Family Medicine 18: 24-year-old female with headaches User: Ralph Marrero Email: email@example.com Date: March 9, 2022, 8:53 PM
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). Perform a reliable focused neurologic exam on a patient who presents with headache. Discuss the importance of continuity of care when treating a patient who presents with chronic headache. Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with headaches. Summarize the key features of a patient presenting with headache, capturing the information essential for differentiating between the common and “don’t miss” etiologies including tension, migraine, cluster, brain tumor, intracranial hemorrhage, medication use headaches. Propose a cost-effective diagnostic work-up for a patient presenting with headache. Describe the acute and prophylactic management of common headaches including migraine. Find and apply diagnostic criteria and surveillance strategies for substance use disorder.
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
Causes of Serious Secondary Headaches
Etiology of secondary headache
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
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
© 2022 Aquifer, Inc. – Ralph Marrero (firstname.lastname@example.org) – 2022-03-09 20:53 EST 1/9
Similar to tension-type headache: Bilateral, pressing, and/or tight 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
Chronic use of any analgesic can cause this type of headache in patients with pre-existing primary headache—it is an interaction between a therapeutic agent used excessively and a susceptible patient. Features
Mild to moderate in severity Diffuse, bilateral headaches that can 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 10 doses of triptans per month.
More than 15 headaches per month in a patient with pre-existing primary headache. Regular overuse of an analgesic taken for acute treatment of headache for more than three months. Not better accounted for by another diagnosis.
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 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 Prevalence 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.
© 2022 Aquifer, Inc. – Ralph Marrero (email@example.com) – 2022-03-09 20:53 EST 2/9
DSM-5 Substance Use Disorder
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.