Approach to patient with Headache

Dr. Hemant M. Shah Assistant Professor, SMIMER

Headache is among the most common reasons patients seek medical attention.

Diagnosis and management is based on a careful clinical approach augmented by an understanding of the anatomy, physiology, and pharmacology of the nervous system pathways that mediate the various headache syndromes.

Old Ad-hoc Headache Classification

1. Migraine
Migraine variants, vascular headaches, atypical facial neuralgia

2. Tension headache (muscular contraction headache) 3. Headache associated with intracranial disturbances
Arteriosclerotic brain diseases, vascular anomalies, aneurysms, tumor,

infections

4. Headache associated with extracranial disturbances

Eye, ear, nose, bones of the skull and neck

5. Headache associated with cranial trauma 6. Hypertension, allergy, arteritis (temporal), fevers, infection 7. Psychogenic headaches
Conversion, tension headaches

International Classification of Headache Disorders 2nd edition

(ICHD-2)

ICHD-2 Classification

Part 1: Primary headache disorders Part 2: Secondary headache disorders Part 3: Cranial neuralgias, central and primary facial pain and other headaches

Common Causes of Headache

Primary headaches are those in which headache and its associated features are the disorder in itself. Secondary headaches are those caused by exogenous disorders.

Primary Headache Type %

Secondary Headache Type %

Tension-type
Migraine Idiopathic stabbing

69
16 2

Systemic infection
Head injury Vascular disorders

63
4 1

Exertional
Cluster

1
0.1

Subarachnoid hemorrhage
Brain tumor

<1
0.1

Anatomy and Physiology of Headache

Pain usually occurs when peripheral nociceptors are stimulated in response to tissue injury, visceral distension, or other factors . In such situations, pain perception is a normal physiologic response mediated by a healthy nervous system. Pain can also result when pain-producing pathways of the peripheral or central nervous system (CNS) are damaged or activated inappropriately. Headache may originate from either or both mechanisms. Relatively few cranial structures are pain-producing; these include the scalp, middle meningeal artery, dural sinuses, falx cerebri, and proximal segments of the large pial arteries. The ventricular ependyma, choroid plexus, pial veins, and much of the brain parenchyma are not pain-producing.

The key structures involved in primary headache appear to be

The large intracranial vessels and dura mater and the peripheral terminals of the trigeminal nerve that innervate these structures
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 ventroposteromedial thalamus and the cortex as the

The pain-modulatory systems in the brain that modulate input from trigeminal nociceptors at all levels of the pain-processing pathways

 The innervation of the large intracranial vessels and dura

mater by the trigeminal trigeminovascular system.

nerve

is

known

as

the

Cranial autonomic symptoms, such as lacrimation and nasal congestion, are prominent in the trigeminal autonomic cephalalgias, including cluster headache and paroxysmal hemicrania, and may also be seen in migraine. These autonomic symptoms reflect activation of cranial parasympathetic pathways, and functional imaging studies indicate that vascular changes in migraine and cluster headache, when present, are similarly driven by these cranial autonomic systems

Intensity of pain rarely has diagnostic value. Headaches are usually benign, but sometimes severe and disabling. Its very important to distinguise serious from benign illnesses.

Complete neurologic examination nessesory.

is also

Headache Symptoms that Suggest a Serious Underlying Disorder

"Worst" headache ever First severe headache Subacute worsening over days or weeks Abnormal neurologic examination Fever or unexplained systemic signs Vomiting that precedes headache

Pain induced by bending, lifting, cough

Pain that disturbs sleep or presents immediately upon awakening Known systemic illness Onset after age 55 Pain associated with local tenderness, e.g., region of temporal artery

PRIMARY HEADACHE
1.) Migraine 2.) Tension-type headache 3.) Cluster headache

Migraine Facts

Migraine is one of the common causes of recurrent headaches

According to IHS, migraine constitutes 16% of primary headaches Migraine afflicts 10-20% of the general population More than 2/3 of migraine sufferers have never consulted a doctor Migraine is underdiagnosed and undertreated Migraine greatly affects quality of life. The WHO ranks migraine among the worlds most disabling medical illnesses

Burden Of Migraine

World - 15-20% of women and 10-15% of men suffer from migraine In India, 15-20% of people suffer from migraine Adults Female: Male ratio is 2 : 1 In childhood migraine, boys and girls are affected equally until puberty, when the predominance shifts to girls.

