Headache Syndrome Karen Alvarez, D.O Nemours Children s Specialty Care Jacksonville, FL
What is a headache? A headache or cephalgia is defined as pain anywhere in the region of head or neck
Where does the pain associated with a Headache come from? - The brain tissue itself is not sensitive to pain as it lacks pain receptors - The pain is sensed by the pain sensitive structures around the brain
- There are 9 areas of the head and neck with pain sensitive structures: the cranium, muscles, nerves, arteries, veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes
What are some of the causes of headaches? Fatigue Sleep deprivation Stress Effects of medications Infections (colds) Head injury Dental/sinus problems Tumors And many, many more
What types of headaches are there? There are more than 200 different types of headaches. To keep things simple, first, headaches are classified as either primary or secondary
Primary: 90% Benign Recurrent Not caused by any underlying disease or structural problem Most common types: migraines and tension headaches Secondary: 10% - Caused by underlying disease: - An infection - Head injury - Vascular disorders - Brain bleed or tumors
Common types of primary headaches: - Migraine: pulsing head pain, photophobia, nausea. - Tension type: non-pulsing band like pressure on both sides of the head, not accompanied by other symptoms - Cluster: short episodes (15-180 min) of severe pain, usually around one eye, with autonomic symptoms (tearing, red eye, nasal congestion). Occur at the same time every day.
Serious causes of secondary headaches - Meningitis: Inflammation of the tissues that cover the brain and the spinal cord. - Has associated fever + neck stiffness, irritability
- Brain bleeds: very sudden headache - Brain tumors: dull headache, worse with exertion and change in position, accompanied by nausea and vomiting, papilledema on exam. Typically the headache has been present for months and tend to wake them up from sleep at night.
Pseudotumor cerebri: Is a condition where pressure around the tissues of the brain and spinal cord is high in absence of a tumor. Headache with: - Grey outs of vision associated with changes in position - Neck pain - Shoulder pain - Double vision - Patient recently on steroids, on contraception pills, on acutane, on tretracycline. - If post pubertal: overweight have increased risk
Hydrocephalus: Known as abnormal fluid accumulation in the ventricles of the brain. Patient with headache, irritability, crossed eyes, uncontrolled eye movements, vomiting, difficulty feeding, excessive sleepiness, and changes in personality
How do you work up a headache patient in an eye clinic? 1. Get a thorough history - Ask about onset and location of headache - Ask about things that make it better or worse - Ask if they currently have a headache (if yes, asses pain level) - Ask about the quality of the pain (sharp, dull, constant or intermittent) - Ask about visual symptoms (aura, lights, color vision changes or changes in quality of vision) - Ask about neurological disorders
- Ask about recent imaging ( CT or MRI) - Make sure to ask about similar episodes in the past - Ask about family hx of headaches - Ask about changes in behavior/ personality - Ask about weakness - Ask about new onset difficulty in speaking - Ask about regression of milestones - Ask if headache wakes patient from sleep and is accompanied by vomiting **Use what you now know about the different types of headaches to formulate questions
2. Check vision with correction and near and distance 3. Check pupils for reactivity and APD 4. Check color vision 5. Check visual fields to confrontation 6. Check motility 7. Check near point of convergence 8. IOP check 9. Anterior segment exam 10. Fundus exam 11. Visual field test ( Humphrey or Goldmann) 12. OCT of the optic nerve (optional, if there is papilledema)
When to do imaging? - Most old chronic headaches do not require imaging, except when they have neurological symptoms, such as weakness. - Also, if the patient has the classical symptoms of a migraine, then imaging is not necessary.
Imaging of patients with the following red flags is Recommended: - Significant vision loss - New onset seizures - New onset of weakness - New onset of confusion - Worse headache of their life - New onset nystagmus - Extraocular muscle palsy or paresis - Papilledema - Headache with suspected meningitis - Headache in immunocompromised people (HIV, cancer)
Lumbar punture: Recommended for patients with suspected meningitis or optic nerve swelling
Treatment: - Migraines: lifestyle changes, medication (beta blockers, NSAIDS, acetaminophen, antidepressants, anticonvulsants) - Tension-type: NSAIDS, acetaminophen. For chronic tension headaches= amitriptyline - Cluster: Sumatriptan, high flow oxygen, prednisone, lithium, verapamil, ergotamine - For secondary headaches: treat the underlying condition.
References: 1. Brown, M. The classification and treatment of headache. Medical Clinics of North America 35(5) 1485-93 2. Goadsby PJ, Raskin NH. Harrison s Principles of Internal Medicine, CH 14 Headache 18e, New York, NY:McGraw-Hill; 2012 3. Brodsky, M. Pediatric Neuro-Ophthalmology, 2e, Springer; 2010