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HEADACHES: PRACTICAL MANAGEMENT Thomas N. Ward, M.D. Introduction Clinical Symptoms And Signs Approach To The Patient Neuroimaging (CT scanning or MRI), blood work, lumbar puncture, angiography, et cetera are necessary when a secondary headache, such as subarachnoid hemorrhage, meningitis, or giant cell arteritis is suspected. Testing is generally not indicated when history and examination suggest a primary (benign) headache disorder. Secondary
Headaches Case Report He has a history of asthma and had had an upper respiratory tract infection about two weeks prior to his presentation with stuffy nose, cough and tearing eyes. He had been coughing green-brownish material for the three days prior to his presentation in our office. Medications included albuterol (Proventil®) and acetaminophen (Tylenol®). His examination was remarkable for equal pupils that were round and reactive to light without tearing, injection or nystagmus. He was able to read and count fingers in both visual fields. His fundi showed what was thought to be early papilledema. He had marked tenderness on palpation of his left frontal sinus and was non-tender to palpation over the other sinuses. He had a non-focal neurological examination. His initial temperature was 100.4 orally and vital signs were stable. A stat head CT scan without contrast was arranged and read as normal. The course and workup of this patient will be discussed (see below). Thus far, this case illustrates the potential hazard of diagnosing a primary headache disorder too soon. A number of diagnostic problems in headache may occur. These problems may be grouped into four categories and are reviewed below (Mathew, 1994). Organic Conditions Presenting With Acute
Headache That May Cause Difficulty In Diagnosis Intracranial aneurysms
Unruptured
Perhaps 1-2% of the general population harbors asymptomatic intracranial aneurysms. Unruptured intracranial aneurysms may cause symptoms due to sudden expansion (headache) or thrombosis (without leaking). Whether imaging with CT scan and lumbar puncture is sufficient to exclude the presence of intracranial aneurysm, is controversial. If sufficient clinical suspicion is present, magnetic resonance angiography (MRA) may be performed, or even conventional angiography. Investigation must be tailored to the particular clinical context and the degree of suspicion. Patients with encephalitis or meningitis usually have fever (unless on antipyretics or steroids), and stiff neck (if in a deep coma, stiff neck may not be present). Headache is common, and focal neurologic deficits may develop. Seizures may occur, possibly followed by stupor and coma. CT scan or MRI is usually performed to rule out an abscess or other mass lesion, followed by a lumbar puncture. Herpes simplex encephalitis, a progressive necrotizing encephalitis with a predilection for the temporal and frontal lobes, presents with fever, loss of sense of smell, and recent memory loss. Headache is common. MRI is positive early; polymerase chain reaction on CSF may be diagnostic. Treatment with acyclovir is initiated as soon as the diagnosis is suspected to try to limit the amount of brain damage. Neurologic and infectious disease consultation is appropriate. Dissection of the carotid or vertebral arteries may occur spontaneously, or in the setting of trauma or underlying vascular disease. Symptoms include neck pain, headache, and neurologic deficits in the distribution of the involved blood vessel. The dissection may be revealed by ultrasound, MR angiography, or conventional angiography. Cerebral venous thrombosis may be present with headaches, seizures, paraparesis (cortical parasagittal leg area), or other focal neurologic deficits. Predisposing conditions include pregnancy (or the immediate post-partum period), dehydration, cancer, coagulation disorders, or trauma. 2. Organic Conditions Associated With Recurrent Headaches Mimicking Primary Headache Disorders Symptomatic
cluster headaches Tumor Cerebral
