HEADAC
HE CHAPTER 21,
HARRISON’S
INTERNAL
MEDICINE
GENERAL PRINCIPLES
•
International Headache Society (www.ihs-headache.org/)
•
characterizes headache as primary or secondary (Table 21-1)
Primary headaches – headache and its associated features are
the disorder in itself
- often results in considerable disability
and a decrease in the patient’s quality of
life
Secondary headaches - caused by exogenous disorders
(Headache
Classification Committee of the
International Headache Society, 2013)
GENERAL PRINCIPLES
Primary Headache Secondary Headache
Type % Type %
Tension-type 69 Systemic infection 63
Migraine 16 Head injury 4
Idiopathic stabbing 2 Vascular disorders 1
Exertional 1 Subarachnoid hemorrhage <1
Cluster 0.1 Brain tumor 0.1
Source: After J Olesen et al: The Headaches. Philadelphia, Lippincott Williams & Wilkins, 2005
ANATOMY AND
PHYSIOLOGY
• PAIN- Stimulation of peripheral nociceptors
- pain-producing pathways of the
peripheral or central nervous
system (CNS) are damaged or
activated
inappropriately
• pain-producing cranial structures: scalp, middle
meningeal artery, dural sinuses, falx cerebri, and
proximal segments of the large pial arteries
• Not pain-producing: ventricular ependyma,
choroid plexus, pial veins, & much of the brain
parenchyma
ANATOMY AND
PHYSIOLOGY
•
The key structures involved in primary headache appear to be the
following:
•
•
The large intracranial vessels and dura mater and the
peripheral
•
terminals of the trigeminal nerve that innervate these
structures (trigeminovascular system)
•
The caudal portion of the trigeminal nucleus, which extends
into
the dorsal horns of the upper cervical spinal cord and receives
input from the first and second cervical nerve roots (the
trigeminocervical complex)
•
•
Rostral pain-processing regions, such as the
ventroposteromedial
thalamus and the cortex
•
•
The pain-modulatory systems in the brain that modulate input
from trigeminal nociceptors at all levels of the pain-
CLINICAL EVALUATION OF ACUTE,
NEW-ONSET HEADACHE
Sudden-onset headache Known systemic illness
Worst” headache ever Onset after age 55
“Vomiting that precedes headache Fever or unexplained systemic signs
Sub acute worsening over days or Abnormal neurologic examination
weeks
Pain induced by bending, lifting, Pain associated with local
cough tenderness, e.g., region of
temporal artery
Pain that disturbs sleep or presents
immediately upon awakening
CLINICAL EVALUATION OF
ACUTE, NEW-ONSET HEADACHE
•
A careful neurologic examination
•
Computed tomography (CT) or magnetic resonance
imaging (MRI) study
•
Lumbar puncture (LP) unless a benign etiology can be
otherwise established
•
Cranial arteries by palpation; cervical spine by the
effect of passive movement of the head
•
Investigation of cardiovascular and renal status by blood
pressure monitoring and urine examination; and eyes by
funduscopy, intraocular pressure, measurement, and
refraction.
•
Evaluation of psychological state of the patient
•
History of otologic or endodontic surgical procedures
SECONDARY HEADACHE
• management focuses on diagnosis and treatment of the underlying condition.
