Nrnp6531Adult Primary Care Week #10
Headaches
• More common (the headache is the main problem)
• More common (the headache is the main problem)
• Includes migraines, tension and cluster headaches - Primary headaches
• Less common
• Result of an underlying disease or condition, such as aneurysm, tumor, hemorrhage,
temporal arteritis, or meningitis - Secondary headaches
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has ≥2 of the following characteristics:
1. unilateral location
2. pulsating or throbbing quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (eg, walking, climbing
stairs)
D. During headache ≥1 of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia - Migraine without aura
A. At least 2 attacks fulfilling criteria B and C
B. ≥1 of the following fully reversible aura symptoms:
1. visual;
2. sensory;
3. speech and/or language;
4. motor;
5. brainstem;
6. retinal
C. ≥3 of the following 6 characteristics:
1. ≥1 aura symptom spreads gradually over ≥5 min
2. ≥2 symptoms occur in succession
3. each individual aura symptom lasts 5-60 min
4. ≥1 aura symptom is unilateral
5. ≥1 aura symptom is positive
6. aura accompanied, or followed in <60 min, by headache - Migraine with aura
A. At least 10 episodes of headache occurring on <1 d/month (<12 d/y) and fulfilling
criteria B-D
B. Lasting from 30 min to 7 days
C. ≥2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
, 3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia - Tension HA
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-
180 min (when untreated)
C. Either or both of the following:
1. ≥1 of the following ipsilateral symptoms or signs:
a) conjunctival injection and/or lacrimation;
b) nasal congestion and/or rhinorrhea;
c) eyelid edema;
d) forehead and facial sweating;
e) miosis and/or ptosis
2. a sense of restlessness or agitation
D. Frequency from 1/2 days to 8/days for > half the time when active - Cluster HA
Fundoscopic, vascular exam, musculoskeletal, neuro/mental status exams - Targeted
PE
•Onset of headache after the age of 50 years
•Asymmetry of pupillary responses
•Decreased deep tendon reflexes
•Headache described as "the worst ever experienced"
•Personality change
•Onset of a new or different headache
•Onset of a headache that progressively worsens
•Papilledema
•Painful temporal arteries
•Neurologic signs or seizures
•Persistent HA after Valsalva maneuver or exertion
•S/S of systemic disorders (i.e. fever, HTN, myalgia, wt. loss)
•"Thunderclap" HA (maximum severity at onset) - Red Flags
CBC, ESR, CRP, TSH, Lyme titer - Labs
• Testing should be avoided if it will not change the management of the patient.
• Testing is not indicated if the patient is not significantly more likely than the general
public to have an abnormality.
• Testing may make sense in a patient who is excessively concerned that he or she has
a serious problem that is causing the headaches. - 3 Principals for Diagnostic Testing
- Meningitis
- Pseudotumor cerebri, hemorrhage
Headaches
• More common (the headache is the main problem)
• More common (the headache is the main problem)
• Includes migraines, tension and cluster headaches - Primary headaches
• Less common
• Result of an underlying disease or condition, such as aneurysm, tumor, hemorrhage,
temporal arteritis, or meningitis - Secondary headaches
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has ≥2 of the following characteristics:
1. unilateral location
2. pulsating or throbbing quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (eg, walking, climbing
stairs)
D. During headache ≥1 of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia - Migraine without aura
A. At least 2 attacks fulfilling criteria B and C
B. ≥1 of the following fully reversible aura symptoms:
1. visual;
2. sensory;
3. speech and/or language;
4. motor;
5. brainstem;
6. retinal
C. ≥3 of the following 6 characteristics:
1. ≥1 aura symptom spreads gradually over ≥5 min
2. ≥2 symptoms occur in succession
3. each individual aura symptom lasts 5-60 min
4. ≥1 aura symptom is unilateral
5. ≥1 aura symptom is positive
6. aura accompanied, or followed in <60 min, by headache - Migraine with aura
A. At least 10 episodes of headache occurring on <1 d/month (<12 d/y) and fulfilling
criteria B-D
B. Lasting from 30 min to 7 days
C. ≥2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
, 3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia - Tension HA
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-
180 min (when untreated)
C. Either or both of the following:
1. ≥1 of the following ipsilateral symptoms or signs:
a) conjunctival injection and/or lacrimation;
b) nasal congestion and/or rhinorrhea;
c) eyelid edema;
d) forehead and facial sweating;
e) miosis and/or ptosis
2. a sense of restlessness or agitation
D. Frequency from 1/2 days to 8/days for > half the time when active - Cluster HA
Fundoscopic, vascular exam, musculoskeletal, neuro/mental status exams - Targeted
PE
•Onset of headache after the age of 50 years
•Asymmetry of pupillary responses
•Decreased deep tendon reflexes
•Headache described as "the worst ever experienced"
•Personality change
•Onset of a new or different headache
•Onset of a headache that progressively worsens
•Papilledema
•Painful temporal arteries
•Neurologic signs or seizures
•Persistent HA after Valsalva maneuver or exertion
•S/S of systemic disorders (i.e. fever, HTN, myalgia, wt. loss)
•"Thunderclap" HA (maximum severity at onset) - Red Flags
CBC, ESR, CRP, TSH, Lyme titer - Labs
• Testing should be avoided if it will not change the management of the patient.
• Testing is not indicated if the patient is not significantly more likely than the general
public to have an abnormality.
• Testing may make sense in a patient who is excessively concerned that he or she has
a serious problem that is causing the headaches. - 3 Principals for Diagnostic Testing
- Meningitis
- Pseudotumor cerebri, hemorrhage
