Migraine Headache Case File

Migraine Headache Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 34

A 33-year-old woman presents with a complaint of headaches. She has had headaches since she was a teenager, but they have become more debilitating recently. The episodes occur once or twice each month and last for up to 2 days. The pain begins in the right temple or at the back of the right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing sensation that gradually worsens and is associated with severe nausea. Several factors aggravate the pain, including loud noises and movement. She has taken several over-thecounter medications for the pain, but the only thing that works is going to sleep in a quiet, darkened room. A thorough history reveals that her mother suffers from migraine headaches. Her vital signs, general physical examination, and a thorough neurologic examination are all within normal limits.

⯈ What is the most likely diagnosis?

⯈ What imaging study is most appropriate at this time?

⯈ What are the most appropriate therapeutic options?

ANSWER TO CASE 34

Migraine Headache

Summary: A 33-year-old woman presents with headaches that are throbbing and over her right eye. Her headaches have occurred since she was a teenager and have progressively worsened. She has not found relief from over-the-counter preparations.

• Most likely diagnosis: Migraine without aura.
• Most appropriate imaging study: No imaging is indicated at this time as there are no "red flag" symptoms or signs.
• Most appropriate therapy: A "triptan" medication given in a means that does not have to be swallowed ( eg, subcutaneous, intranasal, or orally dissolving tablet).

ANALYSIS

Objectives

1. Know the differential diagnosis of chronic headache.
2. Learn the "red flag" symptoms and signs that should prompt rapid, specific diagnostic and treatment interventions.
3. Know how to manage common headache syndromes.

Considerations

The patient described in the case has symptoms that are very characteristic of classic migraines without aura. Her headaches are unilateral, throbbing in nature, and have been progressively worsening. Migraine headaches are the most common headaches of vascular origin and the second most common cause of headaches overall. Migraines are a member of a group of primary headache syndromes differentiated by their associated features. Migraines typically cause recurrent episodes of headache, nausea, and vomiting. They can also be associated with other neurologic symptoms such as photophobia, light-headedness, paresthesias, vertigo, and visual disturbances. In the patient described in this case, the history and lack of physical findings can reasonably lead to the diagnosis of migraine headaches without aura ("common migraine''), the most frequently occurring form. Other classifications of migraines include migraine with aura ("classic migraine''), ophthalmoplegic migraine, retinal migraine, and childhood periodic syndromes that may be precursors to or associated with migraines. During the evaluation of this patient, the focus should be on determining the etiology of the headache, assessing for any red flags (Table 34-1) that may indicate worse pathologic causes, identifying triggers, and therapy for the condition.

According to the International Headache Society, symptoms diagnostic of migraine headache (Table 34-2) include moderate to severe headache with a pulsating quality; unilateral location; nausea and/ or vomiting; photophobia;

Data from South-Paul JE, Matheny SC, Lewis EL, et al. Current Diagnosis and Treatment in Family Medicine. New York,

NY: McGraw-Hill; 2004:330.

phonophobia; worsening with act1v1ty; multiple attacks lasting for 4 hours to 3 days; and absence of history or physical examination findings that would make it likely that the headache is the result of another cause. Common triggers of migraine headaches include menses, fatigue, hunger, and stress.

Adapted from the International Headache Society Classification (Headache Classification Committee of the International

Headache Society, 2004).

Approach To:

Migraine Headaches

DEFINITIONS

PRIMARY HEADACHE SYNDROME: Headaches in which headache and associated features occur in the absence of any exogenous cause. The most common are migraine, tension-type headache, and cluster headache.

MIGRAINE HEADACHES: Vascular headaches typically throbbing unilateral in character, and may be present with or without an aura. There is a high female predominance.

TENSION HEADACHE: The most common primary headache syndrome, typically presenting with pericranial muscle tenderness and a description of a bilateral band-like distribution of the pain.

CLUSTER HEADACHE: Unilateral headaches that may have a high male predominance, can be located in the orbital, supraorbital, or temporal region. It is generally described as a deep, excruciating pain lasting from 15 minutes to 3 hours. These headaches are usually episodic; however, a small subset may have chronic headaches.

CHRONIC DAILY HEADACHE: Experiencing headache on 15 days or more per month. Chronic daily headache (CDH) is not a single entity; it can encompass a number of headache syndromes, including chronic tension headaches, migraines, infection, inflammation, trauma, and medication overuse.