MENINGITIS
• Acute, severe headache with stiff neck and fever
• LP is mandatory
• accentuation of pain with eye movement
• cardinal symptoms of pounding headache, photophobia, nausea, and vomiting are frequently present
INTRACRANIAL HEMORRHAGE
• Subarachnoid Hemorrhage - acute, severe headache with stiff neck but without fever
• Ruptured Aneurysm, AVF or intraparenchymal hemorrhage may also present with headache alone
• Head CT scan can be normal- if the hemorrhage is small or below the foramen magnum (LP is
required)
BRAIN TUMOR
• Headache: 30% of patients with brain tumors as chief complaint
•
: usually nondescript—an intermittent deep, dull aching of moderate intensity, which
may
worsen with exertion or change in position and may be associated with nausea and
vomiting
: disturbs sleep in about 10% of patients
• Vomiting that precedes the appearance of headache by weeks: posterior fossa brain tumors
• History of amenorrhea or galactorrhea: a prolactin-secreting pituitary adenoma (or the polycystic
ovary syndrome) may be source of the headache
• Headache arising de novo in a patient with known malignancy: cerebral metastases or carcinomatous
meningitis, or both
SECONDARY HEADACHE
TEMPORAL ARTERITIS
• An inflammatory disorder of arteries that frequently involves the extracranial carotid circulation
• common disorder of the elderly, annual incidence is 77 per 100,000 individuals age 50 and older
• average age of onset is 70 years, and women account for 65% of cases.
• About half of patients with untreated temporal arteritis develop blindness
• Ischemic optic neuropathy induced by giant cell arteritis is the major cause of rapidly developing bilateral
blindness in patients >60 years
• Treatment with glucocorticoids is effective
• Typical presenting symptoms : headache, polymyalgia rheumatica, jaw claudication, fever, and weight loss
Headache : dominant symptom and often appears in association with malaise and muscle aches
: unilateral or bilateral
: usually appears gradually over a few hours before peak intensity is reached; occasionally, it is
explosive in onset
: dull and boring, with superimposed episodic stabbing pains
: Scalp tenderness is present
: brushing the hair or resting the head on a pillow may be impossible because of pain
: usually worse at night and often aggravated by exposure to cold
• Additional findings: reddened, tender nodules or red streaking of the skin overlying the temporal arteries, and
tenderness of the temporal or, less commonly, the occipital arteries.
• The erythrocyte sedimentation rate (ESR) is often elevated; a normal ESR does not exclude giant cell arteritis.
• A temporal artery biopsy followed by immediate treatment with prednisone 80 mg daily for the first 4–6 weeks
should be initiated when clinical suspicion is high
•
GLAUCOMA
• prostrating headache associated with nausea and vomiting
• headache often starts with severe eye pain
• P.E.: eye is often red with a fixed, moderately dilated pupil
PRIMARY HEADACHE
DISORDERS
• disorders in which headache and
associated features occur in the absence
of any exogenous cause
• most common: migraine, tension-type
headache, and the trigeminal autonomic
cephalalgias (cluster headache)
CHRONIC DAILY HEADACHE
• Headache for 15 days or more per
month.
• not a single entity, it encompasses a
number of different headache
syndromes, both primary and secondary
• considerable disability
• Population-based estimates suggest that
about 4% of adults have daily or near-
daily headache.
CHRONIC DAILY HEADACHE
Primary Secondary
>4 h Daily <4 h Daily
Chronic migraine (a) Chronic cluster Posttraumatic
Headache (b) Head injury
Iatrogenic
Postinfectious
Chronic tension-type Chronic paroxysmal Inflammatory, such as
Headache (a) hemicrania Giant cell arteritis
Sarcoidosis
Beh.et’s syndrome
Hemicrania continua (a) SUNCT/SUNA Chronic CNS infection
New daily persistent Hypnic headache Medication-overuse
Headache (a) headache (a)
MANAGEMENT OF MEDICALLY INTRACTABLE
DISABLING PRIMARY CHRONIC DAILY
HEADACHE
• Neuromodulatory approaches: occipital nerve
stimulation, which appears to modulate thalamic
processing in migraine, and has also shown
promise in chronic cluster headache, short-
lasting unilateral neuralgiform headache attacks
with cranial autonomic symptoms(SUNA), short-
lasting unilateral neuralgiform headache attacks
with conjunctival injection and tearing (SUNCT),
and hemicrania continua
• Single-pulse transcranial magnetic stimulation:
Europe, approved for migraine with aura in the
United States.
