The document discusses the evaluation of headache in adults, including obtaining a thorough history focusing on potential danger signs, performing a physical exam to check for danger signs, and classifying the three main types of primary headaches as migraine, tension, or cluster headaches. It also provides guidance on when imaging studies are indicated based on the history and physical exam findings.

1. Evaluation of Headache in Adults
Bita Fakhri, MD, MPH
Boston Medical Center
Shapiro Primary Care
Clinic
2/27/2013

2. Evaluation of Headache in Adults
 History
 Danger signs on history
 Physical exam
 Danger signs on physical exam
 Three main classes of primary headaches
 Indications for imaging studies

3. History
 Age at onset
 Presence or absence of aura and prodrome
 Frequency, intensity, and duration of attack
 Number of headache days per months
 Time and mode of onset
 Quality, site and radiation of pain
 Associated symptoms and abnormalities
 Family history of migraine
 Precipitating and relieving factors
 Effect of activity on pain

4. History
 Relationship with food and alcohol
 Response to any previous treatment
 Any recent change in vision
 Association with recent trauma
 Any recent changes in sleep, exercise, weight, or diet
 State of general health
 Change in work or life style (disability)
 Change in method of birth control
 Possible association with environmental factors
 Effects of menstrual cycle and exogenous hormones

5. Danger Signs on history
 Sudden onset of headache, or severe persistent
headache that reaches maximal intensity within a
few seconds or minutes (? SAH)
 The absence of similar headaches in the past – the
“first” or “worst” headache of my life (ICH, CNS
infection)
 A worsening pattern of headache (mass
lesion, subdural hematoma, medication overuse
headache)
 Focal neurologic symptoms other than typical visual
or sensory aura (mass lesion, AVM, collagen vascular
disease)

6. Danger Signs on history
 Fever (infection, SAH)
 Any change in mental status, personality, or
fluctuation in the level of consciousness
 The rapid onset of headache with strenuous exercise
(? Carotid artery dissection or ICH)
 Head pain that spreads into the lower neck and
between the shoulders may indicate meningeal
irritation (infection, SAH)
 New headache in patients <5 or >50

7. Danger Signs on history
 New headache type in a patient with cancer suggests
metastasis.
 New headache type in a patient with Lyme disease
suggests meningoencephalitis.
 New headache type in a patient with HIV suggests an
opportunistic infection or tumor.
 Headache during pregnancy or postpartum suggests
possible cortical vein or venous sinus
thrombosis, carotid dissection

8. Physical Exam
 Obtain BP and pulse
 Listen for bruits at neck, eyes, and head for clinical
signs of AVM
 Palpate the head, neck, and shoulder regions
 Check temporal and neck arteries
 Examine the spine and neck muscles
 Functional neurologic examination

9. Danger Signs on Examination
 Neck stiffness and especially meningismus
(resistance to neck flexion) suggests meningitis
 Papilledema (intracranial mass
lesion, pseudotumorcerebri, encephalitis, or
meningitis)
 Focal neurologic signs (intracranial
mass, AVM, collagen vascular disease)

10. Characteristics of Common Headache Syndromes
SYMPTOM MIGRAINE TENSION CLUSTER
HEADACHE HEADACH HEADACHE
E
LOCATION Unilateral in 60- Bilateral ALWAYS
70% -- bilateral or unilateral
glabal in 30%
CHARACTERISTICS Gradual in onset, Pressure or Pain begins
crescendo pattern; tightness that quickly, reaches a
pulsating; moderate waxes and crescendo within
or severe intensity; wanes minutes; pain is
aggravated by deep, continuous,
routine physical excruciating, and
activity explosive in
quality

11. Characteristics of Common Headache Syndromes
SYMPTOM MIGRAINE TENSION CLUSTER
HEADACHE HEADACHE HEADACHE
Patient Patient prefers to rest Patient may Patient remains
appearance in a dark, quiet room remain active or active
may need to
rest
Duration 4-72 hours Variable 0.5-3 hours
Associated Nausea, vomiting, None Ipsilaterallacrimati
symptoms photophobia, on and redness of
phonophobia; may the eye, stuffy
have aura (usually nose; rhinorrhea;
visual, but can pallor; sweating;
invlove other senses Horner’s
or cause speech or syndrome; focal
motor deficits) neurologic
symptoms rare;
sensitivity to
alcohol

12. Treatment of Migraine Headaches
• Abortive therapy:
ASA, tylenol, caffeine, high dose NSAIDs, triptans
• Prophylaxis:
TCA, BB, CCB, Valproic acid, topiramate

13. Criteria for Transformed Migraine and Medication-Overuse Headache.
Dodick DW. N Engl J Med 2006;354:158-165.

14. Preventive Medications Used in Cases of Transformed Migraine or Medication-Overuse
Headache.
Dodick DW. N Engl J Med 2006;354:158-165.

16. Treatment of Cluster Headaches
 Acute treatment: O2, triptans
 Chronic prophylaxis: CCB

17. Indications for Imaging Studies
 Recent significant change in pattern, ferequency, or
severity of headache
 Progressive worsening of headache despite
appropriate therapy
 Focal neurologic signs and symptoms
 Onset of headache with exertion, cough, or sexual
activity
 Orbital bruit
 Onset of headache after age 40

18. CT vs. MRI
 There is no evidence that MRI > CT
 CT-brain and brainstem with and without contrast is
sufficient in most patients.
 MRI along with MRA are indicated when posterior
fossa or vascular lesions are suspected.

19. The Pain of Cluster Headache
 http://www.youtube.com/watch?v=glBmSQRxaIg