arteriovenous malformation The pain of cluster headache is so severe that patients are certain there must be an underlying mass lesion. Imaging is generally normal. However, in symptomatic cluster headache a lesion may often be found in or near the cavernous sinus. The duration of the pain attacks may become progressively shorter, and a fixed neurologic deficit may appear. Cough headache is usually a sudden head pain triggered by coughing or other Valsalva maneuvers. The headache is sudden in onset and severe, but only briefly so (seconds or minutes). It may be followed by a longer duration posterior or holocranial dull ache. Perhaps 10-20% are due to a posterior fossa lesion such as a Chiari malformation. MRI is indicated as part of the evaluation. If imaging is negative, treatment with indomethacin is usually dramatically effective. Lumbar puncture may also be therapeutic (Raskin, 1995). Sex may trigger headaches in several ways. 1) Subarachnoid hemorrhage or sudden-onset migraine, (which may be clinically indistinguishable) may occur. CT, LP, even angiography, may be required. 2) Severe muscle contraction headache may be precipitated (gradual onset, without nausea or vomiting). 3) Postural headache may follow intercourse, presumably due to a nerve root sleeve tear with CSF leakage. The headache is relieved by recumbency and aggravated by standing. Antiphospholipid antibodies (the lupus anticoagulant, anticardiolipin antibodies, antiphosphatidylserine antibody) may occasionally be associated with migraine with prolonged (1 hour) aura or migrainous infarction. A previous history of recurrent miscarriages or venous thrombosis should arouse suspicion. An elevated partial thromboplastin time (PTT ) on routine coagulation testing and a false positive VDRL may provide a clue to their presence. CNS vasculitis may be present with headaches, seizures, and focal neurologic deficits. Laboratory parameters consistent with collagen vascular diseases may be present, but may be absent if disease is confined to the CNS (a privileged area). Imaging may reveal strokes, CSF may contain red and white cells, and rising protein. Angiography may demonstrate beading of blood vessels and segmental narrowing or occlusions. Occasionally meningeal biopsy is performed. Rheumatologic, neurologic, and neurosurgical consultation may be necessary. The headache of pheochromocytoma is generally paroxysmal -- sudden, but brief (less than one-hour duration). Dramatic elevations of blood pressure, with tremor and diaphoresis occur. The headache is often holocranial, pounding, and nausea/vomiting may be present. A 24-hour urine evaluation for products of the tumor (VMA, etc.) is diagnostic. Tip -- mild essential hypertension is typically not associated with headache. Severe paroxysmal elevations of blood pressure, as occurs with pheochromocytoma or the tyramine reaction in patients on MAO inhibitors, is associated with headache. 1. Organic Conditions Associated With Chronic Persistent Headache Or Facial Pain, Often Without Abnormal Physical FindingsArnold-Chiari
Malformation-Type 1 Adult
aqueductal stenosis and hydrocephalus Temporomandibular
joint (TMJ) dysfunction Giant Cell Arteritis (temporal arteritis) Giant cell arteritis is usually manifested as temporal pain, constant, sometimes with jaw claudication. The scalp and superficial temporal arteries may be tender. Most patients are over 50 years old and have an ESR over 50 mm/hr. Untreated, this disease carries a significant risk of blindness and stroke. If the diagnosis is suspected, prednisone is started immediately (60-80 mg per day initially), the patient is then sent for temporal artery biopsy (due to patchy involvement, a substantial length of vessel needs to be obtained. If one side is negative, the opposite side should be considered for biopsy). 2. Brain Tumor Occurring In A Patient With Established MigraineCarrying the diagnosis of a primary headache type, such as migraine, in no way prevents a patient from developing a second type of headache. Brain tumors certainly can occur in patients who also have primary headache disorders. Therefore, if a patient with an established headache disorder develops new or progressive signs or symptoms, or becomes refractory to previously effective therapy, the possibility of the presence of a second type of headache should be considered. Diagnosis And Management Of Primary Headaches Migraine The object of therapy is to ameliorate or terminate patients' migraine attacks, and when necessary, to reduce the frequency and severity of attacks via behavioral treatment, lifestyle changes, and preventative pharmacotherapy. Migraine is often precipitated by various triggers (ie, chocolate, cheeses, menses, sun glare, missing a meal, etc.). Therapy begins as these triggers are identified and subsequently avoided. Avoiding these is the first step. Getting enough sleep and exercise, and dealing with stress is next. It is also important to be sure other medications are not contributing to headache causation, eg, hydralazine, nitroglycerine. The