Learning Objectives
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Learn the common types of headache.
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Understand the difference between primary and secondary headaches.
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Develop an understanding of clinical presentation of specific headache types.
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Develop an understanding of the treatment of specific headache types.
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Develop an understanding of the differential diagnosis of headache.
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Develop an understanding of the potential risks of abortive therapy in the treatment of chronic headache.
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Learn how to identify factors that cause concern.
Brooke Johnson
I asked Brooke how long she’s had headaches and she said, “I’ve had headaches about as long as I can remember.” Brooke said that all of the headache medication she was taking was “eating a hole in my stomach. I take my Fiorinal and Advil, and my headache gets better for a few minutes and then it is back as bad as ever. I take some more, the headache gets better for a few minutes and then it comes right back.” She denied any fever, chills, or neurologic symptoms associated with her headaches.
I asked Brooke to use one finger to point at the spot where it hurt the most, and she pointed to both her temples and then started rubbing her neck. I asked her what the pain was like: an ache, sharp, stabbing, burning? She immediately said, “My entire head just hurts! It just hurts. No throbbing, no stabbing, it just hurts. And my meds don’t work. No matter how many I take! I am really up the creek here. Oh, and don’t let me forget that I need you to refill my Fiorinal.” I asked whether the headache was on both sides or just one side, and she said it was the entire head. I asked Brooke from the time that she knew that she was going to get the headache until the time it was at its worst, was it a period of seconds, minutes, or hours. She said, “Like I told you, I get the headache, I take my headache meds, it gets better for a bit, and then the same headache starts to come back. I take more meds, the headache gets better for a bit, it comes back, and then I take more meds to try and get some relief. I feel like a hamster on a wheel; this is the pits.” I asked Brooke how her sleep was, and she replied, “Who has time to sleep? I’m too busy getting up to take my headache pills. Oh, and before I forget, I need you to refill my Fiorinal.”
On physical examination, Brooke was afebrile. Her respirations were 16 and her pulse was 78 and regular. Her blood pressure was 128/82. There were no cranial abnormalities, and her head, eyes, ears, nose, throat (HEENT) examination was completely normal, as was her fundoscopic examination. Her cervical paraspinous muscles were tender to deep palpation, but no myofascial trigger points were identified. Her cardiopulmonary examination was normal, as was her thyroid. Her abdominal examination revealed no abnormal mass or organomegaly, and there was no rebound tenderness present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed no evidence of weakness, lack of coordination, or peripheral or entrapment neuropathy, and her deep tendon reflexes were normal. There were no pathologic reflexes. Brooke’s mental status exam was within normal limits, but her anxiety was apparent.
Key Clinical Points—What’s Important and What’s Not
The History
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Episodic headaches entire adult life
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A recent increase in the intake of headache medications and over-the-counter analgesics to treat an increase in the intensity and frequency of her previously controlled headaches
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Headaches are holocranial
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Headaches are associated with some nuchal pain
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Character of the headache pain was neither sharp nor throbbing
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No neurologic symptoms associated with headache
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Significant sleep disturbance
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Patient denies fever or chills
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Patient denies significant nausea and vomiting associated with headache
The Physical Examination
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The patient is afebrile
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Normal fundoscopic exam
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Examination of the cranium is normal
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Neurologic exam is normal
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Some tenderness of the paraspinous muscles without myofascial trigger points
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The patient appeared anxious
Other Findings Of Note
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper and lower extremity neurologic examination, motor and sensory examination
What Tests Would You Like to Order?
The following test was ordered:
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Magnetic resonance imaging (MRI) of the brain
Test Results
The MRI of the brain was normal.
Clinical Correlation—Putting It All Together
What is the diagnosis?
Medication overuse (analgesic rebound) headache
The Science Behind the Diagnosis
Clinical Syndrome
Medication overuse headache, which is also known as analgesic rebound headache, is a problematic secondary headache syndrome that occurs in headache sufferers who overuse abortive medications to treat their symptoms. It is estimated that over 60 million people suffer from medication overuse headache. The overuse of these medications results in increasingly frequent headaches that become unresponsive to both abortive and prophylactic medications. Over a period of weeks, the patient’s episodic migraine or tension-type primary headache syndrome becomes more frequent and transforms into a chronic daily headache. This daily headache becomes increasingly unresponsive to analgesics and other medications, and the patient notes an exacerbation of headache symptoms if abortive or prophylactic analgesic medications are missed or delayed ( Fig. 6.1 ). Medication overuse headache is more common in females and in headache sufferers with comorbid depression, anxiety, and other chronic pain conditions. Metabolic syndrome and regular use of benzodiazepines may also predispose patients to medication overuse headache. Some investigators believe the frequency of headaches and the total number of medications taken on a daily basis may serve as a predictor for patients suffering from medication overuse headache and who are likely to relapse. Other investigators believe that medication overuse headache is a behavioral problem due to the commonly seen compulsive drug-seeking behavior, withdrawal symptoms, and high relapse rates. Although the exact underlying pathophysiology responsible for the evolution of medication overuse headache has not been fully elucidated, it has been postulated that dysfunction of the mesolimbic-cortical dopaminergic reward circuitry as well as the trigeminal modulating system and central sensitization may play a role. Medication overuse headache is probably underdiagnosed by health care professionals, and its frequency is on the rise owing to the heavy advertising of over-the-counter headache medications containing caffeine.
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Abby Austin: A 30-Year-Old Administrative Assistant With Frequent Headaches Involving the Head and Neck
Shanice Williams: A 52-Year-Old Female With a Severe Headache and a Progressive Alteration of Consciousness
Cassandra Elliot: A 29-Year-Old Overweight Female With Constant Headache Pain That Worsens With Valsalva Maneuver
Abby Austin: A 30-Year-Old Administrative Assistant With Frequent Headaches Involving the Head and Neck
Brenda Brown: A 66-Year-Old Bookkeeper With Severe, Shocklike Facial Pain
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