NEJM 2002; 346(4): 257-269; XI Congress of the IHS, 2004

Migraine - Definition
Migraine is a familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting
-World Federation of Neurology

Migraine Triggers

Food Disturbed sleep pattern Hormonal changes Drugs Physical exertion

Visual stimuli
Auditory stimuli Olfactory stimuli

Weather changes
Hunger Psychological factors

Phases of Acute Migraine

Prodrome
Aura Headache Postdrome

PRODROME
Vague premonitory symptoms that begin from 12 to 36 hours before the aura and headache Symptoms include Yawning Excitation Depression Lethargy Craving or distaste for various foods Duration 15 to 20 min

AURA
Aura is a warning or signal before onset of headache Symptoms
Flashing of lights
Zig-zag lines Difficulty in focussing

Duration : 15-30 min

HEADACHE
Headache is generally unilateral and is associated with symptoms like:
Anorexia
Nausea Vomiting

Photophobia
Phonophobia Tinnitus

Duration is 4-72 hrs

POSTDROME (RESOLUTION PHASE)

Following headache, patient complains of
Fatigue Depression Severe exhaustion

Some patients feel unusually fresh

Duration: Few hours or up to 2 days

MIGRAINE CLASSIFICATION
According to Headache Classification Committee of the International Headache Society, Migraine has been
classified as:

Migraine without aura (common migraine) Migraine with aura (classic migraine) Complicated migraine

MIGRAINE: CLINICAL FEATURES

Migraine Without Aura
No aura or Prodrome Unilateral throbbing headache may be accompanied by nausea and vomiting During headache, patient complains of phonophobia and photophobia

Migraine With Aura

Aura or prodrome is present Unilateral throbbing headache and later becomes generalised Patient complains of visual disturbances and may have mood variations

MIGRAINE - PATHOPHYSIOLOGY
VASCULAR THEORY
Intracerebral

blood vessel vasoconstriction aura

Intracranial/Extracranial blood vessel vasodilation headache

SEROTONIN THEORY
Decreased serotonin

levels linked to migraine

Specific serotonin receptors found in blood vessels of brain

PRESENT UNDERSTANDING Neurovascular process, in which neural events result in activation of blood vessels, which in turn results in pain and further nerve activation

Brainstem pathways that modulate sensory input. The key pathway for pain in migraine is the trigeminovascular input rom the meningeal vessels, which passes through the trigeminal ganglion and synapses on second-order neurons in the trigeminocervical complex. These neurons in turn project in the quintothalamic tract and, after decussating in the brainstem, synapse on neurons in the thalamus. Important modulation of the trigeminovascular nociceptivedorsal raphe nucleus, locus input comes from the coeruleus, and nucleus raphe magnus.

NEUROVASCULAR PROCESS

Arterial Activation

Release of Neurotransmitter

Worsening of Pain

MIGRAINE: DIAGNOSIS
Medical History
Headache diary Migraine triggers

Investigations (only to exclude secondary causes) EEG CT Brain MRI

Simplified Diagnostic Criteria for Migraine

Repeated attacks of headache lasting 472 h in patients with a normal physical examination, no other reasonable cause for the headache, and: At Least 2 of the Following Features: Unilateral pain Throbbing pain Plus at Least 1 of the Following Features: Nausea/vomiting Photophobia and phonophobia

Aggravation by movement
Moderate or severe intensity
Source: Adapted from the International Headache Society Classification (Headache Classification Committee of the International Headache Society, 2004).

Patients with acephalgic migraine experience recurrent neurologic symptoms, often with nausea or vomiting, but with little or no headache. Vertigo can be prominent; it has been estimated that one-third of patients referred for vertigo or dizziness have a primary diagnosis of mgraiine.

DIFFERENTIATING COMMON PRIMARY HEADACHES

Strictly unilateral Tension headaches: Do not have the associated features like nausea, vomiting, photophobia, phonophobia. The muscle contraction leads to headache. Headache quality is of a tightening (non-pulsating) quality. Usually bilateral. Intensity is mild or moderate Cluster headaches: Severe unilateral pain. Headache associated with lacrimation, nasal congestion, rhinorrhea, facial sweating or eyelid edema. Pain lasts for 15 to 180 minutes. More common in men

Migraine Disability Assessment Score (MIDAS)

