Headaches

Anne Mounsey M.D.

Dept. of Family Medicine
Univ. of Virginia School of Medicine

Objectives
Learn how to distinguish life threatening
headaches from benign headaches.
Learn management of migraine and chronic
tension headache.

Causes of headaches.
1. Traction or dilatation of intracranial or extracranial

arteries.
2. Traction of large extracranial veins
3. Compression, traction or inflammation of cranial
and spinal nerves
4. Spasm and trauma to cranial and cervical muscles.
5. Meningeal irritation and raised intracranial pressure
6. Disturbance of intracerebral serotonergic projections

Pathophysiology of pain
management in migraine
Cortical spreading depression activates the
trigeminal and parasympathetic systems
which causes vasodilatation and release of
neuropeptides that cause inflammation.
Serotonin 5 HT receptors modulate the
release of neurogenic peptides.

Acute onset headache

Sufficient evidence from retrospective and
prospective studies to support the
association of an acute sudden onset
headache with a vascular event.
Sudden onset headache is a red flag
Critical issues in the evaluation and management of patients
presenting to the emergency department with acute headache: Annals
of Emerg Med 2002 (1):39.

Life Threatening causes of acute headaches.

Intracranial
hemorrhage
Subdural hemorrhage
Subarachnoid
hemorrhage.

Meningitis
Hypertensive
encephalopathy.

Subarachnoid hemorrhage:causes
80% of non traumatic hemorrhages from
ruptured saccular aneurysms.
Other causes: AV malformations,
neoplasms, blood dyscrasias.
Commonest ages 40-60 yrs.

Subarachnoid hemorrhage:risk
factors.
Estimated that 5% of population have a berry
aneurysm.
HTN
Smoking and alcohol
Sympathomimetic drugs
Polycystic kidney disease
Coarctation of the aorta
Marfans syndrome

Subarachnoid hemorrhage:useful signs

and symptoms

Sudden onset of worst headache of life.

Worse on exertion eg valsalva, exercise.
75% of patients have nausea and vomiting.
50% of patients have meningism.
25% of patients have neck stiffness.

Linn F et al: Prospective study of sentinel headache in aneurysmal

subarachnoid hemorrhage, Lancet 344:590, 1994.
Locksley HB: Report on the cooperative study of intracranial aneurysms and
subarachnoid hemorrhage, J Neurosurg 25:219, 1966.

Risk factors for SDH

Age, alcohol, anticoagulation or antiplatelet treatment.
May be minimal trauma such as coughing
The signs and symptoms of brain
compression may not appear until up to 2
weeks after the trauma..

Subdural hemorrhage
Dull, mild generalized head pain.
Symptoms of chronic SDH may be subtle.
Up to 50% have altered level of
consciousness
Headache is worse at night and same side as
hematoma
On exam patient may have unilateral
weakness and increased reflexes.

Hypertensive Encephalopathy
Associated with high blood pressure,
nausea, vomiting and blurred vision
Usually associated with blood pressures of
200/130.
Headache diffuse and worse in the morning
and subsides during the day.

Meningitis:useful signs and

symptoms.
The absence of fever, neck stiffness and altered
mental status in a patient with a headache virtually
eliminates the diagnosis of meningitis.
In multiple studies the presence of neck stiffness
on examination has a pooled sensitivity of 70%.
Does this adult patient have meningitis? Attia et al. JAMA
1999;281(2):175-181

Signs of Meningism.
In a prospective study of young adult
patients Kernigs sign had a sensitivity of
9% and a specificity of 100%.
Brudzinskis sign has not been evaluated
since the original report .
Uchihara T, Tsukagoshi H. Headache 1991;31:167-171.

Can response to therapy aid

diagnosis?
No meta-analyses or RCTS to support or refute using
response to therapy as an indicator of underlying
pathology.
Case reports exist of patients whose headaches have
significantly improved with analgesia and then
subsequently died from an intracranial hemorrhage.
Bottom line: Level C recommendation that response
to therapy should not be used as the sole diagnostic
indicator of the etiology of the headache.

Acute H/A: Factors in history associated

with abnormality on neuroimaging.

Headache waking patient up.

Headache worsening with valsalva
Subjective sensory disturbance.
Rapidly increasing headache.
However the absence of these does not rule
out positive findings on neuroimaging.
Annals of Emergency Medicine: Vol 39:1:Jan 2002.

Clinical Policy of the ACEP for management of

patients presenting with acute onset headache.
Level B recommendations:
Patients with headache and abnormal neuro exam
should undergo an emergent non contrast CT.
Patients presenting with an acute sudden onset
headache should be considered for an emergent
CT scan.
HIV patients with a new headache should have
urgent neuroimaging

Clinical Policy of ACEP cont.

