The Massachusetts General Hospital Handbook of Neurology

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

Copyright 2007 Lippincott Williams & Wilkins

> Table of Contents > Adult Neurology > Headache

Headache

A. H&P

Similarity to previous HAs, onset and time course, N/V, photophobia, neck pain, trauma, fever, neurological aura, change in sx with position, h/o cancer, family history of aneurysms or migraine, what drugs work for pain. Cranial or sinus tenderness, eye changes, focal neurological signs.

B. Causes

• 1. Sudden paroxysmal headache (HA): Intracranial hemorrhage (especially subarachnoid), arterial dissection, benign orgasmic HA, thunderclap migraine, hypertensive crisis .

• 2. Subacute progressive HA: Posterior fossa stroke, cerebral vein thrombosis, temporal arteritis, tumor, obstructive hydrocephalus, CSF leak (e.g., post LP), meningitis, sinusitis, or other infection, vascular malformations, glaucoma .

• 3. Recurrent or chronic HA: Migraine, neck arthritis, postconcussive syndrome, pseudotumor cerebri, neuralgia, temporal arteritis, temporomandibular syndrome, drugs (stimulants, solvents, alcohol withdrawal) .

C. Tests

• 1. Sudden or subacute headache (HA): CT without contrast to r/o bleed, or with contrast to r/o tumor.

  • a. Consider also: MRA to r/o vascular malformations, dissections, aneurysm. LP to r/o SAH, meningitis, or leptomeningeal carcinomatosis.

P.53

• 2. Recurrent or chronic HA: Can usually be diagnosed without tests. Consider ESR.

D. Cluster HA

• 1. H&P: Occur at the same time each day, nonthrobbing, uniorbital, ipsilateral running nose, red eye, red cheek, tender temporal artery, lasts 10 min to 2 h, up to 8 times a day, sometimes with Horner's. Alcohol can trigger. Unlike migraneurs, cluster headache sufferers do not lie still, but may walk restlessly. Youngish men.

• 2. DDx: Migraine, trigeminal neuralgia, sinus tumor, Tolosa-Hunt .

• 3. Rx: Ergot, 100% O₂, methysergide, prednisone taper (can cause rebound). Prophylaxis is more effective than treating acute attack; try calcium channel blocker or lithium.

E. Postconcussive HA

See Concussion, p. 119.

F. LP HA

From continued CSF leak. Worse when standing.

• 1. Rx: Lie flat 24 h; aggressive fluids (especially carbonated, caffeinated drinks), pain drugs. Consider blood patch, IM steroids, abdominal binder.

G. HIV HA

see p. 55.

H. Occipital neuralgia

Pain in occiput, usually with trigger point along superior nuchal line. Injection of local anesthetic and steroids may help.

I. Migraine

• 1. H&P: Unilateral (but not always same side), throbbing, N/V, photophobia, phonophobia, often preceded by visual or other neurologic change.

• 2. Rx of acute migraine:

  • a. Treat nausea: E.g., with phenothiazine like metoclopramide 10 mg PO/IM/IV.

  • b. Triptans: 5-HT₁ serotonin receptor agonists. E.g., sumatriptan (Imitrex). SC: 6 mg. PO: 25 mg test; if partial relief in 2 h, try up to 100 mg PO; no more than 300 mg qd. Nasal spray 5-20 mg into one nostril, q2h if needed; no more than 40 qd.

    • 1) Contraindications: Ergots within 24 h, possible CAD.

  • c. NSAID: E.g., naproxen 500 mg PO. Beware of short-acting NSAIDS or quick tapers because of rebound HA.

  • d. Ergots:

    • 1) Contraindications: CAD, HTN, hemiplegic or aphasic migraine (ergots are vasoconstrictors).

    • 2) Dihydroergotamine (DHE): Put pt on a cardiac monitor for first DHE dose. Give metoclopramide 10 mg IV 10 min beforehand, then 1 mg DHE; repeat in 1 h prn; then q6h prn. If it works, try DHE nasal spray, or Cafergot PO.

    • 3) Cafergot: Ergotamine and caffeine. Give 2 tabs, then 1 q30min, max 6 in 24 h.

  • e. Midrin: A sympathomimetic amine with a sedative. Give 2 tabs, then 1qh to relief; max 5 in 12 h.

    • 1) Contraindications: HTN, glaucoma, renal failure, MAOIs.

  • f. Fioricet: 1-2 tabs q4h, for attacks fewer than 3 /month. Beware rebound HA.

  • g. Opiates: Danger of rebound HA and addiction.

  • h. Steroids: For status migrainosus.

P.54

• 3. Prophylaxis of migraine (if having migraines more than 3 /month):

  • a. TCAs: Amitriptyline is the only one with proven efficacy, although nortriptyline is probably also effective and better tolerated.

  • b. Propranolol: Start 10-20 bid. Avoid in asthma, CHF.

  • c. 5-HT antagonists: E.g., methysergide. Need test dose. Danger of retroperitoneal fibrosis.

  • d. Calcium blockers: E.g., verapamil.

  • e. ACDs: E.g., valproate 250-500 mg tid.

J. Rebound HAs

Common after stopping opiates, Fioricet, NSAIDs. Can cause vicious cycle of analgesic use.