THE TREATMENT APPROACH TO MIGRAINE

LONG-TERM TREATMENT GOALS FOR THE MIGRAINE SUFFERER

Reducing the attack frequency and severity

Avoiding escalation of headache medication

Educating and enabling the patient to manage

the disorder
Improving the patients quality of life

MIGRAINE MANAGEMENT

Non-pharmacological treatment

Identification of triggers Meditation Relaxation training Psychotherapy non-specific

Pharmacotherapy

Abortive therapy

Specific
Preventive therapy

MIGRAINE: ABORTIVE THERAPY

Non-specific treatment
Drug
Aspirin Paracetamol Ibuprofen Diclofenac Naproxen

Dose
500-650 mg 500 mg-4 g 200- 300 mg 50-100 mg 500-750 mg

Route
Oral Oral Oral Oral/IM Oral

ABORTIVE THERAPY FOR MIGRAINE

Specific treatment
Drug
Ergot alkaloids Ergotamine 1-2 mg/d; max-6 g/d Oral SC Orally SC, Nasally Orally

Dose

Route

Dihydroergotamine 0.75-1 mg 5-HT receptor agonists Sumatriptan Rizatriptan 25-300 mg 6 mg 10 mg

WHY THE NEED FOR PROPHYLAXIS ?

Abortive drugs should not be used more than 2-3

times a week
Long-term prophylaxis improves quality of life by

reducing frequency and severity of attacks

80% of migraineurs may require prophylaxis

WHEN IS PROPHYLAXIS INDICATED?

According to the US Headache Consortium Guidelines, indications for preventive treatment include: Patients who have very frequent headaches (more than 2 per week) Attack duration is > 48 hours Headache severity is extreme Migraine attacks are accompanied by prolonged aura Unacceptable adverse effects occur with acute migraine treatment Contraindication to acute treatment Migraine substantially interferes with the patients daily routine, despite acute treatment Special circumstances such as hemiplegic migraine or attacks with a risk of permanent neurologic injury Patient preference

PREVENTIVE THERAPY FOR MIGRAINE

Drugs
1.

Dose (mg/d) 40-320

2.

3.

4.

Betablockers Propranolol Calcium Channel Blockers Flunarizine Verapamil TCAs Amitriptyline SSRIs Fluoxetine

10-20 120-480

10-20 20-60

PREVENTIVE THERAPY FOR MIGRAINE (CONTD.)

Drugs
5.

Dose (mg/d)
600-1200 4-8

Anti-convulsant

Sodium valproate Cyproheptadine

6.

Anti-histaminic

Tension Headache
Most common type of headache Higher prevalence in middle aged women Usual frequency is 5 episodes per month Clinical features include -tight, band-like discomfort around the head -intensity of pain is not severe and thus not debilitating -headache does not worsen with physical activity -coexisting anxiety and depression are common

Tension headache-Treatment
Aspirin, acetaminophen, NSAIDs
T/t-Amytriptyline Exercise program Nonpharmacologic regimen like massage, mediation,

and biofeedback Psychotherapy

CLUSTER HEADACHE
Rare form of primary headache
More common in men Recurrent, deep, nocturnal, unilateral, retroorbital searing

pain
Awackening 2-4hrs after sleep onset with severe pain,

unilateral lacrimation congestion.

and

nasal

and

conjunctival

Visual complaints,nausea,or vomitting are rare. Tend to move during attacks (unlike migrain) Presence of periodicity Pain last 30-210 min but tend to recurat the same time of night or several times each 24 h over 4-8 weeks (a cluster) A pain free period of months or years may be followed by another cluster of headaches. T/t: High flow oxygen of 7-10 l/min Prophylaxis with Verapamil Lithium Prednisolon

Clinical Features of the Trigeminal Autonomic Cephalalgias

Cluster Headache Paroxysmal Hemicrania SUNCT(short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.) FM Burning, stabbing, sharp Severe to excruciating

Gender Pain Type Severity

M>F Stabbing, boring Excruciating

F=M Throbbing, boring, stabbing Excruciating

Site
Attack frequency Duration of attack Autonomic features

Orbit, temple
1/alternate day8/d 15180 min Yes

Orbit, temple
140/d (>5/d for more than half the time) 230 min Yes

Periorbital
3200/d 5240 s Yes (prominent conjunctival injection and lacrimation)a Yes No Yes Lidocaine (IV)

Migrainous featuresb Alcohol trigger Cutaneous triggers Indomethacin effect Abortive treatment

Yes Yes No Sumatriptan injection or nasal spray Oxygen Verapamil Methysergide Lithium

