Escolar Documentos
Profissional Documentos
Cultura Documentos
EADACHE
DISORDERS:
Approach to
Non-Migraine
The Foundation Types
for Medical Headaches are associated with a significant decrease
in quality of life. Most headache consultations (80%)
Practice occur in primary care. Since two common headache
types, tension-type headache (TTH) and migraine,
Education often share common presentations, this complicates
a definitive diagnosis. In addition, a small percentage
of headaches which are associated with neurologic
emergencies, raises the issue of suitable investigation.
Experience A systematic approach to the specific diagnosis of
headache can assist the clinician in solving these
Expérience clinical dilemmas and provide direction for selecting
appropriate and effective treatment.
Daciana presents for the third time this year with “sinus”
headache. She had previously been given antibiotics,
resulting in gradual headache relief over a week or two.
Daciana is expecting the same prescription and results Case 3: John, 52 years old, male
again. She has no nasal discharge or fever, and she
didn’t have a cold before this headache started. The John, a teacher, presents with a history of a post-coital
headache is behind her eyes and in her forehead and headache that he describes as a “thunderclap” headache,
has been fairly constant for the last 10 days or so. There which occurred the day before this appointment. He says
is no nausea, vomiting, aura or neurological symptoms, this was the worst headache he’s ever had and rates it
with the exception of slight photophobia. as an intensity of 9 on a scale of 1 to 10. It lasted the
entire day, but has now completely gone. He could not
Blood pressure is normal. Fundi are normal. There is get an appointment yesterday, so he took ibuprofen, 800
tenderness over the forehead and on the orbital rims mg, every six hours. The medication had no appreciable
but not specifically over the sinuses. You notice marked effect on the headache, which “seemed to resolve on
tenderness at the occipital insertion of the paraspinal its own.”
muscles of the neck. The flexion/rotation test reveals
only about 30 degree rotation bilaterally with end range His vital signs are stable, he has no neck stiffness, and
discomfort. You ask Daciana about her neck posture his neurological examination is normal. John has a history
at work and at home. She mentions she often watches of tension headaches, hypertension, and a 20-pack-year
television in bed before going to sleep, with two pillows smoking history. He has never been imaged in the past.
rolled up behind her head. He has no family history of migraine or aneurysm.
What would be your diagnosis? What additional information would you seek?
How would you treat Daciana? How would you handle this case at this juncture?
2
Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010
3
Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010
The headache is typically localized to the neck or Note: Info Points 6 and 7 have a foundation in
occipital regions but may project to the head and/or physiotherapy literature which, unfortunately, is not
face.1 The most important/sensitive signs indicating supported by large randomized control trials but
cervical headache were: based more on expert opinion.
• unilateral headache with side consistency. For
example, if the patient reported that one day the 8. Episodic Tension-type Headache (ETTH) versus
headache was on the left and the other day on Headache Due to Rhinosinusitis
the right, then it was less likely cervical in origin It has been reported that “sinus headache” is
(although it may be bilateral). overdiagnosed. One study (N = 2991) investigating
• headache precipitated or aggravated by certain patients with a supposed history of “sinus
postures such as prolonged reading, keyboarding, headache” reported that 88% of these individuals
turning to look back, neck hyperextension, etc. were subsequently diagnosed with either migraine
• restricted range of motion of the neck especially or migrainous headache, based on headache history
with rotation.6 and symptom description [Level II-2 evidence].10
• evidence of impaired cervical function most Signs such as headache triggers, pain location and
commonly at C1-2.7 The flexion/rotation test autonomic symptoms associated with the sinuses
(method follows) has been shown to accurately (i.e., nasal congestion) often contributed to the
identify dysfunction at this level. With the patient resulting misdiagnoses.11
lying supine, first the neck is flexed bringing the
chin to the manubrium, and then the neck is In the absence of fever or purulent discharge
passively rotated to the right and left (normal (rhinosinusitis), recurrent headaches with “sinus”
rotation is 45 degrees). A decrease in rotation symptoms, should prompt a systematic headache
on one or both sides indicates dysfunction at evaluation.
the level of C1-2.8 Nerve block can relieve
cervicogenic headache3 (but is seldom used in Chronic Headache and Headache Comparisons
general practice).
