Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Headache

Headache is one of the most commonly encountered problems in the clinical medicine. As many as 10-25% of the population will suffer from migraines. Acute and chronic headaches are very common symptoms that may result from a variety of causes, but initially classified as primary (example: migraine, tension, etc) or secondary (example: brain tumor, stroke, trauma, etc).

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Prerequisites

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Describe and discuss:

  • basic neuroanatomy of the pain pathways of the head
  • pathogenesis and pathophysiology of diseases and conditions that lead to or contribute to headaches
  • epidemiology of primary and secondary headaches
  • pharmacology of drugs used to headaches

Demonstrate:

  • ability to take a medical history and perform a physical exam to establish:
    • temporal pattern (onset, duration, aura, prodrome, postdrome, severity, frequency, character of pain)
    • associated symptoms (such as photo- phono, osmo-phobia, nausea, vomiting)
    • sleep pattern and quality (snoring, daytime sleepiness, dozing)
    • triggers, aggravating/alleviating factors
    • stress levels
    • limitation of activities due the headache/migraine
  • ability to take a screening neurological examination
  • ability to identify a secondary headache, particularly one with “malignant” etiology
  • basic communication skills

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Apply Medical Knowledge in the Clinical Encounter

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1.     Describe the clinical features that help to differentiate one etiology from another:

  • secondary
    • malignant
    • non-malignant
  • benign or primary

 

2.     Describe the signs and symptoms that suggest malignant etiology.

Red Flags for Malignant Headaches:

  • new headache
  • “the worst headache”
  • abrupt onset
  • change in the pattern
  • fever
  • stiff neck
  • precipitated by Valsalva (coughing, laughing or sneezing)
  • onset after age 50 years
  • weight loss
  • neurological focal signs
  • decreased mental status
  • papilledema
  • crescendo pattern(s)
  • headache that awakens the patient from sleep
  • after head or neck injury
  • jaw claudication
  • associated with severe hypertension
  • associated with numb chin or cheek
  • history of cancer
  • history of immunosuppression
  • poor response to therapy
  • increased on orthostatic challenge
  • always unilateral
  • scalp tenderness
  • monocular visual loss

3.     Some important headache patterns to keep in mind are:

  • increased ICP: positional, aggravated by Valsalva
  • decreased ICP: aggravated by gravitational challenge, (can be of) spontaneous onset
  • intracranial tumor: progressive, focal neurological signs
  • pseudotumor cerebri: obscurations, fat/female/fertile/forty
  • venous thrombosis: child-bearing age, dehydration, trauma, L-asparaginase
  • meningitis (infectious or non-infectious): meningeal signs, fever
  • chronic daily headache: think of caffeine use; rebound headache: NSAIDS, triptans, opiates; sleep apnea: snoring (patient may not know), daytime sleepiness, symptoms present even when “sleeping in”
  • recurrent headache: think of migraine, cluster, paroxysmal hemicrania
  • think about etiologies you may not think of first: glaucoma, dental disease, bruxism, sleep apnea

4.     Describe risk factors associated with headache.

5.     Describe how lab studies would help in the evaluation of headache, including their indications, limitations, and cost.

6.     Describe how imaging studies would help in the evaluation of headache, including their indications, limitations, and cost.

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Diagnose

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1.     Obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease.

2.     Perform a physical exam, including a screening neurological exam, and a targeted neurological exam (localizing focalizations), to establish the diagnosis and severity of disease.

3.     Generate a differential diagnosis recognizing specific history and physical exam findings that distinguish causes of headache (infectious, oncologic, medications, vascular, ENT, facial, dental, GI, musculoskeletal, and emotional as well as neurological conditions).

4.     Recommend when to order imaging and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Justify test ordering and interpret the results (with consultation). Consider test cost and performance characteristics as well as patient preferences.

5.     Define the indications for and interpret (with consultation) the significance of the results of appropriate clinical tests.

6.     Perform relevant basic clinical diagnostic procedures.

7.     Perform a mental status exam.

8.     Record, present, research, critique, discuss, reflect, and manage clinical information.

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Develop a Management Plan

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1.     Describe and discuss indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with headache.

2.     Describe and discuss the indications, benefits and disadvantages of the medications.

3.     Describe and compare the cost-effectiveness of various agents within each class of medications:

  • abortive: NSAIDS, triptans, DHE, IV magnesium, IV valproic acid
  • prophylactic: amitriptyline, beta-blockers, topiramate, verapamil,

4.     Discuss the non-pharmacologic approaches and potential life-style changes with the instructor and with the patients.

5.     Select an approach to treatment for the patient with headache based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences.

6.     Formulate a prognosis for the patient with headache based on the diagnosis, the treatment plan, and the patient’s characteristics.

7.     Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of a diagnosis related to headache and its potential effect on lifestyle (work performance, sexual functioning, etc.)

8.     Provide education for the patient with primary headache about his or her goals and treatment plan.

  • Provide reassurance, identify and avoid triggers, encourage good diet and sleep hygiene, encourage smoking cessation, encourage stress management, exercise.
  • Treat headache/migraine as early as possible.
  • Avoid opiates/opioids.
  • Minimize use of abortive therapy.
  • Be cost conscious.
  • When using prophylactic medications: begin low and go slow, gradually increase the dose every 2-4 weeks (up to one of 3 goals: control of headache/migraine, intolerable/unwanted side-effects, or maximal recommended dose).

9.     Provide counseling to patients when indicated about the following issues related to prevention.

10.  Refer for psychological support if indicated.

11.  Access and utilize appropriate information systems to ascertain information about health system and community resources.

12.  Plan for follow-up.

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Differential Diagnosis

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  • infectious - meningitis, encephaitis
  • oncologic - brain tumor
  • medications - rebound headache
  • vascular - stroke, vasculitis, temporal arteritis
  • ENT, facial, dental, GI, musculoskeletal, and emotional as well as neurological conditions – migraine, cluster
  • Sleep disorders - sleep apnea, bruxism
  • Other - tension headache, low CSF pressure