Yes No No Yesc No effective treatment

Prophylactic treatment

Indomethacin

Lamotrigine Topiramate

Gabapentin

Chronic Daily Headache

The broad diagnosis of chronic daily headache (CDH) can be applied when a patient experiences headache on 15 days or more per month. CDH is not a single entity; it encompasses a number of different headache syndromes, including chronic TTH as well as headache secondary to trauma, inflammation, infection, medication overuse, and other causes

Classification of Chronic Daily Headache

Primary >4 h Daily Chronic migrainea <4 h Daily Chronic cluster headacheb Secondary Posttraumatic Head injury Iatrogenic Postinfectious Chronic tension-type headachea Chronic paroxysmal hemicrania Inflammatory, such as Giant cell arteritis Sarcoidosis Behet's syndrome Hemicrania continuaa New daily persistent headachea
b

SUNCT/SUNA Hypnic headache

Chronic CNS infection Medication-overuse headachea

a May be complicated by analgesic overuse.

Some patients may have headache >4 h/d. Abbreviations: SUNA, s hort-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms; SUNCT, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.

New Daily Persistent Headache

Clinical Presentation
The headache usually begins abruptly, but onset may be more gradual; evolution over 3 days has been proposed as the upper limit for this syndrome. Patients typically recall the exact day and circumstances of the onset of headache; the new, persistent head pain does not remit. The first priority is to distinguish between a primary and a secondary cause of this syndrome. Subarachnoid hemorrhage is the most serious of the secondary causes and must be excluded either by history or appropriate investigation

Differential Diagnosis of New Daily Persistent Headache

Primary Migrainous-type Featureless (tension-type) Secondary Subarachnoid hemorrhage Low CSF volume headache

Raised CSF pressure headache

Posttraumatic headachea Chronic meningitis
a

Includes postinfectious forms.

Subarachnoid Hemorrhage (SAH)

Extravasation of blood in subarachnoid space activates

SECONDARY HEADACHE

meningeal nocireceptors causing occipital pain and meningismus. SAH accounts for 10% of all strokes and is most common cause of death from a stroke. Causes are saccular aneurysms (80%), blood dyscrasias, arteriovenous malformations, mycotic aneurysms, cavernous angiomas. Risk factors include increased age,hypertension, smoking, excessive alcohol consumption and sympathomimetic drugs.

Clinical Features of SAH

Sudden thunderclap

headache Can be associated with exertional activities Nausea/vomitng-75% Neck stiffness-25% Seizures-10%

Meningismus-50% Subhyloid or retinal

hemorrhages Oculomotor nerve pulsy with dilated pupil Restlessness and altered level of consciousness

Prognosis
It depends on neurological

Grade Condition

0
I II

Unruptured Aneurysm
No symptoms or minimal headache
Moderate/Severe HA, nuchal rigidity, no neuro deficit other than CN pulsy

status at the time of presentation Hunt and Hess scale Grades I and II have good prognosis Grades IV and V have grave prognosis

III
IV

Drowsiness, confusion, or mild focal deficit

Stupor, severe hemiparesis Deep coma, decerebrate

Diagnostic Studies
Emergent CT scan of head
CT is greater than

90% sensitive for acute bleeding-less than 24 hr Sensitivity decreases to 50% by the end of the first week

Diagnostic Studies
When CT is negative a lumbar

puncture should be performed The CSF should be spun and the supernatant fluid should be observed for xanthochromia (develops after 12 hrs)
CSF xanthochromia with

negative CT is diagnostic Xanthochromia by spectophotometry is more sensitive

Diagnostic Studies
Patients with persistent bloody CSF without

xanthochromia should go vascular imaging Up to 90% of patients with SAH have cardiac arrhythmias or EKG findings suggestive of ischemia Typical EKG changes include ST-T wave changes, U waves, and QT prolongation

Treatment
Airway, breathing, circulation and neurosurgical

consultation. Patients with Grade III SAH usually require endotracheal intubation Nimodipine 60 mg PO or NG to lessen the chance of ischemic stroke due to vasospasm Anticonvulsants for patients with evident seizure

Intracranial Infection
Severe HA, nuchal rigidity, HA is common meningismus complaint in meningitis, Encephalitis HA, confusion, brain abscess, fever, change of encephalitis or AIDS mental status, Diagnostic tools include seizures CT of head and LP Brain HA, vomiting, focal Abscess neurological signs, depressed level of consciousness AIDS Toxoplasmosis, CMV, Cryptococcus Meningitis

Brain Tumor
In elderly, brain tumor is usually metastatic from lung

or breast carcinoma. Primary brain tumor are more common in adults younger than 50 years HA is caused either by direct pressure on the brain or elevated ICP Typical presentation is headache that worsens over over weeks to months HA is usually present on awakening initially, then it becomes continuous.