CLINICAL APPROACH

Headaches are an extremely common complaint in primary care, urgent care, and emergency settings. The vast majority of adults have at least one headache each year, although most do not present for medical care. The role of the practitioner is to attempt to accurately diagnose the cause of the headache, rule out secondary causes of headaches ("red flags") that may signify a serious underlying pathology, provide appropriate acute management, and assist with headache prevention when needed. It is important that each individual headache be evaluated in the context of patient's prior headaches. The clinician should remain alert to the possibility of a secondary cause for the headache. Migraine headaches do not preclude the presence of underlying pathology.

The medical history in a patient with headaches should focus on several important areas. The quality and characteristics of the headache and its specific location and radiation should be identified. The presence of associated symptoms, especially neurologic symptoms that may suggest the presence of a focal neurologic lesion or increased intracranial pressure, must be documented. The age at which the patient first developed the headaches, the frequency and duration of the headaches, and the amount of disability and distress that is caused to the patient should be explored. It is also important to note what the patient has done to try to treat the headaches in the past, including as much detail as possible regarding medication usage (both prescription and over-the-counter [OTC]). Determining functional limitations during headaches and categorization of the migraine severity level should also be determined as it will affect the choice of treatment:

Mild: Patient is aware of a headache but able to continue daily routine.

Moderate: The headache inhibits daily activities but is not incapacitating.

Severe: The headache is incapacitating.

Status: A severe headache that has lasted more than 72 hours.

Clinicians should stratify treatment based on severity rather than using stepped care.

The examination should include both a general and a detailed neurologic examination. A funduscopic examination revealing papilledema may be supportive of the presence of increased intracranial pressure. Identifying a focal neurologic deficit increases the likelihood of finding a significant central nervous system (CNS) pathology as the cause of the headache.

A patient with symptoms and signs consistent with migraine and who does not have any"red flag" findings (see Table 34-1) does not require any further testing prior to instituting treatment. Neuroimaging should be performed if there is an unexplained neurologic abnormality on examination or if the headache syndrome is not typical of either migraines or some other primary headache disorder. The presence of rapidly increasing headache frequency or a history of either lack of coordination, focal neurologic symptom, or headache awakening the patient from sleep raises the likelihood of finding an abnormality on an imaging test. Magnetic resonance imaging (MRI) may be more sensitive than computed tomography (CT) scanning for the identification of abnormalities, but it may not be more sensitive at identifying significant abnormalities. CT scanning would be initial imaging for "thunderclap" headaches where intracranial bleeds are considered. Other testing (eg, blood tests, electroencephalogram (EEG]) should only be performed for diagnostic purposes if there is a suspicion based on the history or physical examination.

The treatment of headache is best individualized based on a thorough history, physical examination, and the interpretation of any additional study results. Migraines can often be managed to some degree by a variety of nonpharmacologic approaches. Nonpharmacologic treatment can include patient education, bed rest in a dark room, and removal of known triggers. Most patients benefit from simple avoidance of specific headache triggers. Lifestyle modifications may be helpful. These could include diet changes, regular exercise, regular sleep patterns, avoidance of excess caffeine and alcohol, and avoidance of acute changes in stress levels. Migraine patients do not encounter more stress or triggers than the general population; however, they may have overresponsiveness to these triggers. Some techniques to manage stress may include yoga, meditation, hypnosis, and conditioning techniques such as biofeedback. Other nonpharmacologic treatments which may be effective in some patients include cold applications, constant temporal artery pressure, acupuncture, and hyperbaric oxygen.

The US Headache Consortium lists the following general management guidelines for the treatment of migraine headaches:

• Educate migraine patients about their condition and its treatment, and to participate in their own management.
• Use migraine-specific agents (eg, triptans, dihydroergotamine, ergotamine) in patients with more severe migraines, and in those whose headaches respond poorly to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) or combination analgesics, such as aspirin plus acetaminophen plus caffeine.
• Select a nonoral route of administration for patients whose migraines present early with nausea or vomiting as a significant component of the symptom complex.
• Consider using a self-administered rescue medication for patients with severe migraine who do not respond well to other treatments.
• Guard against medication-overuse or rebound headaches. Patients who require acute treatment on two or more occasions per week should probably be on prophylactic treatment.

