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Classification: 1) primary headache a) migraine headache b) tension headache c) trigeminal autonomic cephalgia - cluster headache, paroxysmal hemicrania, SUNCT syndrome d) primary stabbing, cough, exertion, & sexual headaches e) external pressure headache f) thunderclap headache g) hemicrania continua h) hypnic headache i) nummular headache j) new daily persistent headache 2) secondary headache a) headache associated with head trauma or neck trauma b) headache associated with vascular disorders c) headache associated with non-vascular intracranial disorder d) headache associated with toxins, drugs or withdrawal e) headache associated with infection f) headache associated with disorder of homeostasis g) headache or facial pain associated with extracranial head & neck structures h) headache associated with psychiatric disorder i) cranial neuralgias: - trigeminal neuralgia - facial neuralgias - occipital neuralgia (may be unilateral base of skull to vertex) 3) unclassified headache International Headache Society Etiology: 1) primary headache (> 90% of headaches) a) migraine headache b) tension headache c) trigeminal autonomic cephalgia - cluster headache, paroxysmal hemicrania, SUNCT syndrome d) primary stabbing headache, cough headache, exertional headache, & sexual headaches e) external pressure headache f) thunderclap headache g) hemicrania continua h) hypnic headache i) nummular headache j) new daily persistent headache - also see chronic daily headache 2) secondary headache a) head trauma or neck trauma - postconcussion syndrome, subdural hematoma - whiplash injury b) vascular disorders - stroke, subarachnoid hemorrhage, arterial dissection - vascular malformation, cerebral aneurysm - arteritis, intracranial or extracranial, temporal arteritis - venous thrombosis, dural sinus thrombosis, cavernous sinus thrombosis c) non-vascular intracranial disorders - intracranial hypertension, intracranial hypotension - brain neoplasm or other CNS mass lesion, arachnoid cyst - non-infectious inflammatory disorder, sarcoidosis - Chiari malformation d) toxins, drugs or withdrawal - nitrates, alcohol, caffeine - carbon monoxide - heavy metals: lead, cadmium? - mushrooms - monosodium glutamate (MSG) - ergotamine (withdrawal) - hydralazine - indomethacin - numerous others (see pharmaceutical agents associated with headache) - analgesic rebound headache e) infections - meningitis, encephalitis, cerebral abscess - extracranial infections - opportunistic infections - cryptococcal meningitis - progressive multifocal leukoencephalopathy (PML) - generalized sepsis f) disorder of homeostasis - hypercapnia, hypoxia, dialysis, - hypertensive crisis, malignant hypertension - endocrinopathy: hypothyroidism, pheochromocytoma - hyponatremia, uremia, hyperglycemia/hypoglycemia g) headache or facial pain associated with extracranial head & neck structures - sinusitis - eye pain: acute angle closure glaucoma - cutaneous allodynia h) psychiatric disorders - depression, anxiety disorder i) cranial neuralgias - trigeminal neuralgia - facial neuralgias - occipital neuralgia (may be unilateral base of skull to vertex) j) environmental factors - video display terminal (eyestrain) - cold exposure (brain freeze) - altitude (acute mountain sickness) k) lumbar puncture l) psychosocial stress - purely psychogenic headaches are rare m) anorexia n) acute exertional headaches - coughing - sneezing - straining - running - orgasm o) obstructive sleep apnea (morning headaches) 3) also see etiology of headache not apparent on noncontrast CT Epidemiology: 1) 93% of the population reports headache within the last 12 months 2) 42,000,000 patient visits/year occur with headache as a chief complaint 3) in children, occurs most frequently at age 13; 10% of children have recurring headaches [4] 4) migraine is the most common headache in clinical practice [3] History: 1) pulsating? 