Differential Diagnosis of Headaches

Transcription

1 Angela Nelson, MSN, RN, CCRN, ACNP-BC, FCCM, FAANP Acute Care Nurse Practitioner Department of Neurosurgery AANP 2016 National Conference San Antonio, Texas June Differential Diagnosis of Headaches Presentation Title Goes Here 2 Learning Objectives 1. The participant will be able to identify the presenting symptoms and treatments for the three types of primary headaches 2. The participant will be able to identify the possible causes of secondary headaches 3. The participant will be able to identify the diagnostic criteria for the use of lumbar puncture, CT, MRI and EEG in evaluating headaches. Diagnostic Overview of Primary Headaches Migraine Headache Pattern of recurrent episodes of severe disabling headaches Usually associated with nausea/vomiting Frequently associated with sensitivity to light Normal Neurological Examination Tension Headache Non disabling bilateral headache Normal Neurological Examination Cluster Headache Frequent, brief, unilateral headache Autonomic features Normal Neurological Examination Secondary Headaches 3 4 Secondary Headaches Detailed History Clinical Presentation worst headache of my life Subacute or progressive, worsening over time New or different headache Any headache of maximum severity at onset Headache of new onset after the age of 50 Headache that develops after trauma Persistent headache that develops after valsalva i.e., cough, sneeze, bend or exertion Fever, HTN, Myalgia, Weight Loss, Scalp Tenderness Neurologic symptoms Meningismus Confusion Altered LOC Change or Impairment in Memory Papilledema Causes Cerebral Venous Thrombosis Chiari Malformation CNS Vasculitis Epidural Hematoma Giant Cell Arteritis Intracerebral Hemorrhage Ischemic Stroke Metabolic Causes Subarachnoid Hemorrhage Subdural Hematoma TIA Exposure to Toxins (carbon monoxide) Tumor Glaucoma Hydrocephalus Idiopathic Intracranial HTN Infectious Causes i.e.. Meningitis, encephalitis, abscess Functional disabilities at work, school or housework within past 3 months Any s/s of secondary headache Precipitating factors that aggravate or alleviate the headaches History of other medical problems Current illness Pharmacologic and Nonpharmacologic Treatments that are effective or ineffective Aura Headache Characteristics Time from onset to peak Usual time of onset (i.e. season, month, day menstrual cycle) Frequency and duration Nature of Headache (i.e.. Pulsatile, throbbing, pressing, sharp) Location (ie.unilateral, bilateral, changing sides Severity

2 Physical Examination Focused Physical Examination Vitals Signs including BP, Pulse, Respirations, and Temperature Evaluate Extracranial Structures i.e.. Carotid Arteries, Sinuses, Scalp Arteries, Cervical Paraspinal Muscles Neck Flexion Skin color checking for rash Neurological Examination Level of consciousness, presence of confusion, memory impairments Ophthalmologic exam looking a pupillary symmetry, reactivity, VF, ocular motility, and optic fundi CN Examination including corneal reflexes, facial sensation and symmetry Motor and Sensory Function Symmetric Muscle Tone Strength DTR Sensation Plantar Response Gait, Arm and Leg Coordination Tension Type Headaches More prevalent in females > males Family history is common Age on onset No aura Site of pain is bilateral, occipital or frontal Character of pain is aching, tight or squeezing Severity is mild to moderate Onset to peak is hours Duration can be hours to days Frequency is variable up to several per month Sometimes accompanied with nausea Nocturnal attacks are rare Provoked by stress and exhaustion 7 8 Cluster Headache Prevalence is rare More prevalent in males > females Uncommon to have a family history Age on onset Rare to have associated Aura Site of pain is Unilateral, Frontotemporal or Periorbital Character of pain is boring Severity of pain is severe Duration of pain is typically minutes Frequency is typically many per day Periodic attacks are typical i.e.. same time daily Nocturnal attacks of pain are typical Pacing behavior is common Provoked by alcohol or sleep Often associated with ipsilateral nasal congestion, rhinorrhea, conjunctival injection, ptosis, or lacrimation Diagnostic Criteria of Cluster Headache According to the International Headache Society Frequency of attacks from 1 every other day to 8 per day May be associated with pericranial tenderness on palpation Headaches not attributable to another disorder Further subdivided into: Episodic Cluster Headache Chronic Cluster Headache At least 5 attacks of Severe, Unilateral Orbital, Supraorbital, or Temporal Pain lasting minutes with one or more of the following Conjunctival Injection Eyelid Edema Miosis Nasal Congestion Forehead and Facial Sweating Ptosis Rhinorrhea Lacrimation 9 10 Episodic Cluster Headache Occurring in periods lasting 7 days to one year Separated by pain free periods of 1 month or longer Cluster Headache Chronic Cluster Headache Occurring for > 1 year without remission or with remissions of less than 1 month Tension Headache According to the International Headache Society Increased Pericranial Tenderness on manual palpation is the most significant finding At least 10 episodes of the following: Headaches lasting from 30 minutes to 7 days At least 2 of the following: Pressing/tightening pain Mild to moderate intensity Bilateral Location No aggravation by walking, stairs or similar physical activity Both of the following: No nausea or vomiting Photophobia and Phonophobia are absent Not attributed to another disorder