overuse of symptomatic medication can transform migraine into a chronic daily headache [see below]. In this situation prophylactic medication is ineffective and the offending medications must be stopped. Preventive pharmacotherapy is usually appropriate when patients need to use acute headache medications more than 2 days per week, if the headaches do not respond to abortive medications, (perhaps resulting in visits to the emergency room), or if the patient has had complicated migraine (a prolonged neurologic deficit, or migrainous infarction). Acute symptomatic therapy with medications is used to relieve headache attacks. Prophylactic Treatment Patients in the childbearing years requiring preventative treatment generally should be using an effective form of contraception. However, oral contraceptives may not be appropriate for some migraine patients. It generally takes 2 to 3 months to ascertain medication's preventative effect. Typically, therapy starts “low, go slow”. Start with the lowest dose and increase it slowly until headache control is achieved or unacceptable side effects are encountered. After the headaches are controlled for 6 months or more the medication may be gradually decreased and stopped, as tolerated. Tip: Choose a preventative migraine therapy based on co-morbid/co-existent conditions such as mitral valve prolapse, Raynaud's phenomenon, epilepsy or, depression. Choose a drug that might help both. The major classes of prophylactic drugs include beta-blockers, anticonvulsants, calcium channel drugs, and heterocyclic antidepressants. There are also several miscellaneous drugs, which are sometimes useful (Ward, 2000). Antidepressants Tip-Medications within the same pharmacologic group produce various side effects that are more, or less, acceptable to each individual patient. If one agent is poorly tolerated, consider either a lower dose or a trial of another agent in the same family. Nortriptyline (Pamelor®, others) may be tried if the side effects of amitriptyline are unacceptable. It causes less drowsiness. Again, the initial dose is generally 10-25 mg hs, but as it is also available in a liquid formulation, even lower doses can be employed if necessary. Doxepin (Sinequan®) is another potential option, and is also available in a liquid form. Heterocyclic antidepressants are contraindicated in patients with cardiac arrhythmia, narrow angle glaucoma, prostatism, and uncontrolled seizures (Saper). Beta-Adrenergic Antagonist Drugs Calcium-Channel Blocking Drugs Nonsteroidal Anti-Inflammatory Drugs (Nsaids) Aspirin Tip - These side effects can be ameliorated with concurrent treatment with misoprostol (Cytotec®). It is given as 200 mcg tablets 4 times a day, with meals. The dose may be reduced if necessary to 100 mcg 4 times a day. Anticonvulsants Gabapentin (Neurontin®) and topiramate (Topamax®) have been reported to have efficacy in selected migraine patients (Ward, 2000). Neurontin is not hepatically-metabolized and has little potential for drug interaction. Dosing typically begins at 300 mg tid, and may be slowly raised as high as 1200 mg tid. Topiramate is actually associated with weight loss, which may be of benefit to some migraineurs. For migraine prevention, dosing is begun at 15-25 mg at hs, and slowly raised to as high as 100 mg BID. This drug is a weak carbonic anhydrase inhibitor, and therefore should not be given to patients with a history of renal stones. Higher doses are often associated with significant sedation. Miscellaneous
Headache Preventative Agents Tip- this drug has a rapid onset of action and may be a useful temporary choice to achieve rapid reduction in headaches. Cyproheptadine (Periactin®) is an agent with anti-serotonergic, antihistamine, and calcium channel blocking properties. It has been advocated particularly as a preventative agent for children with migraine. The usual starting dose is 2mg (1/2 a 4mg tablet) twice or thrice daily. The dose may be increased slowly, usually to 4 mg twice or three times daily. It is available as syrup as well, enabling lower dosage titration. Side effects include sedation and weight gain. Symptomatic
