Headache
Cheryl A. Glass and Barbara I. Bailes
Definition
A.Headache is a discomfort of the head that is produced from inflammation and/or tightness of the arteries, nerves, and/or muscles of the cranium. Headaches are a major cause for missed school and work, loss of productivity at work (presenteeism), and disability in adults.
B.There are multiple types of headaches with many sub-categories defined by the International Classification of Headache Disorders (ICHD). Refer to the ICHD-3 website at www.ichd-3.org for a full review of the description of each headache criteria and sub category definitions:
1.Primary headaches include migraines, tension-type headaches (TTH), trigeminal autonomic cephalalgias (TACs), and other primary headache disorders. Other primary headache disorders encompass those induced by coughing, exercise, sexual activity, cold stimulus, and external pressure as well as primary stabbing headache, thunderclap headache, nummular headache, hypnic headache, and new daily persistent headache (NDPH).
2.Secondary headaches include those attributed to trauma or injury to the head and/or neck, cranial or cervical vascular disorder, nonvascular intracranial disorder, at substance withdrawal, infection, disorder of homeostasis, or psychiatric disorder, as well as headache or facial pain attributed to disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure.
3.Painful cranial neuropathies, other facial pains and other headaches, and other headache disorders.
Incidence
Headaches are very common, and their incidence depends on age, gender, and type of headache. Headaches may be self-limiting or refractory to aggressive treatment programs.
A.TTHs, the most common primary headaches, affect 31% to 74% of the population.
B.The prevalence of cluster headaches is less than 1% of the population, with men affected more than women.
C.Chronic daily headaches are more common in females than in males.
D.Medication overuse headaches (MOHs) are reported in 20% to 36% of adolescents with daily headaches.
Pathogenesis
A.Because there are different types of headaches, the origin of each type differs. Many people have a combination of the different types of headaches. Headache causes range from systemic illness, such as infections to medical disorders, tumors or hemorrhage, medications, drug use, and/or stress. Tension headaches occur because of contracted muscles of the scalp and neck. Cluster headaches have an uncertain etiology; however, they appear to be caused by extracerebral vasodilation.
B.Review environmental/seasonal factors. Headaches may be cyclic in the spring and summer months with allergic rhinitis and in the fall and winter with carbon monoxide poisoning from gas heaters.
C.Medications are associated with headaches; examples include the following:
1.Nitroglycerine.
2.Nifedipine.
3.Dipyridamole.
4.Selective serotonin reuptake inhibitor (SSRIs).
Predisposing Factors
A.Tension, stress.
B.Cervical, or back, disorders.
C.Medications (e.g., nitroglycerine).
D.Bruxism.
E.Sleep disorders (e.g., sleep apnea, snoring, insomnia).
F.Foods/caffeine/alcohol.
G.Hormonal changes.
H.Family history of headaches.
I.Sexual activity.
J.Cough.
K.Exertion/exercise.
L.Viral/infectious etiologies.
M.Poor-fitting dentures.
N.Faulty/inefficient gas heating.
O.Trigeminal neuralgia (TN).
P.Valsalva maneuvers.
Q.Head trauma.
Common Complaints
A.Pain and location depend on the type of headache.
B.Characteristics of the headache depend on the type of headache.
C.Depending on the type of headache, other symptoms may coexist, such as lacrimation, nasal congestion, restlessness, and visual changes.
Subjective Data
A.Use the acronym PQRST for subjective information:
P: Provocation, or worsening of factors stimulating headaches.
Q: Quality of pain, severity of pain.
R: Region of headache.
S: Strength of pain, evaluate pain on scale of 0 to 10.
T: Time, including onset, frequency, and duration of headaches.
B.Assess whether the patient has migraine headaches frequently. Is this the first or worst headache ever experienced by the patient?
C.If recurrent headaches exist, note frequency and patterns of similar headaches.
D.Note whether the patient has ever identified potential triggers of recurring headaches such as dietary, stressors, and odors (i.e., perfumes, cigarette smoke).
E.Identify the location of pain, along with radiation if present.
F.Describe the type of pain: Throbbing, constant, or burning.
G.Assess the presence of associated symptoms: Nausea or vomiting, photophobia, noise sensitivity, or the presence of halos around lights.
H.Determine whether the patient experiences any neurologic symptoms and/or prodromal symptoms prior to a headache.
I.Review the methods used in the past to abort and/or prevent headaches and the results.
J.Inquire about past diagnostic evaluations for headaches.
K.Note a family history of headaches.
L.List current medications, including over-the-counter (OTC) medications and herbals.
M.Review the patient’s medical history for head trauma, allergies, presence of a ventriculoperitoneal (VP) shunt, or other neurologic diagnoses.
N.Is the patient in the second or third trimester of pregnancy?
O.Does the patient present with a fever or have a recent history of infection?
P.Rule out gas exposure.
Physical Examination
Physical exam may be normal unless patient presents with a headache:
A.Check blood pressure (BP) pulse, and respirations (temperature if meningeal signs are present).