3 Migraine Headaches According to the International Headache Society 3 Types 1. Migraine without Aura 2. Migraine with Aura 3. Chronic Migraine Occurs in 18% of women Occurs in 6% of men Occurs as a result of a complex interaction between the nervous system and the vascular system as well as alterations in chemical activity Neurological pathways become stimulated such as the sympathetic nervous system Increased sympathetic activity causes many of the s/s I.e. nausea, vomiting, diarrhea, decreased circulation with pallor Migraine can be divided into 5 phases Most experience 2 or more Vary between individuals and attacks Phases can merge with each other Clinical Presentation 1. Prodromal Symptoms 2. Aura 3. Headache 4. Accompanying Phenomena 5. Postdrome Prodomal Can occur hrs to several days before headache Occurs in 50 80% May lead to aura or headache without aura Symptoms tend to be consistent for each patient Photophobia Phonohobia Stiff Neck Depression, Anger Euphoria, Hyperactivity Food Cravings Impaired Concentration Sluggishness, Fatigue Anorexia Chilled Feeling Urinary Frequency Fluid Retention Increased Thirst Aura Occurs in 20% migraines Focal visual, motor, sensory, cognitive and/or brainstem disturbances Variable relationship to headache Headache usually follows aura by 5 20 minutes Visual symptoms Bright image with zigzag quality, brief flashes of light, distortions in shape and size Motor Hemiparesis Monoparesis Sensory Parasthesias Reduced sensations Language Dysphagia Dyslexia Brainstem Diplopia Ataxia, Vertigo Cognition Difficulty with abstract reasoning Transient global amnesia Headache 42% of attacks of aura without headaches Not an essential feature of a migrainous attack Typically throbbing and often steady Usually unilateral Usually gradual over minutes to hours Most often occurs on waking in am Lasts 4 72 hrs Pain is reduced with complete inactivity May be worsened with head down position Usually abates with sleep May occur more frequently with periods of stress Accompanying Phenomena Not always present Anorexia, intolerance of food Vomiting Cold, clammy skin Goose bumps Hypertension Hypotension and bradycardia Frequent yawning Nasal congestion Epistaxis Dizziness Temperature dysregulation Photophobia Phonophobia Intolerance of being touched

4 Postdrome Often characterized by tiredness and listlessness Irritability or difficulty concentrating Scalp Tenderness Aching or weak muscles Food Cravings Anorexia Limited food tolerance Euphoria Depression Typical Characteristics: Unilateral location Pulsating quality Moderate or severe intensity Aggravated by routine physical activity Associated with nausea +/or photophobia and phonophobia Most common subtype Usually more disabling Migraine without Aura Criteria for Dx: At least 5 attacks with the following: Headaches lasting 4 72 hrs Headaches with at least 2 of the following criteria: Unilateral location Pulsating quality Moderate or severe intensity Aggravated by routine physical activity During attack 1 of the following: Nausea/and or vomiting Phonophobia + photophobia No attributable to another disorder Migraine with Aura Chronic Migraine Aura symptoms are usually but not always followed by headaches Aura usually develops over 5 20 minutes and last <60 minutes Criteria for Diagnosis: At least 5 attacks with following: Fully reversible visual, sensory or speech symptoms, with no motor weakness At least 2 of the following: Homonymous visual symptoms including flickering of lights, spots, lines, loss of vision and unilateral pins and needles or numbness At least 1 symptoms develops over 5 minutes and/or different symptoms occur in succession Each symptoms last 5 60 minutes Not attributable to another cause Headache >15 days per month for at least 3 months At least 5 attacks fulfilling criteria of a Migraine without Aura On >8 days per month for the last 3 months pain and symptoms have been relieved or treatment with Triptans or Ergot has prevented the following symptoms: AT LEAST 2 OF THE FOLLOWING: Unilateral Location Pulsating Quality Moderate or Severe Pain Intensity Aggravated by routine physical activity AT LEAST 1 OF THE FOLLOWING: Nausea and Vomiting Photophobia and Phonophobia No medication overuse Not attributable to another cause Precipitating Factors Precipitating Factors Many migraines have no obvious triggers Single trigger may provoke the onset it is usually a combination of factors Exposure to a known precipitating factor increases the probability of an attack within 48 hours Environmental Temperature exposure Change in altitude, climate Bright or flickering lights Loud noise Motion Strong Odors Physical Strain Lifestyle Habits Chronic high stress levels Disturbed sleep patterns Obesity Skipping meals and/or poor diet Smoking Hormonal Menopause Menstruation or Ovulation Oral Contraception Use Puberty Pregnancy Menopause Estrogen Replacement in Post Menopausal Emotional Anxiety Anger Depression Excitement or Exhilaration Let down response