9. Chronic Daily Headache is actually considered to be
The presence of painful segmental dysfunction a category of headache, not a diagnosis.
occurring in C1-3 most clearly identified patients with • This category includes headache that is present
cervicogenic headaches from those with migraine or > 15 days/month for > 3 months and involves
tension-type headaches.5 a variety of primary and secondary headache
types.12
7. Mechanism of Cervicogenic Headache • Risk factors for chronic daily headache include
Flexing the neck to bring the chin to the manubrium obesity, history of > 1 headache/week, caffeine,
tests the entire cervical spine. In cervicogenic and overuse of acute headache treatments (>
headache, however, the concern is with the upper 10 days/month).12
three segments of the cervical spine (occipito-axial • Other risk factors implicated in chronic daily
region). In order to test and limit flexion to the headache include stressful life events, neck
upper three segments, have the patient lie supine injury, and snoring (which appears to be a
and retract the chin as if making a “double chin.” common factor).13;14
Similarly, to extend only the upper three segments,
have the patient, still while lying supine, thrust 10. Chronic Tension-type Headache (TTH) versus
the chin forward. Chin retraction (flexion) or chin Hemicrania Continua
protrusion (extension) is held for a few minutes at • Unlike chronic TTH which is often bilateral,
a time. If either of these postures results in the hemicrania continua has a unilateral
headache increasing, decreasing, or terminating, the presentation.3
pain is coming from the upper cervical spine. The • Although this rare, continuous, moderately
pain usually results from static loading in the end severe headache may vary in intensity, it never
range (which creates static postural distortion) not completely disappears.15
necessarily from dynamic movement of the spine. • Cranial autonomic disturbances, such as
The flexion/rotation test (see Info Point 6) may help miosis and eye-tearing, accompany hemicrania
to confirm if the dysfunction is at the level of C1- continua.12
2.8;9 (Information summarised from pp. 189-199 in
McKenzie, 1990)
4
Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010
11. Chronic Tension-type Headache (TTH) versus Chronic 15. Subarachnoid Hemorrhage
Migraine3 • Fewer than half of patients present with a
• Chronic TTH: All days with a headache which characteristic sudden, violent headache.19
meets chronic TTH criteria • Sentinel headache, which may be confused with
• Chronic migraine: > 15 days/month for > 3 migraine, sinusitis, or neck problems, may occur
months1 6 – 20 days before the actual hemorrhage.20
• Chronic TTH with episodic migraine: < 50% of Sentinel bleed is thought to represent a small
days with a headache which meets migraine or “leak” of an aneurysm which subsequently
probable migraine criteria seals itself. Presenting signs depend on the
• Chronic migraine: ≥ 50% of days with a headache aneurysm location. This headache may also
which meets migraine or probable migraine resemble thunderclap headache. Nonsteroidal
criteria. anti-inflammatory drugs (NSAIDs) may relieve
pain temporarily.
12. Medication overuse headache
• This type of headache can be associated with
triptans, ergots, or analgesics (Appendix 1),12 APPROACH TO THE PATIENT WITH HEADACHE
and can complicate a diagnosis of chronic daily
headache.13 16. History
• The risk of medication overuse headache For each patient with headache, a medical and social
increases with both the frequency of use and history (including history of head and/or neck trauma,
the number of medications used for acute use of alcohol and medication) should be done. For
headache.16 each headache type (a patient may have more than
• Since medication overuse headache is refractory one type of headache), a thorough headache history
to treatment, termination of acute medications is critical to an accurate diagnosis.2;21-23
is essential for accurate diagnosis and
effective management.12 “Withdrawal symptoms • Headache: Age of onset, duration, frequency,
usually last for 2 – 10 days (average 3.5 days) progression, family history of headache
and include withdrawal headache, nausea, • Pain: Severity, characteristics, location, radiation,
vomiting, arterial hypotension, tachycardia, activity limitation
sleep disturbances,restlessness, anxiety, and • Associated symptoms: Aura, systemic signs
nervousness. The withdrawal phase is much (such as rash), focal neurologic symptoms,
shorter when patients are overusing only nausea, vomiting, phonophobia, photophobia
triptans.”16 • Precipitating or aggravating factors: Including
• If discontinuation does not reduce headache lifestyle changes (diet, sleep, travel), strenuous
frequency, then chronic daily headache could be unaccustomed physical activity, positional
considered as a diagnosis.3 changes
• Treatment: Type, amount, effectiveness and
13. The Contribution of Caffeine duration of relief, frequency of use.
• Headaches associated with consumption of
caffeine result more from withdrawal of caffeine Requesting that the patient keep a headache diary
than from its use or overuse.1 for a few weeks can provide valuable information.
