CMED

311 – PBL Session

on Headache
August 8, 2017
CASE 1
•  General Data: 15 year-old female, right-handed, from Malate,
Manila

•  Chief Complaint: Headache
•  History of Present Illness:
2 months prior to consult, the paKent started complaining of
headache localized to the leM temporal area which spreads to involve
the enKre head. She characterized the pain as throbbing, pulsaKng or
someKmes squeezing in character. Pain intensity is between 5-8/10.
On occasion, she feels nauseated or vomits when she has a headache.
She prefers to be in a dark and quiet room when she has a headache.
Bright lights, strong smells, and loud noise make her headache worse.
The headache usually lasts for several hours. She takes Paracetamol
tablet which only provides temporary relief. Headaches were
occurring about once a week.
2 weeks prior to consult, around the Kme of her periodical exams,
headaches were occurring almost daily. Her mother reports that she
has been staying up late and has been only geXng 5-6 hours of sleep
over the last two weeks.

•  Review of Systems:
Only perKnent informaKon is that she wears eyeglasses for myopia

•  Birth and Maternal History:
•  Born FT via SVD to a 28 y/o G1PO mother, no complicaKons
•  BW: 3000 g NBS – normal

•  Developmental History: No reported delays
•  Grade 9 student – Honors Class

•  Past Medical History: (+) asthma – not on any medicaKons
•  No hospitalizaKons or surgeries

•  Family Medical History: (-) migraine, (+) Hypertension – father
•  Personal Social History: Lives at home in a condo with her mother
who is a housewife. Father works as an OFW in the Middle East.
She is an only child.

•  Physical Exam:
Weight 45 kg
HR = 90 bpm RR= 18 BP= 100/60 T= 36.4 C
•  Well-groomed, well-nourished, ambulatory, not in
distress
•  HEENT: pink conjuncKvae, anicteric sclerae, no nasal
discharge, no CLAD, TMs intact with no erythema, no
nasopharyngeal congesKon, no oral lesions
•  Chest and Lungs: symmetric chest expansion, lungs
clear to auscultaKon
•  CVS: disKnct heart sounds, regular rate and rhythm, no
murmurs, no thrills, full and equal pulses
•  Abdomen: soM, nondistended, nontender,
normoacKve bowel sounds, no organomegaly
•  ExtremiKes: no deformiKes, no swelling, no pedal
edema
•  Neurologic examinaKon:
•  Mental status: awake, alert, oriented to Kme, place
and person, answers appropriately, follows commands
•  CNs II-XII – intact
•  Funduscopy: sharp discs, no papilledema, no
hemorrhages
•  Motor: normal muscle bulk and tone, strength 5/5 in
all extremiKes
•  DTRs: 2+ in upper and lower extremiKes, symmetric
•  (-) Babinski
•  Gait: normal
•  Cerebellars: no ataxia, no dysmetria
•  Sensory: normal to light touch, temperature, vibraKon
•  Meningeals: no nuchal ridgidity

 Causes of headache
•  Hormones (estrogen)
•  Error of refracKon (myopic)
•  Stress/FaKgue- I
•  Environmental (CO, Pb, Noise polluKon)
•  Asthma – exerKonal headache
•  Sleep deprivaKon
•  Neurovascular problems – HPN, AVM, Aneurysm
•  Hypogylcemia
•  Increased ICP
•  Tumor
•  Pseudotumor cerebri
•  DehydraKon
•  Systemic viral infecKon
•  NutriKon – caffeine, alcohol, MSG
•  Trauma
•  Intracranial hemorrhage
•  SinusiKs
•  Meds – NSAIDs (analgesic rebound headaches)
•  OKKs Media

Anatomic substrate and pathophysiologic mechanisms
in the generaKon of headache
ANATOMIC
•  SCALP
•  Middle menigeal a
•  Falx cerebri
•  Dural sinuses
•  Proximal segments of PIA artery
•  CN V
•  Large intracranial vessels in dura meter
•  Rostral pain-processing regions
•  Muscles
•  Referred pain from TMJ, teeth, gums, sinuses, ears
PRIMARY SECONDARY
•  d/t the headache itself •  Present because of another
•  Ex. Migraine, Tension type condiKon
headache, cluster headache •  Symptom of an underlying
disorder
 DifferenKal Diagnoses
Group 2
1. Migraine headache
2. Tension-type headache
3. Cluster Headache

Group 1
1. Migraine headache
2. Error of RefracKon
3. Tension-type headache
 Other informaKon in history to help
support your diagnosis
•  LMP
•  Menarche
•  Meds
•  Diet – coffee, MSG
•  Vices – alcohol, smoking illicit drugs
•  RelaKonships – friends, love-life
•  Psychiatric condiKon – depression
•  Timing of headache
•  Type of vomiKng
•  Presence of aura
•  Sexual acKvity
 Primary Working Impression
•  Common Migraine (Migraine without aura)
 Guide QuesKons: Session 2
•  Discuss ICHD criteria for Migraine Headache
vs. Tension Type Headache
•  What diagnosKc tests are warranted in this
case, if any?
•  What features of a paKent presenKng with
headache warrant further invesKgaKon?
•  What is the management plan for this
paKent?


