Headache

Edward Bifulco, DC
 “Doctor…my brain hurts…”
95% of patients that present to a
physician with the chief complaint of
headache are certain that they have a
brain tumor.
-- Less than 5% of all brain tumors have
headache as a significant presenting
complaint
 Background
91-95% of all people experience HA in a
12 month period.

Of these 15-18% seek medical care

Acute onset
Chronicity
Severity
Associated S&S
 Primary Vs Secondary
Primary
 No specific organic cause .

Secondary
 Caused by underlying organic
disease.
 Hx is king!
Most common HAs will present with a
normal neuro and general examination.

Headache history is vital in making the

dianosis.
 Headache History
Is this a first or worst HA?
Symptoms with the HA?
Onset?
Location?
Quality?
PMH and Meds?
Recent trauma or dental procedure?
 First or Worse HA
Most will be primary migraine in late
childhood or early teens.
Onset after 50 suggests temporal arteritis
or SOL.
Chiros rarely see “first or worst”
Has...usually go to ER or have had
multiple Has before seeking treatment.
 S&S
May help DDx primary Vs secondary
Red flags
 Diplopia
 Loss of vision in single eye
 Stiff neck
 Unilateral weakness or paresthesia
 Ataxia
 etc
 Onset
Sudden and severe onsets tend to be
secondary and significant.
Think vascular!
 Subarachnoid hemorrhage
 Acute ischemia
 Acute hemorrhagic stroke
 Red Flags
HA after age 50
 Temporal arteritis, mass lesion
ESR and imaging
Sudden onset of severe HA
 Subarachnoid hemorrhage
 Hemorrhage into a mass lesion
 Posterior fossa mass lesion
Imaging and/or lumbar puncture
 Red Flags
Increasing frequency and severity
 Mass lesion
 Subarachnoid hemorrhage
 Medication misuse
Imaging, lumbar puncture, toxicology screen
 Red Flags
New onset with HIV or Cancer:
 Meningitis
 Brain abscess
 Mets
Imaging
With signs of systemic illness
 Meningitis Lymes Dz
 Encephalitis systemic infection
 Red Flags
Focal neurologic signs:
 Mass lesion
 Vascular malformation
 CVA

Trauma
 Intercranial hemorrhage
 Hematomas Post-traumatic HA
 Headache Syndromes
-- Migraine
-- Psychogenic
Caffeine Rebound
-- Post-concussive Syndrome
-- Cranial (Giant Cell) Arteritis
hypertension
-- Subarachnoid Hemorrhage
-- Meningitis/encephalitis
-- Occipital Headache
-- Acute sinusitis
-- Hypertension
-Cluster
-Analgesic Rebound
-Trigeminal Neuralgia
-Benign Intracranial
-Intracerebral hemorrhage
-Intracranial Mass lesions
-Lumbar puncture headache
Acute glaucoma
 Migraine

Migraine is the most common cause of

severe recurrent headaches.

A conservative estimate states that 10%

of the population suffers from migraine.
 Migraine
Vascular Headache
Frontal-temporal most common
unilateral
Severe
Pulsatile/Throbbing
Lasts hours to days
Nausea + Vomiting common
Vomiting is less common and may herald severe
underlying disorder, especially if new.
-- May progress to bilateral or to a common
“tension headache.”
-- Pt feels “wiped out” for hours to days after the
attack.
-- Stress may ppt the HA.
- Common pattern is to have HA at the end of
periods of stress, when the pt is coming
down from an adrenaline high....
--
 “Menstrual Migraine”
A few days prior to or at the onset of their
period.
Reduction in pain after menopause
May change with preg. / childbirth
Most common: decrease in frequency and
intensity in mid-life, picks up again at age
65+
 Migraine: Provocative
Hunger/Hypoglycemia
Bright lights / Loud noises
Stress
Hyperventilation
Head trauma
Upper respiratory infection
Foods that contain tyramine
Foods that contain nitrates
 Pain Descriptors
Throbbing/Pounding
“Hot dagger through the eye”
Frontal-Temporal
Orbital
Occipital-Orbital
The area of pain may feel extremely
tender and /or bruised for several days
after the HA ceases.
 Prodrome
Usually visual: Fortification spectra,
Scotoma etc.
May be non-visual
 vasomotor, change in mood, numbness etc
Precede the HA by 10-30 minutes.
Evolve slowly over 5-10, fade as HA
starts.
 Childhood Migraine

pallor, nausea, vomiting

attacks are shorter in duration than adult
“abdominal migraine
HA becomes CC around age 10
 Vasospastic Migraine
AKA: Basilar migraine
looks like a TIA unilateral
subjective paresis
Subjective paresthesia/numbness
“brainstem signs”

Worry about future stroke!

 Migraine: Variants

A typical Migraine: Prodrome without HA

Common Migraine- HA without prodrome
“Vestibular Migraine- Vertigo
 Mechanisms
Vasaopasm, then dilation
Vasospasm causes prodrome, Dilation
causes HA, (“Traditional View:)
“Neurovascular theory”
Seizure variant: Wave of depolarization
causes aura, resultant vasodilation
causes HA
 Medical Rx
Vasoconstrictors
Anti-Seizure meds
Analgesics: do not do much, but opiates
are frequently tried.
Hospital for status migrainous: continuous
HA for 24 hours +
 Non-med Rx