5
Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010
initial investigations would include neuroimging (CT • As part of the acute medication withdrawal,
or magnetic resonance imaging, depending on the a tricyclic antidepressant may be initiated to
presentation). If the CT is negative, lumbar puncture reduce headache frequency.12
is a consideration. Urgent neurologist referral might • Prednisone taken for several days may reduce
also be considered.19 the duration of severe withdrawal headache:12
o 60 mg for five days.12
o A tapered prednisone regimen (60 mg
MANAGEMENT STRATEGIES for two days, 40 mg for two days, 20 mg
for two days plus ranitidine 300 mg/day)
19. Tension-type Headache (TTH) has been associated with significantly
• Patients typically treat episodic TTH with NSAIDs reduced headache symptoms and a lack of
or acetaminophen.2 Unfortunately, no evidence withdrawal symptoms.25
guides specific selection of medications for • Discontinuation of medication as an inpatient
individual patients. may be needed for patients who:12
• Limiting analgesic use to a maximum of twice o Are unsuccessful in attempting termination
weekly can prevent development of medication as outpatients
overuse headache. o Are consuming a barbiturate or opioid dosage
• Prophylactic agents, such as amitriptyline that makes outpatient discontinuation
(Elavil®), can reduce both headache frequency unsafe
and acute use of medications in patients with o Have medical or psychiatric conditions that
chronic TTH. makes outpatient termination inadvisable.
• It is also appropriate to identify, and attempt
to modify, factors (such as smoking) that may 21. Cervicogenic Headache
be triggering or exacerbating these headaches. • When successful management is applied to the
Results from the HEAD-hunt study24 (N=51,383 cause of the problem, pain should resolve within
completed questionnaires) indicated that three months.1 Physical and manual therapy is
“[p]revalence rates for headache were higher the basis of treatment.
amongst smokers compared with never • Appropriate use of analgesics or anaesthetic
smokers, most evident for those under 40 years injected into trigger points allows patients to
smoking more than 10 cigarettes per day (OR participate in physical therapy.26 A controlled
1.5, 95% CI 1.3–1.6)” trial found the effectiveness of physiotherapy
o The possibility of reversed causality is was not dependent on age, gender or headache
worth consideration, i.e., the fact that the chronicity.27
headache itself may contribute to smoking,
because stressful situations could increase 22. Hemicrania Continua
the urge to smoke. This rare headache responds completely to
o In addition, the addictive nature of nicotine, indomethacin.3
particularly when used daily, may increase
the likelihood of experiencing a headache Non-pharmacologic Approaches
in a way similar to medication overuse
headache.24 23. Behavioural interventions can reduce symptoms of
TTH.28 Therapies include biofeedback, meditation,
20. Medication Withdrawal in Medication Overuse relaxation training, hypnosis, and cognitive
Headache behavioural therapy.
• Although there is a lack of well-conducted
trials to assess the effectiveness of solely 24. A recent review of RCTs (N = 2317 patients) involving
discontinuing medication,12 termination of acupuncture in patients with frequent episodic and
medications for acute headache remains the chronic TTH, concluded that acupuncture could be
treatment of choice, since patients seem to valuable in patients with frequent TTH [Level I-1
improve after medication is discontinued. On Evidence].29
average, withdrawal symptoms last 3.5 days
(range 2-10 days).16
• Although simple analgesics can be terminated
abruptly, opioids and barbiturates should be tapered
off over a period of approximately one month.12
6
Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010
7
Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010
type exists. This, however, cannot be diagnosed until use cranial computed tomography (CT) (Info Point 18). If the
of acute headache medication has been discontinued CT scan is negative, a lumbar puncture is indicated to
and characteristics of the underlying headache have assess for blood in the cerebrospinal fluid (CSF) and
been observed (Info Points 9, 12). It is important to must be done within 10 days of onset of subarachnoid
explain to Katie the cause of her daily headaches and hemorrhage to detect xanthachromia.
the need for her to discontinue acetaminophen. She
needs to pick a time when she can devote several days to Case evolution: John was not imaged at the first
this process (Info Point 20). Some patients may require presentation, but sent home with reassurance. He went
hospitalization for detoxification. Starting a tricyclic on to have a subarachnoid hemorrhage a week later (Info
antidepressant upon medication discontinuation may Point 15). His symptoms were similar to the headache
reduce headache frequency after withdrawal of acute he experienced with the sentinel bleed. However, the
medications (Info Point 20). Prednisone has also been symptoms persisted and he developed unilateral
used to facilitate withdrawal (Info Point 20). weakness and facial droop.