5 Dietary Considered a trigger when the migraine occurs within 6 hrs or intake, effect is reasonably reproducible and withdrawal leads to improvement Aged cheeses Alcoholic beverages Caffeine containing beverages Chocolate Citrus Fruit Food Additives (i.e. sulfites, nitrites, artificial sweeteners, monosodium glutamate) Ice cream Precipitating Factors Medicinal Caffeine and caffeine withdrawal Hormone Therapy Nifedipine Nitroglycerine Oral Contraception Miscellaneous Localized cranial disturbances Head or neck injuries General metabolic or infectious conditions Most primary headaches can be diagnosed with diagnostic testing Diagnosis typically involves a comprehensive history, neurologic examination and focused physical examination Diagnostic testing is often necessary to distinguish primary from secondary causes when the presenting s/s are similar Blood Work Lumbar Puncture ESR/CRP R/O Temporal Arteritis in >50 with new onset migraine ESR/Rheumatoid Arthritis Factor/ANA R/O Collagen Vascular Disease (Lupus) in those with headaches and arthralgia CBC/HIV/Lyme Antibody Test R/O Infectious causes TSH Hypothyroidism CBC including plt R/O Anemia, TTP BUN/Creatinine Renal Failure Endocrine Studies R/O Pituitary Tumor Urine Drug Screen R/O Drug Use MRI/CT always performed before a lumbar puncture Exception is when acute meningitis is suspected Platelet count >50,000 CSF opening pressure should always be measured when evaluating headaches Diagnostic Indications Meningitis Encephalitis Meningeal Carcinomatosis Lymphomatosis Subarachnoid Hemorrhage High and Low CSF pressure Lumbar Puncture Indications First or worst headache Headache with fevers Headaches with symptoms suggesting other infectious causes Subacute or progressive headaches in pts with hx HIV+ or carcinoma Atypical chronic headache R/O Psuedotumor Cerebri EEG According to the Quality Standards Subcommittee of the American Academy of Neurology (ANN) The electroencephalogram (EEG) is not useful in the routine evaluation of patients with a headache The only indication would be the presence of a headache with associated symptoms suggesting a seizure, i.e. atypical aura or LOC Not indicated to exclude a structural cause for headaches