Cold on head/neck, Warm hands/feet

Feverfew
Vitamin E
EPO/ Fish Oil
Posture and muscle balance
-- ADL/Lifestyle -Diet
-- Acupuncture -Magnesium
 CMT
Prodrome is best time for acute care
- Personal opinion: C0-C1
-- During HA: Good luck!
Between Episodes:
 - CMT head to toe, however, CMT may ppt
HA!
 Cluster Headache
“Horton’s Headache”, “Histamine cephalgia:,
“Horton’s cephalgia” “Alarm-clock headache”
Very rapid onset
Prickling/tingling of the orbit and nose.
Strong lacrimation, runny nose
Eye becomes bloodshot
Rapidly becomes a “red hot poker” or “acid
being poured into the nose or eye” ache.
Male: Female = 10:1
Typically wakes Pts from sleep: 1, 4, 7
a.m. often cited
Multiple daily attacks for 6-12 weeks
Vastly exacerbated by alcohol
Attacks tend to be at the same time each
day, and clusters tend to be the time of
year.
 HA lasts from 10 minutes to 2 hours
 Tension HA
-- Anxiety/Depression
-- Classic: “Tight band around my head”
or “my head is in a vise”.
-- Suboccipital to frontal: “TIGHT”
-- If temporal consider TMF as source of
tension
--
In general:
- waxes and wans, worse as day
progresses
- relieved by massage, OTC, exercise,
alcohol
- no real increase in activity to EMG
-- Acute may be same as migraine
-- Chronic may persist overnight
-- May last for years
 Cervioco-genic HA
-- Cervicogenic headaches follow the
same pattern.
Cervicogenic HA will show some positive
findings on a detailed examination of the
cervical spine.
 Cervicogenic
The dura attaches to Occiput, C1 and C2,
and may share noicieptive input from
these structures.
 Adjust!!!!
The rectus capitus posterior minor blends
with the dura in a large number of HA
sufferers.
 Myofascial work!!!
 Cervicogenic
Hypertonus as per EMG on symptomatic
side.

Deep neck flexors weak as compared

with SCMs
 Rebound
Caffeine / stimulants
Ergot
Analgesics
Narcotics
 Post-Concussive Syndrome
Lightheadedness Headache
Tinnitus
Impaired comprehension
Difficulty with abstraction Easy fatigue
Loss of libido Vertigo/dizziness
Photophobia Impaired memory
Insomnia Mood swings/Depression
Personality changes Neck pain
Phonophobia Impaired logic
Irritability Alcohol intolerance
 Post-Concussive Syndrome

Diffuse axonal injury

Lateral or rotational forces may be more
damaging than sagittal.
Can not be imaged with todays technology
“Punch drunk” fighter
Symptoms can last for over one year!
-- Rule out subdural hematoma in acute
syndrome
 Trigeminal Neuralgia
-- Mouth-Ear Zone in 60%, Nose-Orbit Zone in 30%
-- The eye is not involved.
-- “Red hot poker being pushed up the nose.” Eye is
“surrounded in a rim of agony.”
-- The pain is transient, but leaves an ache behind.
-- Attacks may occur once or twice per day, up to
once every minute or two.
Trigger zones
- Alar of nostril, outer upper lip, medial eyebrow
- Touch, temperature
 Natural Hx:
Elderly (60+), Increasing severity,
Increasing frequency
Patient may look haggard and unkempt
due to inability to shave, wash, brush
teeth....
Kill nerve, acp, CMT, anti-siezure meds
etc
 Temporal Arteritis
Inflammatory HA
Older population (60+)
Do ESR: 50 + possible, 100+ probable
50% have underlying C-V dz
Needs “Roids” ASAP
Central retinal artery - blindness
 Subarachnoid Hemorrhage
Aneurism of vessels in the subarachnoid
space
15% have symptoms prior to rupture
Typically non-specific headache, Very
similar to migraine
Simultaneous onset of vertigo, nausea,
and headache may be a clue
Headache (Sub C0)
Nausea
Vomiting
Neck stiffness
1% have sudden onset of back pain
without HA
10% have sudden onset of head and
neck pain
May look like exertional HA!
 Occipital Neuralgia
Irritation to the Greater occipital nerve
May also present with
numbness/paresthesia
Common post trauma, esp. CAD

Physical pressure on the nerve or its

distribution usually PPt or increases
symptoms.
 Hypertension

200/120 mmHg+, Occipital or vertex

Dull, throbbing, diffuse, aching
Worse in early A.M. while still in bed
If diastolic is below 110 this is not a likely
cause
 Intercranial Mass
Increased Intercranial Pressure
Waxes and wans, but never goes away
Changes with body position, typically
worse with lying down.
 Sinusitis

Pain is centered over the affected sinus

Increases with flexion, pressure,
pounding etc....
Discharge, Post nasal drip, etc
Chronic cases may have thickening of the
mucosa
 Meningitis/Encephalitis
Same signs and symptoms as
subarachnoid hemorrhage
Add fever into the clinical picture
 Pseudo Tumor Cerebri
Idiopathic intracranial hypertension (IIH)
is a disorder of unknown etiology.
Obese women of childbearing age.
The primary problem is chronically
elevated intracranial pressure (ICP), and
the most important neurological
manifestation is papilledema,
May lead to progressive optic atrophy and
blindness.
 Pseudo Tumor Cerebri
Weird aside:

May be due to excess estrogen

These patients not only do not get post

spinal tap HAs, but they actually feel
better!
 Pseudo Tumor Cerebri
Rx

Shunt
Optic Nerve fenestration
Weight loss
A variety of drugs…
 General
Rule out pathology + infection
Get a neuro consult if nervous
Diet/Supplementation
Lifestyle
Soft tissue
Acupuncture
Biofeedback
Adjust