Level C recommendation:
Patients over 50 with a new headache
should be considered for urgent
neuroimaging.
Emergent means done immediately
Urgent means scan appointment is arranged
prior to discharge and included in disposition.
Annals of Emergency Medicine: Vol 39:1:Jan 2002.

Migraine: IHS criteria

5 attacks of
Headache lasting 4-72 hours.
Must be associated with nausea or vomiting or
photophobia and phonophobia
Must have 2 of the following
1.
2.
3.
4.

Unilateral
Pulsating
Moderately severe.
Aggravated by physical activity

Sinus H/A vs. Migraine

Summit study.
Prospective multi center observational study of
2,991 patient with self diagnosed or physician
diagnosed sinus headache. Using the IHS migraine
criteria 80% of them had migraine.
Schreiber CP, et al. Archives of Internal Medicine. In publication

Phases of migraine
Premonition: eg hunger, energy surges,
irritability.
Prodrome: aura.
Headache phase
Postdrome.

Migraine Treatment
Drug

Level of
Evidence

Tylenol
NSAIDS
Triptans
Fiorinal
Midrin
Opiates
DHE
Steroids

B
A
A
A
B
A
B
C

Triptans
Meta-analysis of 53 studies showed all the oral
triptans are effective and well tolerated.
Rizatriptan 10mg, eletriptan 80mg amd almotriptan
12.5 mg were the most effective.
40-80% two hour headache response.
Give as early as possible in migraine attack.
Nasal spray or S/C injection may be more effective.
Oral triptans in acute migraine:a meta-analysis of 53 trials. Ferrari MD. Lancet. 358
(9294):1668-75. 2001 Nov 17.

Percentage of patients with two hour headache response

for each treatment ((bars are 95% confidence interval of
the percentage)

NNT for headache response at 2 hours

Consider prevention when:

US Headache consortium guidelines.
Interferes with patients daily routine.
>2/week
Acute medications ineffective or
contraindicated.
Presence of uncommon migraine conditions
Hemiplegic migraine
Basilar migraine
Migraine with prolonged aura.

Migraine Prevention
Drug
Valproate
Amitriptyline
Propranolol
Prozac
Riboflavin
Gabapentin
ACE
Aspirin
Clonidine
Verapamil

Evidence
A
A
A
B
B
B
B
B
B
B

Episodic Tension Type Headache.

IHS Criteria
Tension type headaches < 15 per month.
Lasts 30 mins to 7 days
No nausea or vomiting
No photophobia and phonophobia (1 ok)
Headache has at least 2 of the following criteria:
a.
b.
c.
d.

pressing/tightening
Bilateral
Mild-moderate
Not aggravated by physical activity.

Causes of TTH
Some evidence that like migraine caused by
serotonin imbalance but to a lesser extent
than migraine.
This would indicate that similar treatments
would work.

Treatment of TTH
Simple analgesia:ibuprofen is more
effective than acetaminophen.
Combine analgesics with a sedating anithistamine eg diphenhydramine.
Limit treatment to 2 days a week to prevent
rebound headaches.

Chronic Daily Headache

Affects 4-5% of the population.
Definiton: head pain for at least 4 hours for more
than 15 days/month.
Often develops from an episodic headache
disorder either migraine or episodic tension type
headache
Includes chronic tension type headache(CTTH)
and chronic daily migraine

Chronic Tension Type Headache.

Develops from episodic tension type
headaches
The most common form of CDH.
Familial tendency.
Medication rebound headache may be a
factor in the transformation of episodic
headache to CDH.

Chronic Tension Type Headache

Affect women more than men

Most common in middle age
Stress is often a trigger
Average duration is 4-13 hours.

Treatment of CTTH.
Treating each headache increases the
frequency and severity of the headaches.
Reserve medications for worse than usual
headache.
Expert opinion: treat 2 headaches a week.

Prevention of CTTH

Tricyclic antidepressants.
Stress management
Tizanidine
SSRIs:prozac
Anticonvulsants:gabapentin and topiramate.
Acupuncture

Rebound Headaches. IHS

criteria.

Headache for 15 days/month with at least one of

the following characteristics and 2,3 and 4.
a.
b.
c.

Bilateral
Pressing/tight non pulsating quality
Mild/moderate intensity

Simple analgesic use >15 days a month for 3

months
Headache has increased during analgesic use
Headache resolves or reverts to previous pattern
within 2 months after discontinuation of analgesia .

Rebound headaches
Most significant factor in their development
is the lack of awareness by physicians and
patients. Prevention better than cure
Triptans, all analgesics and ergotamines
have been associated with medication
rebound headaches.

Rebound headaches
If patient is unable to tolerate abrupt
cessation of medication may need to titrate
down over 2 weeks.
May need inpatient treatment to
successfully withdraw
Various regimes including tizanidine, daily
triptans, steroids and parenteral DHE have
been used.