B.Inspect:
1.Observe overall appearance for the presence of discomfort, photosensitivity (use of sunglasses indoors), and level of consciousness (LOC).
2.Examine the eyes; perform funduscopic exam.
3.Inspect the ears, nose, and throat.
C.Auscultate:
1.Listen for bruit at neck, eyes, and head for clinical signs of arteriovenous malformation (AVM).
D.Palpate:
1.Palpate the head, eyes, ears, temporomandibular joint (TMJ) syndrome, sinus cavities, temporal and neck arteries.
2.Palpate cervical vertebrae, cervical muscles, and shoulder regions. Identify potential trigger areas: Occipital nerves leave halfway between the middle of the neck at the back of the neck and lateral to this area. When palpating this trigger area, pain may be reproduced with palpation.
3.Examine the spine and neck muscles.
4.Assess cervical range of motion (ROM).
E.Perform neurologic exam.
1.Extraocular movements (EOMs)
2.Pupil response.
3.Getting up from a seated position without any support.
4.Walking on tiptoes and heels.
5.Tandem gait.
6.Romberg test.
7.Symmetry on motor, sensory, deep tendon reflexes (DTRs), and coordination tests.
8.Perform neck flexion for nuchal rigidity.
Diagnostic Tests
Tests are selected based on history and physical exam:
A.Sinus films to rule out sinusitis or a lesion.
B.Sleep studies for obstructive sleep apnea.
C.CT scan or MRI: Needed if headache is severe, no results are achieved with drug therapy, and/or aura is present.
D.People with any positive neurologic signs of an intracranial process should have neuroimaging.
E.Lab tests are rarely needed for headaches, unless an infectious process is suspected.
Differential Diagnoses
A.Headache:
1.Tension.
2.Cluster.
3.MOH.
4.Migraine.
5.Combination headache.
6.NDPH.
7.Hypnic headache (occurs only in the elderly).
B.Sinusitis.
C.Meningitis: Meningism, acute headache with fever, lethargy, nausea or vomiting, irritability, photophobia, and systemic infection.
D.Space-occupying lesion: Subacute and progressive pain, new onset for adults older than 40 years.
E.Temporal arteritis: New-onset progressive headache for adults older than 50 years, with presenting symptoms of temporal artery swelling, pain, pulselessness, visual changes, mental sluggishness, systemic symptoms (fever, anorexia, malaise), and erythrocyte sedimentation rate (ESR) greater than 50 mm/hr.
F.Carotid dissection: Sudden headache with neck pain, radiating to the face, ear, or eye; onset related to neck movement or trauma, Horner’s syndrome, tinnitus, ipsilateral tongue weakness, cervical bruit or tenderness, diplopia, and syncope.
G.TMJ syndrome: Jaw claudication, clicking, and locking sensation, ill-fitting dentures.
H.Carbon monoxide poisoning.
I.Temporal arteritis.
J.Trigeminal neural.
K.Pregnancy-induced hypertension (PIH).
L.Medication-induced headache: Review side effects of current medications (individual and/or combination of drugs).
Plan
A.General interventions:
1.Encourage the patient to restrict associated triggers, such as food, alcohol, and exposure to odors.
2.Encourage the patient to exercise daily.
3.Have the patient begin a stress management routine, including yoga, meditation, and massage.
4.Tell the patient to take medications as prescribed.
5.Cluster headaches can be exacerbated by alcohol.
6.Use ice/heat for muscular tension.
7.Individual and/or family psychotherapy should be considered.
8.Complementary and alternative medicine (CAM):
a.Nutraceutical options:
i.Magnesium 400 to 600 mg/d.
ii.Riboflavin 400 mg/d.
iii.Coenzyme Q10.
iv.Alpha lipoic acid.
b.Herbal preparations:
i.Feverfew 50 to 82 mg/d.
ii.Petasites hybridus (Butterbur).
iii.Cannabis (Marijuana).
c.Acupuncture.
d.Oxygen/hyperbaric oxygen therapy.
e.Transcutaneous electrical nerve stimulation (TENS) unit.
f.Chiropractic manipulation.
g.Physical therapy.
h.Continuous positive airway pressure (CPAP).
i.Biofeedback.
j.Relaxation training.
B.Patient teaching:
1.Encourage the patient to keep a diary of headaches and associated factors to try to pinpoint headache triggers.
2.Teach patients who have menstrual headaches to avoid precipitating factors, such as alcohol, tyramine, or phenylethylamine foods; missed meals; and sleeping late.
3.Discuss sleep hygiene guidelines (see section Sleep Disorders
of Chapter 25).
4.For muscular headaches that are nonmenstrual, biofeedback, breathing exercises, and visualization are helpful. Prevention must be stressed. Encourage lifestyle changes and daily exercise.
5.When patients overuse various analgesics for headaches, paroxysmal migraines can convert into chronic daily headaches. Caution patients regarding this effect.
6.MOHs occur with the highest incidence involving opioids, butalbital-containing combinations, and acetylsalicylic acid (aspirin)/acetaminophen/caffeine combinations, as well as triptans. Withdrawal of the overused medication is the treatment of choice for MOHs.