8
Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010
Strength of Recommendations
The Foundation’s module team would like to acknowledge
the assistance of Roger Butler, Carol Geller, and Liz Shaw A Good evidence to recommend the clinical action.
for their participation in the initial roundtable discussion.
We also wish to thank the Practice Based Small Groups B Fair evidence to recommend the clinical action.
facilitated by Murray Awde (London, Ontario) and Ruth
Simkin (Winnipeg, Manitoba) who pilot tested this C Existing evidence is conflicting and does not allow
making a recommendation for or against the use
educational module and provided suggestions for
of the clinical action. However, other factors may
improvement. influence decision making.
Disclosures of competing interests: D Fair evidence to recommend against the clinical action.
No competing interests were declared for Christine E Good evidence to recommend against the clinical
Thornton, Linda Gagnon, Sian Spacey, Richard Russek, action.
or Joanna Gorski.
I Insufficient evidence (in quantity and/or quality) to
make a recommendation. However, other factors may
influence decision making.
While every care has been taken in compiling the information contained
in this module, the Program cannot guarantee its applicability in specific
clinical situations or with individual patients. Physicians and others Adapted from: The Canadian Task Force on the Periodic Health
should exercise their own independent judgement concerning patient Examination. www.ctfphc.org/ctfphc&methods.htm Accessed
care and treatment, based on the special circumstances of each case. December 15, 2008.
Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM,
Anyone using the information does so at their own risk and releases et al. Current methods of the US Preventive Services Task Force: a
and agrees to indemnify The Foundation for Medical Practice Education review of the process. Am J Prev Med 2001;20(3S):21-35. PMID:
and the Practice Based Small Group Learning Program from any and all 11306229 2007 update available at www.ahrq.gov/clinic/uspstf/
grades.htm Accessed December 15, 2008.
injury or damage arising from such use.
9
Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010
References
(1) The International Classification of Headache Disorders: 2nd (17) Joubert J. Diagnosing headache. Aust Fam Physician 2005;
edition. Cephalalgia 2004; 24 Suppl 1:9-160. PM:14979299 34(8):621-625. PM:16113697
(2) Millea PJ, Brodie JJ. Tension-type headache. Am Fam Physician (18) Diagnosis and management of headache in adults. Quick
2002; 66(5):797-804. PM:12322770 Reference Guide. 2008; 107. Edinburg, UK. Scottish
Intercollegiate Guidelines Network (SIGN). Accessed July,
(3) Bigal ME, Lipton RB. Tension-type headache: classification 2009
and diagnosis. Curr Pain Headache Rep 2005; 9(6):423-429.
PM:16282043 (19) Richman E. When a Headache Isn’t Just a Headache. Neurology
Reviews com 2000; 8(11). Accessed July, 2010.
(4) Spierings EL, Ranke AH, Honkoop PC. Precipitating and
aggravating factors of migraine versus tension-type headache. (20) Singer RJ, Ogilvy CS, Rordorf G. Etiology, clinical manifestations,
Headache 2001; 41(6):554-558. PM:11437890 and diagnosis of aneurysmal subarachnoid hemorrhage.
UpToDate 2009; 17.3. Accessed July, 2010. www.uptodate.
(5) Zito G, Jull G, Story I. Clinical tests of musculoskeletal com
dysfunction in the diagnosis of cervicogenic headache. Man
Ther 2006; 11(2):118-129. PM:16027027 (21) Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA,
McCrory DC, Booth CM. Does this patient with headache have
(6) Vincent MB, Luna RA. Cervicogenic headache: a comparison a migraine or need neuroimaging? JAMA 2006; 296(10):1274-
with migraine and tension-type headache. Cephalalgia 1999; 1283. PM:16968852
19 Suppl 25:11-16. PM:10668112
(22) Ryan RE, Jr., Pearlman SH. Common headache misdiagnoses.