2) without medications, duration 4-72 hours? 3) unilateral? 4) nausea? 5) disturbance of daily activities? POUNDING (Pulsatile, One day, Unilateral, Nausea, Disturbing) - 3/5 positive responses suggests migraine Physical examination: - sensorimotor testing - reflex testing - cranial nerve assessment - assessment of eye movements - cognitive assessment - funduscopy - visual field examination [3] Clinical manifestations: - duration - trigeminal autonomic cephalgia of short duration (< 3 hours) - any headache lasting > 72 hours, consider status migrainosus - tension headache may last up to 7 days (not associated with nausea) - migraine generally lasts 4-72 hours, episodic - migraine: nausea, disabling, often unilateral, photophobia - trigeminal autonomic cephalgia: unilateral WARNING signs in patients with headaches 1) headache during exertion or straining a) berry aneurysm b) increased intracranial pressure 2) headache with fever a) meningitis b) encephalitis 3) headache with nuchal rigidity a) meningitis b) encephalitis 4) headache with drowsiness & confusion - increased intracranial pressure - meningitis - encephalitis - metabolic 5) headache with abnormal physical exam (pupil size, facial asymmetry, extraocular muscle abnormalities, abnormal funduscopic exam, abnormal reflexes) - subdural hematoma 6) headache in a patient who looks ill New WARNING signs [3,19] 1) first or worst headache [3] 2) abrupt-onset or thunderclap headache 3) progression or change in headache pattern 4) neurologic symptoms lasting > 1 hour 5) new headache in a patient < 5 years or > 50 years 6) new headache in pregnant women, cancer patients or immunocompromised patients 7) anticoagulation [3] 8) recurrent headaches with pain during sleep or with morning emesis [19] 9) recurrent headaches with focal neurologic findings [19] 10) headache triggered by position, exertion, sexual activity, or Valsalva maneuver [3] 11) headache with loss of consciousness or altered state of consciousness [3] Laboratory: - erythrocyte sedimentation rate & serum C-reactive protein for suspected temporal arteritis Special laboratory: - lumbar puncture for suspected meningitis - EEG of no benefit [3] Radiology: - routine imaging in patients without WARNING signs* not indicated [3,14] - newly diagnosed migraine - tension headache with a normal neurologic exam - chronic stable headache with no neurologic deficit [20] - neuroimaging if warning signs - MRI neuroimaging is preferred modality [3,12] - new headache with: - optic disc edema - subacute head trauma - exertional headache - neurologic deficit - cancer - immunocompromised patient - pregnancy - suspected trigeminal autonomic origin (cluster headache) - age > 50 years [20] - chronic headache with new features or progression [20] - reserve head CT for emergency situations - thunderclap headache [20] * see Clinical manifestations Complications: - chronic headache &/or migraine associated with risk of suicide (hazzard ratio = 1.5-1.6) [9] Management: 1) lifestyle measures: regular meals, regular sleep, hydration, regular exercise [22] 2) NSAIDs generally more effective than tricyclic antidepressants for tension headache - tricyclic antidepressants more useful than SSRI in patients with migraine or tension headaches [10] 3) for chronic daily headache with characteristics of both tension headache & migraine, gabapentin (up to 2400 mg QD) may be useful [5] 4) acupuncture may be of benefit for chronic headache [6] 5) mirtazapine may be useful chronic tension headaches in patients without depression [7] 6) do not use bultalbital-containing analgesics (Fioricet) or opiates as 1st line therapy for recurrent headache [3,12] 7) opiates* may be useful for chronic headaches [7] 8) limit OTC analgesic use to 2 days/week [12] * structured, monitored program