Brain Tumor
HA is often worse with sneezing, bending, coughing.
Diagnostic tools include CT with IV contrast or MRI(best test)

Giant Cell Arteritis

Systemic inflammatory

process of small and medium size arteries. Mean age of onset is 71 years, rare before 50 Headache is intermittent, worse at night or on exposure to cold Associated symptoms include jaw claudication, fever, anorexia, pain and stiffness in joints aka polymyalgia rheumatica

On exam there is tenderness

of temporal artery. Its a medical emergency because long term sequelae is permanent visual loss. Diagnostic tests include ESR, CRP, LFTs, platelet count Definite diagnosis is by temporal artery biopsy Treatment is prednisone 60120mg daily.

Acute Glaucoma
Sudden onset of eye pain Due to congenital

radiating to head, ear, teeth, and sinuses. Visual symptoms include blurriness, halos around lights, and scotomas. Nausea and Vomiting

narrowing of the anterior chamber angle that leads to elevated intraocular pressure (IOP) Medications that elevate IOP include mydriatics, sympathomimetics

Acute Glaucoma
Physical exam shows a red

eye with a fixed middilated pupil and shallow anterior chamber (separates it from cluster HA) IOP in the range of 60 to 90 mmHg ( not found in iritis) Treatment includes topical miotics, b-blockers, carbonic anhydrase inhibitors, optho consult

Posttraumatic Headache(PTHA)
Estimated that 30-50% of 2 Chronic PTHA may last

million closed head injuries per year develop headache. Associated with dizziness, fatigue, insomnia, irritability, memory loss, and difficulty with concentration. Acute PTHA develops hours to days after injury and may last up to 8 weeks.

from several months to years. Patients have normal neurological examination and imaging Treatment for acute PTHA is symptomatic while for chronic PTHA, adjunct therapies include betablockers and antidepressants.

Postdural Puncture Headache

Most common

Thought to be due to

complication following lumbar puncture (up to 40%) Most common in 18 to 30 year old patients It can last up to 5 days Bilateral throbbing HA that worsens with upright position

persistent leak of CSF that exceeds its production Treatment includes rest, fluids, and blood patch, caffeine or theophylline for persistent HA

Medication-Induced Headache
Medication use, abuse or

withdrawal s the cause. Common in patients with chronic headache disorders like migraine or tension-type. Most common meds include ASA, NSAIDs, Tylenol, barbiturateanalgesic combinations, caffeine, and ergotamine

Patients build tolerance

to the meds and subsequently require higher doses for symptomatic relief. Treatment includes withdrawal of the overused medications

High Altitude Headache

Main symptom of Acute Mountain Sickness Can occur at altitudes higher than 5000 feet in unacclimatized individuals. HA is throbbing, located in temporal or occipital area and worsens at night or early in the morning. Treatment includes supplemental oxygen and descent to a lower altitude.

Carbon Monoxide Poisoning

Usually gradual, subtle, dull, nonfocal throbbing pain

associated with nausea, chest pain. Symptoms may wax and wane as patients may enter and leave the area of carbon monoxide Exposure to engine exhaust, old or defective heating systems, most common in winter months. Non focal neurological exams. Diagnosis is made by elevated carboxyhemoglobin Treatment is oxygen

Hypertensive Headache
Elevated blood pressure is

not as important in HA as the rate by which the blood pressure increases Nonetheless, HA with severe HTN is well documented especially in hypertensive encephalopathy Treatment is directed at lowering blood pressure slowly HA may last for days until brain edema has resolved

COUGH HEADACHE
Transient severe pain with coughing,bending,sneezing or stooping Last for sec to few min Usually benign Posterior fossa mass lesion in 25% cases Indomethacin 25-50mg tid

Key Concepts
HA is a challenging yet common complaint in ED Diseases that we cannot afford to miss are SAH, CO poisoning, temporal arteritis, bacterial meningitis/encephalitis Be liberal with use of CT Remember CT doesnt rule out SAH-need LP. If CT and LP are negative think of temporal arteritis if older than 50 years, and CO poisoning. Dont forget the eyes!