(7) Ogince M, Hall T, Robinson K, Blackmore AM. The diagnostic Prim Care 2004; 31(2):395-405, viii. PM:15172514
validity of the cervical flexion-rotation test in C1/2-related
cervicogenic headache. Man Ther 2007; 12(3):256-262. (23) Steiner TJ, MacGregor EA, Davies PTG. Guidelines for All
PM:17112768 Healthcare Professionals in the Diagnosis and Management
of Migraine, Tension-Type, Cluster and Medication-Overuse
(8) Mulligan BR. Self Treatments for Back, Neck, Limbs. A new Headache. 3:1-52. 2007. Hull, UK, British Association for the
approach. 2nd ed. London, ON: Canzed Seminars (Canadian Study of Headache. Accessed July, 2010.
distributor); 2006.
(24) Aamodt AH, Stovner LJ, Hagen K, Brathen G, Zwart J. Headache
(9) McKenzie RA. The Cervical and Throacic Spine: Mechanical prevalence related to smoking and alcohol use. The Head-HUNT
Diagnosis and Therapy. Waikanae: NZ: Spinal Publications; Study. Eur J Neurol 2006; 13(11):1233-1238. PM:17038038
1990.
(25) Krymchantowski AV, Barbosa JS. Prednisone as initial
(10) Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson treatment of analgesic-induced daily headache. Cephalalgia
MS, Powers C. Prevalence of migraine in patients with a history 2000; 20(2):107-113. PM:10961766
of self-reported or physician-diagnosed “sinus” headache. Arch
Intern Med 2004; 164(16):1769-1772. PM:15364670 (26) Biondi DM. Cervicogenic headache: a review of diagnostic
and treatment strategies. J Am Osteopath Assoc 2005; 105(4
(11) Eross E, Dodick D, Eross M. The Sinus, Allergy and Migraine Suppl 2):16S-22S. PM:15928349
Study (SAMS). Headache 2007; 47(2):213-224. PM:17300361
(27) Jull GA, Stanton WR. Predictors of responsiveness to
(12) Dodick DW. Clinical practice. Chronic daily headache. N Engl J physiotherapy management of cervicogenic headache.
Med 2006; 354(2):158-165. PM:16407511 Cephalalgia 2005; 25(2):101-108. PM:15658946
(13) Hutchinson S. Chronic daily headache. Prim Care 2004; (28) Sierpina V, Astin J, Giordano J. Mind-body therapies for
31(2):353-67, vii. PM:15172511 headache. Am Fam Physician 2007; 76(10):1518-1522.
PM:18052018
(14) Scher AI, Lipton RB, Stewart WF. Habitual snoring as a risk
factor for chronic daily headache. Neurology 2003; 60(8):1366- (29) Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White
1368. PM:12707447 AR. Acupuncture for tension-type headache. Cochrane Database
Syst Rev 2009;(1):CD007587. PM:19160338
(15) Silberstein SD. Chronic daily headache. J Am Osteopath Assoc
2005; 105(4 Suppl 2):23S-29S. PM:15928350
(16) Katsarava Z, Jensen R. Medication-overuse headache:
where are we now? Curr Opin Neurol 2007; 20(3):326-330.
PM:17495628
10
APPENDIX 1. ICHD-II CLASSIFICATION OF HEADACHE DISORDERS*
*Synthesized from information found in The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004; 24 Suppl 1:
9-160.
11
APPENDIX 2. RED FLAG HEADACHES AND HEADACHE FEATURES
Some feature of history or examination suggests a secondary headache cause (red flag). The following red flags should
prompt urgent headache investigation.
Sources: 1) Millea PJ, Brodie JJ. Tension-type headache. Am Fam Physician 2002; 66(5):797-804; 2) Joubert J. Diagnosing headache. Aust Fam
Physician 2005; 34(8):621-625; 3) Diagnosis and management of headache in adults. Quick Reference Guide. 2008; 107. Edinburg, UK. Scottish
Intercollegiate Guidelines Network (SIGN); 4) Richman E. When a Headache Isn’t Just a Headache. Neurology Reviews com 2000; 8(11); 5) Ryan RE,
Jr., Pearlman SH. Common headache misdiagnoses. Prim Care 2004; 31(2):395-405, viii.
12