Related

etiology of headache not apparent on noncontrast CT pharmaceutical agents associated with headache

Specific

chronic daily headache cold-stimulus headache (brain freeze) cough headache drug-induced headache; medication overuse headache migraine headache nummular headache; coin-shaped cephalgia occipital neuralgia orthostatic headache post-traumatic headache postural headache primary stabbing headache; ice-pick headache sleep apnea headache tension headache (stress headache) thunderclap headache trigeminal autonomic cephalgia

General

pain [odyn-]

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1028-31
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Journal Watch 21(13):104, 2001 Fearon P & Hotopf H Relation between headache in childhood and physical and psychiatric symptoms in adulthood: national birth cohort study. BMJ 322:1145, 2001 PMID: 11348907
  5. Journal Watch 24(3):23, 2004 Spira PJ et al Gabapentin in the prophylaxis of chronic daily headache: a randomized, placebo-controlled study. Neurology 61:1753, 2003 PMID: 14694042 - Silberstein SD, Neurology 61:1637, 2003
  6. Journal Watch 24(11):91, 2004 Vickers AJ, Rees RW, Zollman CE, McCarney R, Smith CM, Ellis N, Fisher P, Van Haselen R. Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial. BMJ. 2004 Mar 27;328(7442):744. Epub 2004 Mar 15. PMID: 15023828 http://bmj.bmjjournals.com/cgi/content/full/328/7442/744
  7. Journal Watch 24(14):116, 2004 Bendtsen L, Jensen R. Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache. Neurology. 2004 May 25;62(10):1706-11. PMID: 15159466 - Saper JR, Lake AE 3rd, Hamel RL, Lutz TE, Branca B, Sims DB, Kroll MM. Daily scheduled opioids for intractable head pain: long-term observations of a treatment program. Neurology. 2004 May 25;62(10):1687-94. PMID: 15159463
  8. Bigal ME, Ashina S, Burstein R, Reed ML, Buse D, Serrano D, Lipton RB; AMPP Group. Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology. 2008 Apr 22;70(17):1525-33. PMID: 18427069
  9. Veterans Administration Memorandum Dec 24, 2009 Recent VHA Findings regarding chronic pain conditions and suicide risk
  10. Jackson JL et al. Tricyclic antidepressants and headaches: Systematic review and meta-analysis. BMJ 2010 Oct 20; 341:c5222 PMID: 20961988 http://www.bmj.com/content/341/bmj.c5222/T5.expansion
  11. De Luca GC, Bartleson JD. When and how to investigate the patient with headache. Semin Neurol. 2010 Apr;30(2):131-44 PMID: 20352583
  12. Choosing Wisely: American Headache Society Five Things Physicians and Patients Should Question http://www.choosingwisely.org/doctor-patient-lists/american-headache-society/
  13. Torelli P, Allais G, Manzoni GC. Clinical review of headache in pregnancy. Neurol Sci. 2010 Jun;31 Suppl 1:S55-8. PMID: 20464584
  14. Callaghan BC et al. Headaches and neuroimaging: High utilization and costs despite guidelines. JAMA Intern Med 2014 Mar 17 PMID: 24638246
  15. Martin VT The diagnostic evaluation of secondary headache disorders. Headache. 2011 Feb;51(2):346-52. PMID: 21284622 - Dodick DW Pearls: headache. Semin Neurol. 2010 Feb;30(1):74-81 PMID: 20127586
  16. Loder E, Weizenbaum E, Frishberg B et al Choosing wisely in headache medicine: the American Headache Society's list of five things physicians and patients should question. Headache. 2013 Nov-Dec;53(10):1651-9 PMID: 24266337
  17. Nagy AJ, Gandhi S, Bhola R, Goadsby PJ. Intravenous dihydroergotamine for inpatient management of refractory primary headaches. Neurology. 2011 Nov 15;77(20):1827-32. PMID: 22049203
  18. Nye BL, Ward TN. Clinic and Emergency Room Evaluation and Testing of Headache. Headache. 2015 Oct;55(9):1301-8. Review. PMID: 26422648
  19. NEJM Knowledge+ Question of the Week, April 2, 2019 https://knowledgeplus.nejm.org/question-of-week/4824/ - Lewis DW, Ashwal S, Dahl G et al. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002 Aug 27; 59:490-498 PMID: 12196640
  20. Whitehead MT et al. for the Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria headache. J Am Coll Radiol 2019 Nov; 16:S364. PMID: 31685104 https://www.jacr.org/article/S1546-1440(19)30620-9/fulltext
  21. Robbin MS Diagnosis and Management of Headache. A Review JAMA. 2021;325(18):1874-1885. May 11. PMID: 33974014 https://jamanetwork.com/journals/jama/fullarticle/2779823
  22. NEJM Knowledge+ - No authors listed Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition Cephalalgia. 2018 Jan;38(1):1-211. PMID: 29368949
  23. Sico JJ, Antonovich NM, Ballard-Hernandez J et al 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Management of Headache. Ann Intern Med. 2024 Oct 29. PMID: 39467289
  24. National Institute of Neurological Disorders and Stroke (NINDS) NINDS Headache Information Page https://www.ninds.nih.gov/Disorders/All-Disorders/Headache-Information-Page