 Migraine vs. Tension Type Headache
MIGRAINE TENSION-TYPE
CASE 2
 Case 2
•  General Data: 50 year-old male, right-handed,
from Bacoor, Cavite

•  Chief Complaint: Headache
 Case 2: History of Present Illness

•  3 months PTA, paKent started complaining of intermilent headache, localized to
the bifrontal regions, 5-6/10 in severity, with no other associated symptoms.
PaKent only takes Paracetamol as needed which seemed to relieve the headaches.
He did not seek consult at that Kme.
•  2 months PTA, paKent noKced that headaches were occurring more frequently,
about 2-3x per week. He sKll did not seek any consult and only took Ibuprofen
•  1 month PTA, there was increase in severity of the headaches which were now
occurring daily. He consulted at a local health clinic and at the Kme of the consult,
his BP was elevated at 140/80. He was advised to take amlodipine 5 mg once a day
for BP control. He conKnued to experience intermilent headaches.
•  2 weeks PTA, headaches started occurring daily and were more severe, 8-10/10.
He was unable to go to work. He also noKced that his right arm was weak. He was
unable to liM objects with his right arm.
•  3 days PTA, he started having episodes of vomiKng associated with the headache.
•  1 day PTA, he woke up at 6 AM with severe headache and he vomited twice. His
wife also noted that he had a right facial droop. He was brought to a nearby clinic
and was advised admission.

•  Review of Systems:
•  Skin: no rashes
•  HEENT: wears eye glasses, no nasal discharge
•  Respiratory: no cough, no shortness of breath
•  CVS: no chest pain, no palpitaKons
•  Abdomen: no change in bowel habits
•  GU: no urinary frequency, no urinary urgency
•  Musculoskeletal: no muscle/ joint pains
•  Past Medical History: (+) hypertension
•  No hospitalizaKons or surgeries

•  Family Medical History: (-) migraine, (+) Hypertension –
both parents
•  Personal/Social History: married, with 2 grown children
•  Works as a construcKon worker
•  Cigarele smoker – smokes 1 pack per day for 25 years
•  Drinks alcohol – 1-2 bolles of beer every weekend
•  Denies illicit drug use
•  Physical Exam:
•  Weight 60 kg
•  HR = 76 bpm RR= 20 BP= 100/60 T= 36.7 C
•  Well-groomed, well-nourished, ambulatory, not in distress
•  HEENT: pink conjuncKvae, anicteric sclerae, no nasal discharge, no
CLAD, TMs intact with no erythema, no nasopharyngeal congesKon,
no oral lesions
•  Chest and Lungs: symmetric chest expansion, lungs clear to
auscultaKon
•  CVS: disKnct heart sounds, regular rate and rhythm, no murmurs,
no thrills, full and equal pulses
•  Abdomen: soM, nondistended, nontender, normoacKve bowel
sounds, no organomegaly
•  ExtremiKes: no deformiKes, no swelling, no pedal edema

Neurologic examina<on:
•  Mental status: awake, alert, oriented to Kme, place and person, answers
appropriately, follows commands
•  CNs:
•  II – visual acuity 20/25 with correcKon, no visual field cuts
•  III, IV, VI – limited abducKon of both eyes
•  VII – right facial droop but able to wrinkle forehead
•  VIII – intact gross hearing
•  IX, X – normal swallowing and phonaKon, intact gag
•  XI- good SCM tone and strength
•  XII – tongue midline on protrusion
•  Funduscopy: (+) papilledema in both eyes
•  Motor: normal muscle bulk, increased tone in RUE>RLE, normal tone in
LUE and LLE, Strength is 4/5 in RUE, 4+/5 in RLE, 5/5 in LUE and LLE
•  DTRs: 2+ in LUE and LLE, 3+ in RUE and RLE
•  (+) Babinski on the right
•  Gait: drags right leg when walking
•  Cerebellars: no ataxia, no dysmetria
•  Sensory: normal to light touch, temperature, vibraKon
•  Meningeals: no nuchal rigidity
 Guide Ques<ons: SESSION 1

•  What are the salient features of this case?
•  What is causing the headache in this paKent?
•  Localize the lesion. Describe the anatomic and
pathophysiologic mechanisms involved in the
generaKon of headache in this paKent
•  What are the most likely causes of headache in this
paKent?
•  What other informaKon would you like to obtain from
the history?
•  What is your primary working impression and why?