Migraine Treatment Acetaminophen is a non-prescription alternative in patients who cannot tolerate aspirin. Several pain models demonstrate the equivalent analgesic efficacy of aspirin and acetaminophen on a milligram to milligram basis. A study in patients with tension and tension-vascular headaches observed no difference between 1000 mg acetaminophen and 650 mg aspirin in relieving headache pain. Gastric stasis during a migraine attack impedes the absorption of medications, such as aspirin and acetaminophen. Tip-Concomitant administration of metoclopramide (Reglan®) significantly increases serum concentrations of both these agents, by increasing gastrointestinal motility. (Volans) [see below for further discussion]. Oral medications may be limited in their utility by their incomplete absorption and the frequent vomiting accompanying migraine. The use of the rectal route of administration is available for aspirin and acetaminophen. Codeine and other drugs may also be prepared in this fashion by pharmacists (Ward). Dependence can occur in patients who use these products uninterrupted for 48 hours or more. Unless withdrawal is carried out, such patients are unlikely to benefit from other antimigraine therapy. Aspirin and acetaminophen are commonly combined with caffeine and butalbital to enhance analgesic activity. These combinations are called BAC (butalbital, aspirin or acetaminophen, caffeine) and are sold as Fiorinal®, Esgic® and Fioricet® (with acetaminophen). This combination works for many patients with headache. Tip-Sometimes patients have an adverse reaction to the caffeine in this combination. Phrenilin® combines acetaminophen and butalbital, avoiding this problem. BAC may be abused in chronic headache patients, complicating their treatment. It is important to detoxify these patients from all rebound-producing medications, including simple analgesics, when using excessive quantities (eg, more than 2 days a week). An effective BAC detoxification protocol to do this has been published (Sands). Nonsteroidal
Anti-inflammatory Drugs (Nsaid) Ketorolac (Toradol®), the first parenteral NSAID available in the United States, has modest effects in the treatment of migraine. However, relief from pain and disability with I.M. ketorolac are significantly less than the combination of IV DHE 45® and metoclopramide. Keterolac may also be administered intravenously. Other NSAIDs found to be effective in the treatment of migraine include diclofenac sodium, flufnenamic acid, flurbiprofen, ibuprofen and mefenamic acid (See Table 1). The most common adverse effect with all NSAIDs is dyspesia. Diclofenac was better than placebo, but relieved only 27 % of migraine attacks. (Lance) Table 1: Dosing Guidelines For Nsaids For Treating Migraine Naproxen
sodium (Anaprox®) Diclofenac
sodium (Voltaren®) Flufenamic
acid Flurbiprofen
(Ansaid®) Ibuprofen
(Motrin®) Mefenamic
acid (Ponstel®) Tolfenamic
Acid Antiemetics Metoclopramide should be used sparingly as it may cause dystonia and akathisia, especially in adolescents (Welch). Keeping the dose below 30 mg per day decreases the chance such a reaction will occur. Patients should be warned of the potential dystonic reaction and have 25 mg of diphenhydramine (Benadryl®) available. Administration of a narcotic analgesic (eg, meperidine-Demerol®) or anticholinergic agents may antagonize increased gastrointestinal motility produced by metoclopramide Metoclopramide provided pain relief in 67% of patients after one hour compared to 19% for placebo, in a controlled, double blind study (Text cited in Raskin 1988). Recent studies suggest that some antiemetics may be useful as single agents in the treatment of migraine attacks. Controlled studies have shown intravenous chlorpromazine (Thorazine®) 0.1 mg/kg and prochlorperazine (Compazine®) 10 mg effectively terminate migraine attacks (Lane/Jones cited in Raskin 1988) Chlorpromazine may be useful when treating migraine with intravenous dihydroergotamine (DHE-45®) (Welch). Chlorpromazine and prochlorperazine may cause tardive dyskinesia that occasionally is irreversible. Promethazine (Phenergan®) suppositories (12.5mg-25 mg-50mg) are effective in treating nausea and vomiting, with little likelihood of dystonia. Isometheptene Ergot
Preparations Rectal ergotamine (Cafergot® or Wigraine®) is available in 2 mg suppositories. Tip - It is useful to take one-quarter to one-half a suppository initially, followed by one-quarter every 30 minutes as needed to a maximum daily dose of two suppositories or 4 mg. Again, patients should determine the subnauseating dose when they are headache-free. Since patients using rectal ergotamine appear to be at higher risk for developing a dependency on ergotamine, there is a weekly limit of 5 suppositories. Gradual overuse of oral or rectal ergotamine may lead to dependency and the development of ergotamine headache. The patient develops a rebound or withdrawal ergotamine headache