration.

TAKE NOTE!
Why do ECG before IV caffeine administration?
• To rule out significant abnormal ECG findings prior.
• Caffeine has significant amplitude and wave
changes.

• Because IV caffeine is safe and can be curative, it


spares many patients the need for further
Secondary NDPH investigations.
• If unsuccessful, an abdominal binder may be helpful.
1. Low CSF Volume Headache
• If a leak can be identified, an autologous blood patch
• Head pain is positional.
is usually curative.
• Begins when the patient sits or stands upright and
A blood patch is also effective for post-LP
resolves upon reclining.
headache.
• Located at the occipitofrontal and is usually a dull
ache but may be throbbing.
• Recumbency usually improves the headache
within minutes, and it can take only minutes to an
hour for the pain to return when the patient resumes an
upright position.
• Most common cause of headache due to persistent
low CSF volume is CSF leak following LP.
Post-LP headache usually begins within 48 h but
may be delayed for up to 12 days.
• Beverages with caffeine may provide temporary
relief.
• Besides LP, index events may include epidural
injection or a vigorous Valsalva maneuver, such as
from lifting, straining, coughing, clearing the eustachian
tubes in an airplane, or multiple orgasms.
• When imaging is indicated to identify the source of a
presumed leak, an MRI with gadolinium is the initial
study of choice.
Spinal MRI with T2 weighting may reveal a leak,
and spinal MRI may demonstrate spinal
meningeal cysts whose role in these syndromes is
yet to be elucidated.
The source of CSF leakage may be identified by
spinal MRI with appropriate sequences, or by CT,
preferably digital subtraction, myelography.

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2. Raised CSF Pressure Headache 3. Posttraumatic Headache
• A traumatic event can trigger a headache process that
Idiopathic intracranial hypertension lasts for many months or years after the event.
(PSEUDOTUMOR CEREBRI) • Complaints of dizziness, vertigo, and impaired memory
• A disorder associated with obesity, female gender, and, can accompany the headache.
on occasion, pregnancy. • Symptoms may remit after several weeks or persist for
• Typically present with a history of generalized months and even years after the injury.
headache that is present on waking and improves • Typically, the neurologic examination is normal and CT
as the day goes on. or MRI studies are unrevealing.
• Generally present on awakening in the morning and is • Chronic subdural hematoma may on occasion mimic
worse with recumbency. this disorder.
• Transient visual obscurations are frequent and may • The underlying theme appears to be that a traumatic
occur when the headaches are most severe. event involving the pain-producing meninges can
• trigger a headache process that lasts for many years.

• Space-occupying lesion 4. Other Causes


• Pseudotumor cerebri
•…
• Persistently raised intracranial pressure can trigger
chronic migraine.
5. Treatment
These patients typically present with a history of
• Treatment is largely empirical and directed at the
generalized headache that is present on waking
headache phenotype.
and improves as the day goes on.
• Tricyclic antidepressants, notably amitriptyline, and
Generally worse with recumbency.
anticonvulsants, such as topiramate, valproate,
Visual obscurations are frequent.
candesartan, and gabapentin, have been used with
─ Diagnosis is relatively straightforward when
reported benefit.
papilledema is present, but the possibility must
• The monoamine oxidase inhibitor phenelzine may also
be considered even in patients without
be useful in carefully selected patients. The headache
funduscopic changes.
usually resolves within 3–5 years, but it can be quite
• It is most efficient to obtain an MRI, including an MR
disabling.
venogram, as the initial study.
• If there are no contraindications, the CSF pressure
should be measured by LP.
This should be done when the patient is
symptomatic so that both the pressure and the
response to removal of 20–30 mL of CSF can be
determined.
• Initial treatment is with ACETAZOLAMIDE (250–500
mg bid)
Headache may improve within weeks.
• If ineffective, TOPIRAMATE is the next treatment of
choice
• Severely disabled patients who do not respond to
medical treatment require intracranial pressure
monitoring and may require SHUNTING.

IV. PRIMARY CARE AND HEADACHE MANAGEMENT

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• The challenging task of the primary care physician is to
identify the very few worrisome secondary headaches
from the very great majority of primary and less
dangerous secondary headaches.
• After treatment has been initiated, follow-up care is
essential to identify whether progress has been made
against the headache complaint.
• Not all headaches will respond to treatment, but, in
general, worrisome headaches will progress and will
be easier to identify.
• When a primary care physician feels the diagnosis is a
primary headache disorder, it is worth noting that >90%
of patients who present to primary care with a
complaint of headache will have migraine.
• In general, patients who do not have a clear diagnosis,
have a primary headache disorder other than migraine
or tension-type headache, or are unresponsive to two
or more standard therapies for the considered
headache type, should be considered for referral to a
specialist.
• In a practical sense, the threshold for referral is also
determined by the experience of the primary care
physician in headache medicine and the availability of
secondary care options.

TAKE NOTE!

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