 GUIDE QUESTIONS: SESSION 2

•  What diagnosKc tests are warranted in this
case? Explain the reason for ordering such
tests – Results will be provided to you in the
next session
•  Based on the test results, what is your Primary
Working Impression?
•  What is the management plan for this
paKent?

 DiagnosKc Tests
•  CBC
–  Hgb 130 / Hct 0.43
–  WBC 6.7 (neu -0.4, lym-0.5, eos-0.1)
–  Plt 200

•  FBS – 100 mg/dl

•  Na – 141
•  K – 3.7
Head CT scan
Brain MRI with Contrast
Some Key Points about headaches
•  Headaches can result from primary or
secondary causes. IdenKfying the cause for
the headache is crucial in management

•  Headache can be a primary problem –

PRIMARY HEADACHE

•  Headache can be a symptom of another

disorder – SECONDARY HEADACHE
 What causes the headache?
•  The brain is an insensate organ and is not able to feel

•  Headache is due to the sKmulaKon of:
–  pain-sensiKve nerve fibers in large cerebral arteries and
veins
–  the periosteum of the skull
–  the muscle and skin of the scalp
–  the sinus mucosa
–  the temporomandibular joint, the teeth, or the gingiva
Key points in the history
•  Headache onset, duraKon, and severity
•  Associated symptoms
–  Nausea, vomiKng
–  Weakness
–  Sensory symptoms
–  Visual disturbance
•  Family history of migraines
•  MedicaKon history
–  NSAIDs
•  Factors that may have precipitated the headache
•  Sleep history
–  DuraKon, sleep schedule, snoring, excessive dayKme sleepiness
•  Diet history
–  Caffeine, processed foods
Key points in the PE
•  Vital signs – including BP
•  Skin rashes or lesions
•  Signs of neurologic abnormaliKes – focal
deficits, cranial nerve palsies
•  Hematomas or other signs of trauma
•  Signs of papilledema on funduscopy
•  Signs of meningeal irritaKon
•  HEENT exam
 Secondary headaches
Headache alributed to head and/or neck trauma
Acute post-traumaKc headache
Chronic post-traumaKc headache
Headache alributed to cranial or cervical vascular disorder
Headache alributed to nonvascular intracranial disorder
Headache alributed to high cerebrospinal fluid pressure
Headache alributed to low cerebrospinal fluid pressure
Headache alributed to intracranial neoplasm
Headache alributed to epilepKc seizure
Headache alributed to a substance or its withdrawal
MedicaKon-overuse headaches
Headache alributed to infecKon
Headache alributed to disorder of homeostasis
Headache of facial pain alributed to disorder of cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth, or other facial or cranial structures
Headache alributed to rhinosinusiKs
Headache alributed to psychiatric disorder
 Serious causes of Secondary
Headaches
•  Related to increased intracranial pressure
–  Mass lesion – tumor, vascular malformaKon
–  Intrinsic increase in intracranial pressure –
pseudotumor cerebri

•  Other causes
–  Subarachnoid hemorrhage
–  AVM, aneurysm
–  Meningeal irritaKon
–  Stroke
–  Hypertensive encephalopathy
Headaches related to intracranial mass

•  Severe occipital headache
•  Sneezing, coughing, any Valsalva maneuver, or
change in head posiKon exacerbates the pain
•  Pain is worse in the morning or awakens the
paKent from sleep
•  ProjecKle vomiKng without nausea and focal
seizures may occur
 IndicaKons for neuroimaging in a
paKent with headache
•  Abnormal neurologic examinaKon

•  Abnormal or focal neurologic signs or symptoms
•  Focal neurologic symptoms or signs developing during a headache (i.e.,
complicated migraine)

•  Focal neurologic symptoms or signs (except classic visual symptoms of
migraine) develop during the aura, with fixed laterality; focal signs of the
aura persisKng or recurring in the headache phase

•  Seizures or very brief auras (<5 min)

•  Unusual headaches in children

•  Atypical auras including basilar-type, hemiplegic

IndicaKons for neuroimaging in a child
with headache
•  Trigeminal autonomic cephalalgia including cluster headaches in child or
adolescent

•  An acute secondary headache (i.e., headache with known underlying
illness or insult)

•  Headache in children <6 yr old or any child that cannot adequately
describe their headache

•  Brief cough headache in a child or adolescent

•  Headache worst on first awakening or that awakens the child from sleep

•  Migrainous headache in the child with no family history of migraine or
its equivalent