6 Imaging Studies Neuroimaging Recommendations for Nonacute Headaches Patient with unexplained abnormal findings on neurologic examination Patient with atypical headache features or the headache does not fulfill the strict definition of primary headache Neuroimaging is not typically indicated in those with a normal neurological examination and the presence of migraines There are no evidenced based recommendations for MRI vs. CT in the evaluation of Migraine or other nonacute headache Treatment Options Pain Relieving Medication NSAIDS Acetaminophen Combination Drugs I.e. Acetaminophen, ASA, Caffeine Triptans Sumatriptan (Imitrex) Rizatriptan (Maxalt) Almotriptan (Axert) Naratriptan (Amerge) Zolmitriptan (Zomig) Frovatriptan (Frova) Eletriptan (Relpax) Ergot Ergotamine and caffeine combo drugs Migergot Cafergot Dihydroergotamine (DHE) IM/SC/IM/Nasal Antiemetics Metoclopramide Prochlorperazine Opiates Codeine Dexamethasone Beta Blockers Propranolol Calcium Channel Blockers Verapamil Zestril Tricyclic Antidepressants Amitriptyline Nortriptyline Protriptyline Treatment Options Preventive Medication Anticonvulsants Valproate Topiramate Gabapentin Lamotrigine Botox The goals of preventive therapy are to: 1. Reduce attack frequency, severity, and duration 2. Improve responsiveness to treatment of an acute attack 3. Improve function and reduce disability Muscle Relaxation meditation Yoga Adequate Sleep Rest and Relaxation Hypnosis TENS Therapeutic Touch Treatment Options Non Pharmacologic Acupuncture Biofeedback Massage Chiropractic Treatment Herbs, Vitamins and Minerals Vitamin B2 Feverfew Butterbur Magnesium Coenzyme Q Treatment Options for Acute Migraine Attacks Determine the Level of Disability using one of the following 1. Migraine Disability Assessment (MIDAS) 2. Headache Impact Test (HIT 6) Mild Pt is aware of headache but able to continue with daily activities NSAIDS ASA Acetaminophen Triptans Combo Triptans + NSAIDS Treatment Options for Acute Migraine Attacks Moderate Inhibits daily activities but not incapacitating NSAIDS Ergot Dihydroergotamine (DHE) Triptans Severe Inability to continue daily activities Dihydroergotamine (DHE) Ketorolac (IM/IV) Magnesium Triptans Consider antiemetics Consider combination of agents

7 Subarachnoid Hemmorhage Primary causes include Aneurysm, AVM and head trauma Worst headache of my life 30% survive without major disability Outcome is associated with neurological status at time of Presentation % die before getting medical attention 38 Secondary Headaches Giant Cell Arteritis Inflammatory disease of blood vessels usually affecting large and medium arteries of head and neck Form of Vasculitis Also called temporal vasculitis Considered medical emergency due to potential to cause blindness or stroke S/S: Headache, fever, scalp sensitivity, tongue/jaw claudication, decreased visual acuity, visual loss MRI/CT typically negative Gold standard Diagnostic: Biopsy Case Study 67 year old male with a new headache Present for the last 3 weeks reported as mild to moderate in severity Worse on right No n/v or light/sound sensitivity Aching in jaw and tongue during meals over last week Treated with steroids Underwent brain biopsy Treated with no residual defecits Presentation Title Goes Here Secondary Headaches Chiari Malformation Chiari Malformation Structural defect of cerebellum Parts of cerebellum is located below the forman magnum Normally, cerebellum rests in a space in rear of skull Primary Caused by structural defects occurring during fetal development Secondary When there is excessive drainage of CSF, ie trauma S/S: Neck pain, headaches made worse by straining, balance difficulty, Dizziness, numbness in arms and legs Type I Extension of tonsils in forman magnum Type II Both cerebellum and brain tissue extend into forman magnum Type III Brain tissue and cerebellum extend into and through forman magnum into spinal cord Type IV Underdeveloped Cerebellum year old male with 5 year history of frequent headaches PMH: Anxiety Asthma Meds: Relpax, Albuterol Dx: Hydrocephalus/Chiari Malformation Type I S/S initially improved with change in diet/advil App 1 year ago started to become anxious/overwhelmed after starting college Headaches were increasing in frequency and severity Described as throbbing, visual spots No longer responsive to Advil Exam: Normal MRI: Increasing Hydrocephalus Sx: Posterior Fossa Decompression

8 Common Usually caused by viruses Typically treated if s/s >10 days s/s: Thick, discolored or bloody nasal discharge, fever, cough, headache If headache primary symptom then less likely to be sinus headache Sinus Headaches 45 year old female with PMH of recurrent sinus headaches Headache over forehead and checks Clear nasal discharge and nasal congestion Stomach upset Occuring 8 9 times per year and did miss work Underwent accupunture, chiropractic Tx and repair of Deviated Septum x2 Headaches still present Diagnosed with Migraine without Aura with good response to typical therapy Crawford, CC, Huynh, MT et al. Systematic Assessment of the Quality of Research Studies of Conventional and Alternative Treatments of Primary Headache. Pain Physician 2009; 12: Evans, RW. for Migraine and Other Primary Headaches. Neurology Clinics 2009, 27, Silberstein, S. Practice parameter: Evidenced-based guidelines for migraine headache: Report of the Quality Standards Subcommittee for the American College of Neurology. Neurology 2000;55; Presentation Title Goes Here