that is successfully treated with another dose of the drug. The total daily dose may slowly increase over years transforming a migraine headache into a chronic daily headache (Mathew, 1993). Other side effects include nausea, vomiting, abdominal pain, diarrhea, muscle cramps, paresthesias of the extremities, vasoconstriction and loss of pulses, and angina. Dihydroergotamine (DHE-45®) is effective in aborting migraine, and is more effective than meperidine plus hydroxyzine and utorphanol (Raskin, 1986) (Silberstein, 1990) (Welch). Up to 90 % of migraines treated with intravenous DHE 45® abated - it is also useful in treating drug-induced headache (Sands) (Silberstein 1990). Patients can be taught to give themselves subcutaneous or intramuscular injections. DHE-45® comes in ampules (1mg in 1 ml) - the dose may be titrated between 0.5-1.0 mg twice daily, as needed. The goal is to use the smallest effective dose. Initially metoclopramide or another antiemetic should be taken prior to DHE-45® to help control drug-induced nausea and vomiting. Many patients later find the metoclopramide is no longer necessary. The side effects of DHE-45® are similar to those of ergotamine but less severe. An intranasal formulation, Migranal®, is also available.The ergots are contraindicated in patients with severe hypertension, peripheral vascular disease, ischemic heart disease and thrombophlebitis. They should be used cautiously in patients with peptic ulcer disease, bradycardia, renal and hepatic abnormalities. The ergots can not be used with “triptan” drugs ( sumatriptan (Imitrex®), zolmitriptan (Zomig®), naratriptan (Amerge®), rizatriptan (Maxalt®)) within 24 hours. Sumatriptan Other “triptan” drugs available include zolmitriptan (Zomig®), naratriptan (Amerge®), and rizatriptan (Maxalt®). In the USA, these agents are presently available only as oral treatments. Other triptans (eg, eletriptan, almotriptan, frovatriptan), and other formulations (nasal sprays, injections) will likely become available in the future. Failure to respond to one triptan does not preclude a successful response to another (Ward 2000). These agents give superior results if used as early in the migraine attack as possible. Narcotics It is important to note that the efficacy of oral meperidine is approximately 25 % of the IM preparation. Oral meperidine should be used in a very limited way for selected patients with severe migraine and as a rescue medication when other measures fail. Medication use should be closely monitored. Transnasal butorphanol (Stadol NS®) has been used in the treatment of migraine. While US regulatory agencies formerly did not view it as a narcotic, it does contain the morphine molecule, and its major side effect is sedation. As a mixed agonist-antagonist, it may have less addiction potential. Nonetheless, overuse may occur, and it seems capable of causing rebound (Ward, unpublished observations). The initial dose of 1 mg = 1 puff in one nostril is approximately equipotent to 5 mg of morphine. Onset of action is rapid (minutes). Tip: Transnasal butorphanol is potent and very rapid in onset of action. It is an alternative to the patient reporting to the emergency department for parenteral narcotics. The patient is advised to take one puff, then go to bed. If this is too strong for the patient, yet relieves head pain, physicians may direct the pharmacist to dilute it in half with an equal volume of normal saline. Again, medication use should be closely monitored. Tip - pregnant migraine patients: There are very few medications that can be safely used, including acetaminophen, and meperidine. Combination analgesics are to be avoided. Oral meperidine can be titrated to produce the appropriate effect. Fortunately many migraineurs experience fewer headaches during pregnancy. Tension-Type
Headache Patients often complain of a dull ache across their forehead or in the back of their neck or both. The pain or pressure may be at the vertex, as well. It may feel as if a tight band is compressing the head. The pain location may vary and may even be unilateral at times. The neck muscles are usually tight. Patients do not often complain of photophobia, nausea or vomiting. Routine activity is generally not impaired, and there is less disability associated with headache episodes than there is with migraine. In primary tension-type headache the neurologic examination is normal, except for possible tightness/spasm in pericranial and cervical muscles. When the headache is chronic, depression and anxiety may be present. Tip-tension-type