The goal of therapy in migraine prophylaxis is a reduction in the severity and frequency of headache by 50% or more. Options for pharmacologic treatment and prophylaxis of migraines are listed in Tables 34-3 and 34-4, respectively.

OTHER HEADACHE SYNDROMES

Tension-Type Headache

Tension headache is the most prevalent form of primary headache disorder, typically presenting with pericranial muscle tenderness and a description of a bilateral band-like distribution of the pain. Headaches can last from 30 minutes to 7 days and there is no aggravation by walking stairs or similar routine physical activity. There is no associated nausea or vomiting. Both photophobia and phonophobia are absent, or one, but not the other, is present. They can be either episodic ( <180 d/y) or chronic (>180 d/y).

Initial medical therapy of episodic tension-type headache includes aspirin, acetaminophen, and NSAIDs. Combination analgesics containing caffeine are secondline options. Measures to minimize risk of medication-overuse headaches include limiting use of drugs to treat acute headache to 2 to 3 d/wk, avoiding opioids and sedative hypnotics, and monitoring medication intake.

The general management principles for the treatment of migraine headaches can also be applied to the treatment of chronic tension-type headaches. In frequent headache sufferers, the combination of antidepressant medications and stress management therapy reduces headache activity significantly. Other prophylactic treatments of chronic tension-type headaches include electromyography (EMG) biofeedback, acupuncture, cognitive behavioral therapy, and relaxation training. Pharmacologic therapies for prophylaxis include amitriptyline as a first line, mirtazapine, venlafaxine, calcium channel blockers, and β-blockers.

Cluster Headache

Cluster headache is strictly unilateral in location and can be located in the orbital, supraorbital, or temporal region. It is generally described as a deep, excruciating

aNot all drugs are specifically indicated by the FDA for migraine. Local regulations and guidelines should be

consulted.

Note: Antiemetics (eg, domperidone 10 mg or ondansetron 4 or 8 mg) or prokinetics (eg, metoclopramide 10 mg)

are sometimes useful adjuncts.

Abbreviations: 5-HT, 5-hydroxytryptamine; NSAIDs, nonsteroidal anti-inflammatory drugs.

Reproduced, with permission, from Kasper D, Fauci A, Houser S, et al. Harrison's Principles of Internal Medicine. 19th ed.

New York, NY: McGraw-Hill Education; 201 S. Table 447-4.

pain lasting from 15 minutes to 3 hours. The frequency can vary from one every other day to eight attacks per day. Cluster headaches are associated with ipsilateral autonomic signs and symptoms, and have a much greater prevalence in men. Compared to migraine sufferers who often desire sleep and a quiet, dark environment during their headache, individuals with cluster headache pace around, unable to find a comfortable position. The first-line treatment of cluster headache includes 100% oxygen at 6 L/ min, and triptans. Second-line treatment for acute attacks includes intranasal lidocaine, dihydroergotamine, prednisone, octreotide, and somatostatin. Verapamil, lithium, melatonin, antiepileptics, and prednisone may

aCommonly used preventives are listed with typical doses and common side effects. Not all listed medicines are

approved by the US Food and Drug Administration; local regulations and guidelines should be consulted.

bNot available in the United States.

cNot currently available worldwide.

Reproduced, with permission, from Kasper D, Fauci A, Hauser S, et al. Harrison's Principles of Internal Medicine. 19th ed.

New York, NY: McGraw-Hill Education; 2015. Table 447-6.

be used for prophylactic treatment. Because of side effects related to chronic use, ergotamine and prednisone need to be used with caution.

Chronic Medical Conditions

Patients with certain underlying medical conditions have a greater incidence of having an organic cause of their headache. Patients with cancer may develop headaches as a consequence of metastases. Someone with uncontrolled hypertension (with diastolic pressures >110 mm Hg) may present with the chief complaint of headache. Patients with HIV infection or AIDS may present with central nervous system metastases, lymphoma, toxoplasmosis, or meningitis as the cause of their headache. It is always important to evaluate each headache in context and consider secondary causes.

Medication-Related Headache

Numerous medications have headache as a reported adverse effect. Medicationoveruse headache (formerly drug-induced or "rebound" headache) may occur following frequent use of any analgesic or headache medication. This includes both nonprescription ( eg, acetaminophen, NSAIDs) and prescription medications. Caffeine use, whether as a component of an analgesic or a beverage, is another culprit in this category. The duration and severity of the withdrawal headache following discontinuation of the medication vary depending on the medication(s) involved. Any contributing, underlying psychological conditions that may lead to medication overuse may make discontinuation of the medication difficult and should be addressed.

