NT WIRELESS Aura Tearing Nausea/Voriting za> Weokness/Numbness/Weight change Injury Runny nose Estrogen exposure ( OCPs) Leg/ Taw/ Joint pain Energy level Stress Speech difficulties oomempns PHYSICAL EXAMINATION for Headache HEENT: Palpation of the Sinuses & Temporomandibulor joints, Funduscepic exam, Nose, Mouth, Teeth & Throat, Neck Examination: Inspection, palpation Cordiovarcular exon’ Auscultarion Pulmonary exem: Ausculration Newrelogy exem* CN2-12, uecle strength, OTRe, Kemig’ eign & Brudineki eign DIFFERENTIAL DIAGNOSIS for Headache Migraine headache: Unileteral headache, Visual disturbance, photophobia, flashlight, A/V, trigger by chocolate, alechol and cheese Tension headache: Bilateral sqeezing headache, associated with stress inhis/her lif, no visual disturbances, Cluster headache: Unilateral headache, associated with red tearing eye hinerrhea and nasal stuffiness Preudotumer cerebri Meningitic: headache, farigue, fever, lethargy, se of appetite, N/V, blotchy rashes or red rashes, neck stiffness confusion, photophobia Sinusitie:Headahce, nacal discharge, fatigue, fever Temporal arteritis (Giant cell art Subarachnoid hemorrhage: severe h Intracra Severe headache, N/V, azsociated with obesity vitamin A roxciy, OCPS itis): Unilateral headache, shoulder pan, jaw pain with chewing contusion, NAV. mass: Severe headache, N/V, weightloss, double vision, DIAGNOSTIC WORKUP for HeadachePreudotumor cenebri ‘Meningitis: headache, fatigue, fever, lethargy, loss of appetite, N/V, blotchy rashes or red rashes, neck stiffness confusion, photophobia Sinusitis: Headahce, nasal discharge, fatigue Fever. Temporal arteritis (Giant cell arteritic): Unilateral headache, shoulder pain, jaw pain with chewing Subarachnoid hemorrhage: severe headache, confusion, N/V, Intrecranial mass: Severe headache, N/V, weight lk Severe headache, N/V, associated with obesity, vitamin A toxeity, OCP ouble vision, DIAGNOSTIC WORKUP for Headache cee ese T of head RL Lumbar puncture CT of Sinuses Usmle-aid.«Muscle Contraction = Tension headache Inflammation * Infectious causes (meningitis, sinusitis) = TMJ Traction/Compression * Intracranial hemorrhage = Tumors = Pseudotumor cerebri = Hydrocephalus . Persistent CSF leak after Psychogenic « Vascular Fever Migraines Hypertension - vessel dilation and increased ICP Hypoxia - causes cerebral vasodilation CO poisoning, near drowning Chronic disease exacerbation (CF, cyanotic heart disease) = aeHeadache -> AT&T WIRELESS * Aura * Timing * Nausea / Vomiting * Tearing and any other eye symptoms * Weakness / Numbness * Injury * Runny nose during the attacks * Estrogen exposure (OCPs) * Leg (aint) pain * Energy level * Stress * Speech diticutiesSuspected migraine headache | Fever, altered mental status, oF meningisrmus? ves No Wenngusor | "Aw ose? subarachnoid + Occipitonuchal location? hemorrhage + Older than $5 years? + Abnormal neurologic examination? + Increasing headache frequency? * Lack of coordination? + Localized neurologic signs? + Headache causing awakening from sleep? + Atypical features? + Does not fulfil strict definition of migraine? ves Consider neuroimaging | ‘More serious conditions ruled ‘out and migraine diagnosed Mid to moderate intensity Moderate to severe intensity _Inemergency department setting { | Cod torres “Tal of combination “iptans antiemetics with acetaminophen/asiin? without intravenous caffeine (Excesin { diydroergotamine Migraine) oF nonsteroidal oor meponse (OH) consider anthinflammatory adjunctive dexa- rmethasone ‘drugs also consider |sometheptene compounds 4 Poor response. ' Triptans 4 Poor response Increase triptan dose or “Tal ofa different triptan Consider sumatriptan’ naproxen (Trexima) Consider ditydroergotamine nasal spray (Migranal) ‘Also consider isometheptene ‘compounds or intranasal lidocaine (xyocaine) NOTE: Abortive migraine therapy should be used as soon as possible after symptom development for maximum benefit: if abortive therapy is unsuccessful or used more than twice weelly, consider adding proptylactic therapy. Patients with nausea and vomiting may require nonoral medication. For all medications, consider patient comorbidities and contraindications.Migraine headache ‘Clinical Question: Does This Pationt Have a Migraine Headache? Patiant with unditfe rentated headache | Consider raferral to nowrologist or neuroimaging if diagnosis is uncertain ‘Are atlaast 4 ofthe following features of the POUNDing scala present? 1.Pulsatla quality 2..Duration of 4 to 72 hours 3.Unilataral location 4. Nausea or vomiting 5. Disabling intansity |__| Nonmigraine headache ‘Clinical Question: Dogs This Patient Need Nouroimaging? charactey, or adult-onset migraine} ¥ Perfarm neuroimaging at discrotion of physician Perform neuroimaging and lumbar punctura y Patient wth headache Classify headache ¥ ’ ' Now headacho ‘Acuta thunderclap Chronic headache (new onset, change in headache Any high-risk features present? {(Cluster-type headache, abnormal findings on neurological exam, undefined headache [le, not cluster-migraina or tansion type], haadacha ‘with aura, headache aggravated by exertion ' or Valsalve-like manuaver, headache with vomiting) Consider referral to ‘Considar referral to | Ro | Not present nrtogit agnostic nourlogist agnosie eee pre cy Perform Perform neursimaging paeeiane Dy neurainoaa at icra ofphiysiten Figure 1. POUNDing Algorithm. (Adaptad trom Detsky ME et al. JARAA 2006.4)DIAGNOSTIC HIERARCHY FOR CHRONIC HEADACHE AND OROFACIAL PAIN CEPHALIC NON-CEPHALIC PSYCHOGENICaD medscape. DAILY HEADACHE SELF-MONITORING FORM ‘SOCIAL SECURITY NUMBER: PATIENT 1D NUMBER: sleep quality. DIRECTIONS: Four times each day, please rate your headache intensity, disability evel, and-stress using the rating scales below. Mark the times that you were sleeping and eating by coloring (or putting x) in the boxes. You may indicate % hour increments by coloring Ys of a box (or use slash). Also, record body temperature, whether menstruating, and ratings of sleep amount HEADACHE INTENSITY DISABILITY stress | SLEEP SLEEP 10 EXTREMELY PAINFUL. tp hsiaceivopecitettcarico |} 10 COMPLETELYIMPAIRED (Bede | 10 exrrewey | AMOUNT | QUALITY : es ¢ é 1a Toomuc | :0 ExcELLENT 8 VERY PAINFUL... uaterm mas crowmon die || 2 SEVERELY MPAIRED 2 VERY ° ° ? tei leerecom cena es 7 ; 2 # venvaoon 6 PANFUL tiyrewscrn arts nel cncertaw || @ MODERATELY IMPAIRED 6 wooerstey |? i 5 ateare 5 ; s #6000 Sa 5 penrecr |s { ROLVPANEULongenmymacenaeenim| 4 MOLY AARED ¢ mer | been 2 2 4 SLGHTLYPANFUeyramheseionm| 2 MALY BARED 2 mm [2 2 Ree ome 1 1 0 NOHEADACHE 0 NOMPARMENT © wostress [> rooume Jo vervecor WEEKLY MEDICATION LIST (AND AMOUNT): MONDAY HEADACHE: | DISABILITY: STRESS: ‘SLEEP; | MEALSNACK: ‘WEDIGATION (AND AMOUNT): — Bai t2e te 22 Sa da Sa G Ta ta Se 10a ta tio ip 20 3p 40 40 60 Tp 8 99 100116]