headache in patients who also have migraine may respond differently to treatment than in those patients who do not also have migraine. “Fibromyalgia” is often seen in migraine patients, and sometimes in those also having tension-type headache. This condition may be treated with physical measures, exercise, trigger point injections, muscle relaxants, and amitriptyline. Sleep disturbances are often prominent. Tension-type headache often may coexist or blend with episodic migraine headache, along a clinical spectrum. Chronic tension-type headache may also be exacerbated by drug-induced or rebound headache caused by increasing symptomatic medication use over time. It is important to find out exactly how much medication the patient uses. Tip-ask about over-the-counter, and herbal, remedies, as well as prescription medications. Treatment
of Tension-Type Headache Caffeine, present in medications, beverages and foods, often causes rebound headache. If the patient is taking over 500 mg daily, it is useful to slowly taper the caffeine ingestion. When the patient reports that caffeine ingestion provides headache relief within 1 hour, it virtually confirms the diagnosis of caffeine withdrawal headache. Amitriptyline, nortriptyline or doxepin can be used for prophylactic therapy (see above). Tip- Elderly patients often cannot tolerate the smallest dose tablets or capsules because of their increased sensitivity to medication. Doxepin (Sinequan®) comes in a concentrate that may be added to juice or other drink. This gives precise control over the dose and permits these patients to be successfully treated. Nortriptyline is also available in liquid form. Non-pharmacological treatments may also be useful. Biofeedback seems helpful, especially in combination with relaxation training and psychotherapy (Kunkel). Physical therapy and, if appropriate, an exercise program may be useful. Cluster
Headache The headaches of cluster patients occur typically in episodes or bouts lasting 2 to 4 months. During this time the attacks occur spontaneously or may be provoked by alcohol, histamine, or nitroglycerin). The time between bouts is a "remission" that may last from 1 month to 20 years, in episodic cluster headache. Occasionally, remissions are permanent. Some patients have chronic cluster headache, without remission (fewer than 14 days per year without attacks). The Differential Diagnosis Of Cluster Headache Includes:
Treatment Of Cluster Headache Symptomatic Treatment Of
Cluster Headache Prophylactic
Treatment Of Cluster Headache Tip-Prednisone causes immediate bone loss, even when given for a short time. This concern is especially important for women. Bone loss may be prevented by taking Vitamin D 50,000 units weekly and calcium, one gram per day. One inexpensive and easy way to achieve this intake of calcium is to take 4 Tums daily. Other measures to protect the stomach (such as H2 blockers, antacids, or proton pump inhibitors) may be advisable. Methysergide (Sansert®) is used as described under the treatment of migraine (see above). It tends to be most effective early in the course of the disease. It has been reported to have an efficacy of 65 % (Kudrow). Verapamil (Calan®, others) has been effective in several studies. Patients may require up to 480 mg per day (egg, as Calan SR 240 BID) or, cautiously, even higher doses. Adding oral ergotamine 2 mg 1 hour prior to bedtime increases the effect of the verapamil (Kudrow). Lithium is effective in episodic cluster and chronic cluster. The dose has to be gradually built up to avoid untoward reactions. This dose escalation takes place while controlling the cluster with the prednisone treatment. Lithium can be prescribed at 300 mg daily for 3 days then increased every 3 days until it is taken three times daily. It is necessary to follow the lithium serum level to monitor for toxicity. The concomitant use of diuretics, NSAIDS, and severe sodium -restricted diets are contraindicated, since this may cause toxicity. The symptoms of lithium toxicity include tremor, polyuria and mild nausea initially. Diarrhea, vomiting, drowsiness, muscular weakness, and incoordination occur with greater lithium intoxication. Stopping the lithium and monitoring the patient is necessary in this situation. Valproic acid (Depakote®) appears to be another treatment option in the treatment of cluster headache (Ward 2000). Recent studies suggest that for refractory cases, gabapentin (Neurontin®), and topiramate (Topamax®) might be useful. Combinations of verapamil and lithium, or verapamil and valproic acid, for example, may be effective when monotherapy fails. When all medical treatment fails surgical treatment may be appropriate. Currently the procedure of choice is percutaneous radiofrequency lesions directed against the trigeminal ganglion. This tends to produce the highest success rate and the least complications. Case