Case Studies

Headache Case #1
40-year-old man presents with a history of headache

since adolescence Over the past two years, headaches gradually have increased in frequency and severity; daily head pain for past 6 months Functionally incapacitated by headache 7 days per month

Headache Case #1 (cont.)

Usual headache is of mild intensity, constant,

nonpulsatile, nonlateralized, pressure-like, and not accompanied by nausea, vomiting, photophobia or phonophobia Most severe headaches last 1 to 2 days and involve pain that is pulsatile, lateralized to the left, increased by routine physical activity, and accompanied by nausea, vomiting, photophobia, and phonophobia

Headache Case #1 (cont.)

Some of these attacks are preceded by tunnel vision

and bright flashes at the periphery of both visual fields Severe attacks typically begin with an intensification of the usual headache, with severe tightness, stiffness, pain of the left lateral neck Physical examination was notable only because of marked tenderness to palpation at the left occipital skull base in the region of the greater occipital nerve

Headache Case #1: Questions

1. What is your diagnosis?
a. Chronic tension type headache b. Mixed tension type and migraine headache c. Transformed migraine d. Probably primary headache syndrome but needs brain imaging and lumbar puncture to rule out organic disorder

Headache Case #1: Questions (cont.)

2. This patients headaches are likely to respond to
a. b. c. d. Propranolol Oral sumatriptan Left greater occipital nerve block All of the above

Headache Case #2
46-year-old woman presented for evaluation and

management of chronic daily headache Significant headaches started at 12 years of age Since then, she has had head pain with features characteristic of migraine with and without sensory or visual aura

Headache Case #2(cont.)

Following surgery (hysterectomy/ oophorectomy) 10

years ago, her headaches became more of a problem; she has had daily headaches for 5 years She is functionally incapacitated by headache almost every day

Headache Case #2(cont.)

Has been to the emergency department for headache 7

times within the last month, and called her physician 1 week prior to her initial appointment to request acute headache medication Past medical history is otherwise notable for borderline personality disorder, chronic anxiety/depression, and 2 hospitalizations for suicidal ideation (no attempt)

Headache Case #2: Questions

1. The most likely diagnosis for this patient is
a. Chronic tension type headache b. Idiopathic intracranial hypertension c. Transformed migraine with analgesic overuse d. Brain tumor

Headache Case #3
31-year-old women with a long-standing history of

episodic migraine without aura comes to see her physician for urgent evaluation of a new problem: while at work, she abruptly developed an out-of-body sensation and a metallic taste in her mouth According to onlookers, she stared blankly and straight ahead for 45 seconds, failed to respond to questions, and swallowed repeatedly; she did not lose postural tone or exhibit tonic-clonic activity

Headache Case #3(cont.)

After this event, the patient appeared flustered and

was confused for a few minutes Reviewing her past, she claimed that she may have had this experience about 12 times over the previous 13 years, though the episodes were less intense She reported no recent change in the character or frequency of her headache syndrome

Headache Case #3(cont.)

The patient had about 15 headache days out of the

previous 30 days; 6 of these were functionally incapacitating headaches, despite aggressive treatment with oral sumatriptan, subcutaneous sumatriptan, and oral oxycodone/aspirin Her medical history is otherwise unremarkable Family history: her maternal grandmother and mother have had migraine; a maternal aunt and cousin have epilepsy

Headache Case #3: Questions

1. Her episode at work last week likely represented
a. b. c. d. Complicated migraine Panic attack Complex partial seizure A transient ischemic attack (TIA)

Headache Case #4
45-year-old man presents for evaluation and

management of chronic daily headaches Experienced his first significant headaches at age 36; these headaches resolved spontaneously after 2 months but then recurred 1 year later and have been daily since then

Headache Case #4(cont.)

The patient experiences 2 to 4 headaches each day,

typically lasting 30 to 45 minutes and involving pain that is often prominent in the right eye, extending to the temple Treatment with propranolol, amitriptyline, oral sumatriptan, oral rizatriptan, and naproxen sodium have been ineffective for headache Medical history: unremarkable The patient smoked 1 pack of cigarettes per day for at least 20 years

Headache Case #4: Questions

1. The most likely diagnosis for this patient is
a. Nasopharyngeal carcinoma b. Chronic cluster c. Chronic migraine d. Chronic paroxysmal hemicrania