COMPREHENSION QUESTIONS

34.1 A 28-year-old man presents for evaluation of headaches. He has had several episodes of unilateral throbbing headaches that last 8 to 12 hours. When they occur, he gets nauseated and just wants to go to bed. Usually they are relieved after he lays down in a dark, quiet room for the remainder of the day. He is missing significant work time due to the headaches. He has a normal examination today. Which of the following statements is accurate regarding this situation?

A. He needs a CT scan of his head to evaluate for the cause of his headache.

B. When he gets his next headache, he should breathe in 100% oxygen and use a triptan medication.

C. If he has not already done so, he should use aspirin 650 mg orally every 4 hours as needed and take a stress-management class.

D. An injectable or nasal spray triptan is most appropriate.

34.2 A 52-year-old woman presents to the office for an acute visit complaining of 2 hours of headache. She says that it came on suddenly with no account of trauma and is the worst headache she has ever had. She has had migraines since she was an early adult. The pain is described as "stabbing" and is more severe on the left side. She takes no medications and recently stopped taking oral contraceptive pills after going through menopause. Her blood pressure is elevated at 145/95 mm Hg, but otherwise she has no focal neurologic abnormalities on examination. She is alert and oriented to person, place, time, and situation. Which of the following is the most appropriate management at this time?

A. Prescribe a triptan medication.

B. Schedule a noncontrast head CT scan for tomorrow morning.

C. Call 911 and transfer the patient to the nearest emergency room.

D. Prescribe an antihypertensive medication and follow up in 2 weeks.

34.3 A 43-year-old man presents with headaches that he has had daily for several months. Every morning at work, usually between 9 and 10 AM, he has to take 650 mg of acetaminophen to relieve the headache. This has been going on for the past 3 months and he is at the point of looking for a new job, as he thinks that job stress is the cause of his symptoms. His examination is normal. Which of the following is the most appropriate advice for him?

A. Continue with the as-needed acetaminophen and find a less-stressful career.

B. He should start an antidepressant for headache prophylaxis.

C. His headaches are most likely to improve if he stops taking the acetaminophen.

D. A triptan is a more appropriate treatment for him.

ANSWERS

34.1 D. This patient gives a history very consistent with common migraine headaches. There are no red flags found on history or examination, so no further testing is necessary at this point. As he has significant nausea, he may benefit from nonoral medication. A triptan delivered by injection or nasal spray is a reasonable starting point for him.

34.2 C. The acute onset of the most severe headache in a patient's life is concerning for the presence of a subarachnoid hemorrhage. This is a medical emergency. This patient should be transported by emergency medical services to the nearest emergency facility for stabilization and management.

34.3 C. This situation is typical of a medication-related headache. While finding a new, less-stressful job may be beneficial, the problem will not resolve until he discontinues the daily use of his over-the-counter analgesic.

CLINICAL PEARLS

⯈ Migraine headaches can occur in children and adolescents, as well as adults .

⯈ Most patients presenting for the evaluation of headaches do not need diagnostic testing beyond the history and physical. However, the presence of focal neurologic deficits or other red flag symptoms/signs should prompt an immediate workup or referral.

REFERENCES

BeithonJ, Gallenberg M,Johnson K, et al. Institute for Clinical Systems Improvement: diagnosis and treatment of headache. Available at: http://bit.ly/Headache0113. Updated January 2013. Accessed April 19, 2015. 

Goadsby PJ, Raskin NH. Migraine and other primary headache disorders. In: Kasper D, Fauci A, Hauser S, et al., eds. Harrison's Principles of Internal Medicine.19th ed. New York, NY: McGraw-Hill; 2015. Available at: http://accessmedicine.mhmedical.com. Accessed May 25, 2015. 

Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders. 3rd ed. (beta version). Cephalgia. 33(9):629-808. 

Migraine in Adults. In Dynamed (database online]. EBSCO Information Services. Available at: http:// search.ebscohost.com/login.aspx?direct=true&site=DynaMed&id=114718. Updated July 25, 2014. Accessed February 15, 2015. 

Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults. Neurology. 2012;78:1337-1345.

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