Report (Part 2) He was admitted and treated with nafcillin 2 grams and cefuroxime 1.5 grams, intravenously. Acetaminophen and ibuprofen were prescribed for his pain. Repeat CT scan of the brain this time with additional views of the paranasal sinuses showed fluid collections in both maxillary and ethmoid sinuses, as well as the left frontal and sphenoid sinuses. He underwent bilateral intranasal antrostomies, a left intranasal ethmoidectomy and a left sphenoidotomy. Subsequently his WBC normalized and he did well. Discussion Does the quantity of analgesic taken have any significance? The case is presented to sensitize you to the fact that not all headache is migraine or cluster. Also, many routine brain CT protocols do not include adequate views of the paranasal sinuses. Therefore, if clinically appropriate, these additional views should be obtained. References Barton CW. Evaluation and treatment of headache in the emergency department: a survey. Headache 34(2): 91, 1994. Headache Classification Committee of the International Headache Society: Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 8 (suppl 7): 1, 1988. Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: disability and economic costs. Arch Int Med 159(8):813-818,1999. Kudrow L. Diagnosis and treatment of cluster headache. Med Clin N Am. 75:579-594, 1991. Kunkel RS. Diagnosis and treatment of muscle contraction (tension-type headaches. Med Clin N Am. 75:595-603, 1991. Lance JW. Migraine: treatment, in mechanism and management of headache. 5th ed., Butterworth-Heinemann Ltd., Oxford, pp.128-9, 1993. Mathew N. Chronic refractory headache. Neurology: 43 (Suppl 3) S26-S33,1993. Mathew N. Diagnostic problems in headache. Case studies of headache, AAN dinner seminar, May 1994. Rapoport AM, Weeks RE, Sheftell F D, Baskin SM, Verdi J. The 'Analgesic washout period': A critical variable evaluation in the evaluation of headache treatment efficacy. Neurology 36 (suppl 1):100, 1986. Raskin NH. The cough headache syndrome: treatment. Neurology 45(9):1784. 1995. Raskin, NH. Headache 2nd Ed. Churchill Livingstone Inc. New York, NY. 1988. Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology 36:995-997, 1986. Sands GH. A protocol for butalbital, aspirin, caffeine (BAC) detoxification in headache patients. Headache 30: 491-496, 1990. Silberstein SD, Schulman EA, Hopkins MM. Repetitive intravenous DHE in the treatment of refractory headache. Headache 30:334-339, 1990. Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States. JAMA 267: 64-69, 1992. Volans G N: Migraine and drug absorption. Clin. Pharmacokinet. 3:313-318, 1978. Ward TN, Scott G. Dihydroergotamine Suppositories in a Headache Clinic. Headache 31:465-466, 1991. Ward TN. Providing relief from headache pain. Postgrad Med 2000: 108(3); 121-128. Welch KMA. Drug therapy of migraine. NEJM 329: 1476-1483, 1993. Self-Assessment1. A 35-year-old woman, with a past history of occasional migraine, has sudden onset of severe generalized headache and nausea, causing her to stop her activities and lie down. The headache persists and her family takes her to the emergency room. The primary diagnostic consideration for the examining physician is:
2. The above individual undergoes a noncontrast CT scan of the head which is read by the radiologist as negative. The next step for the examining physician is:
3. The following organic conditions can mimic recurrent primary headache disorders:
4. A 68-year-old female presents with a three week history of severe unilateral headache and scalp tenderness. She has had one episode, the day prior, of transient ipsilateral monocular visual loss, which has completely resolved. A stat sedimentation rate is 65 mm/hr. The following steps should be instituted:
5. Pick the one true statement among the following:
6. The mainstay drug(s) for treatment for episodic tension-type headache are:
7. Overuse of medications which symptomatically treat tension-type headache may lead to: 8. The following medication should not be used for migraine prophylaxis:
9. Label the following statements True (T) or False (F):
10. New-onset headache, followed shortly by confusion and/or seizures, may be secondary to:
Answers 1.
B |