MEDICATION-OVERUSE
•
HEADACHE
Overuse of analgesic medication for
headache can aggravate headache
frequency, markedly impair the effect
of preventive medicines,
and induce a state of refractory daily or
near- daily headache
Management of Medication Overuse:
Outpatients
• Reduce the medication dose by 10% every 1–2
weeks
• Nonsteroidal anti-inflammatory drug (NSAID) :
•
• Naproxen, 500 mg bid, if tolerated, will help relieve
residual pain as analgesic use is reduced
• NSAID overuse is not usually a problem for patients with
daily headache when a NSAID with a longer half-life is
taken once or twice daily
• overuse problems may develop with more frequent
dosing schedules or shorter acting NSAIDS. Once the
• When a patient has substantially reduced
analgesic use, a preventive medication should be
introduced
Management of Medication Overuse:
Inpatients
• Detoxification
• Antiemetics and fluids are administered as required
• Clonidine is used for opioid withdrawal symptoms
• For acute intolerable pain during the waking hours: Aspirin, 1 g IV (not
approved in United States), is useful
• IM chlorpromazine can be helpful at night; patients must be adequately
hydrated.
• IV dihydroergotamine (DHE) : given 3- 5 days into the admission, as the
effect of the withdrawn substance wears off
•
: every 8 h for 5 consecutive days, can induce
a significant remission that allows a
preventive treatment to be established.
NEW DAILY PERSISTENT
HEADACHE (NDPH)
Primary Secondary
Migrainous-type Subarachnoid hemorrhage
Featureless (tension-type) Low cerebrospinal fluid (CSF) volume
headache
Raised CSF pressure headache
Posttraumatic headache
Chronic meningitis
Clinical Presentation (NDPH)
• presents with headache on most if not all
days
• patient can clearly, and often vividly,
recall the moment of onset
• Abrupt, but onset may be more gradual;
evolution over 3 days
• priority is to distinguish between a
primary and a secondary cause of the
syndrome
• Subarachnoid hemorrhage - most serious
Low CSF Volume Headache
• Head pain is positional: begins when the patient sits or stands upright and
resolves upon reclining.
• Occipitofrontal, dull ache but may be throbbing
• chronic low CSF volume headache : history of headache from one day to
the next that is generally not present on waking but worsens during the day
• Recumbency improves the headache
• The most common cause: CSF leak following LP
• Post-LP headache : 48 h but may be delayed for up to 12 days
: incidence is 10 – 30%
: Beverages with caffeine may provide temporary
relief.
• epidural injection or a vigorous Valsalva maneuver, such as from lifting,
straining, coughing, clearing the eustachian tubes in an airplane, or
multiple orgasms
• MRI with gadolinium is the initial study of choice
• TREATMENT : Bed rest
Raised CSF Pressure Headache
• Intracranial hypertension (pseudotumor cerebri) without visual problems
• present with history of generalized headache that is present on waking and improves
as the day goes on
• worsens with recumbency
• Visual obscurations are frequent
• papilledema is present, diagnosis is straightforward
• Formal visual field testing should be performed even in the absence of overt
ophthalmic involvement
• Obstructive sleep apnea or poorly controlled hypertension: Characteristic with
headache on rising in the morning or nocturnal headache
• Initial Study : MRI, MR venogram
• CSF pressure should be measured by LP if there are no contraindications,
• elevated opening pressure and improvement in headache following removal of CSF are
diagnostic.
• TREATMENT: acetazolamide (250–500 mg bid)
•
: topiramate is the next treatment of choice
Posttraumatic Headache
•
headache process that lasts for many months or years
after a traumatic event
•
injury to the head, an infectious episode, typically viral
meningitis, a flulike illness, or a parasitic infection
•
dizziness, vertigo, and impaired memory can
accompany the headache
•
neurologic examination is normal and CT or MRI
unremarkable
•
Also seen after Carotid dissection, SAH, and after
intracranial surgery
•
TREATMENT : empirical
: TCA (amitriptyline), anticonvulsants
(Topiramate, valproate, gabapentin)
