Diagnosing headaches a pain for doctors
From the June ACP Observer, copyright © 2007 by the American College of Physicians.
By Stacey Butterfield
SAN DIEGO—As neurologist-in-chief at Brigham and Women's Hospital, Martin A. Samuels, MACP, sees a lot of headaches—tension-type, migraine, cluster, caffeine withdrawal, sex and more.
Unlike many internists, he truly enjoys diagnosing and treating the various types of head pain. "Doctors worry about headache. And that lack of confidence is transmitted to the patient, and that leads to the failure of treatment," said Dr. Samuels.
Martin A. Samuels, MACP: "Most episodic headaches are migraines."
If an internist can get comfortable with headaches and develop an interest in them, "Life can be a lot more interesting and a lot more fun. The problems are just as interesting and just as complex," as more unusual disorders, he said.
During a pre-course at Internal Medicine 2007, Dr. Samuels worked to spread his appreciation for headaches to fellow internists by revealing a few tips for successful diagnosis and treatment.
Sympathy and certainty
When a patient comes into the office with a headache, there are things that you should ask and, equally important, a couple of questions that you should definitely not ask, said Dr. Samuels.
Never give patients a questionnaire about their headaches, because many patients are suggestible enough that they will say 'yes' to all of the symptoms on the list. "You get an incomprehensible morass of data," he said.
Also, many symptoms that could indicate serious neurological problems are also common to less serious headaches. For example, a physician concerned about the possibility of intracranial pressure might ask a patient whether the headache wakes him or her from sleep.
"The patient will say, 'Yes, why do you ask, doctor?' Now you've painted yourself into a corner," said Dr. Samuels. The answer to the question is not actually useful, since almost all headaches can wake someone from sleep, but the patient will assume that it is a symptom of a serious problem.
While you want to avoid making patients worry, it's also important not to downplay their symptoms by asking, "Is it a bad headache?" Everyone gets headaches, and everyone knows that everyone gets headaches, so a patient who goes to the trouble of seeing a doctor unquestionably thinks that his or her headache is bad, Dr. Samuels said.
When asked to rate their pain on a scale of 1-10, almost all headache patients will choose 8, 9, or 10. "You don't go to the doctor for a 1, 2, or 3. A lot of them will say 11," commented Dr. Samuels.
Any implication that the headache might not be that bad will negatively impact the doctor-patient relationship. "It's not for you to argue with people about it. The point is you don't know how much a person is suffering."
"The unspoken elephant in the room is that people who come to the doctor for headache often have a concern about a brain tumor."
—Martin A. Samuels, MACP
Many headache patients are also suffering from fear of a more serious illness. "The unspoken elephant in the room is that people who come to the doctor for headache often have a concern about a brain tumor," said Dr. Samuels.
Patients' descriptions of their headaches will often be influenced by their Internet research, Dr. Samuels noted. Physicians should discount statements like "It's the worst headache of my life," (which patients have likely read somewhere and use to emphasize the seriousness of the problem), and try to uncover specific information about how this headache differs from past ones.
"Listen for the delta, not the drama," advises Dr. Samuels. "I like to take the psychiatric approach to taking a history: Tell me about your headaches."
Chances are good that the headache will turn out to be a migraine. Most episodic headaches are migraines," said Dr. Samuels. A number of headaches that go by other names are actually likely indicators of a migraine sufferer, including ice cream headaches, orgasmic headaches, exercise-induced headaches and altitude headaches.
Patients are often surprised to learn that their headaches are migraines. "A lot of people are very insistent, 'I have headaches but not migraines,'" said Dr. Samuels. A careful life history can uncover additional migraine-related symptoms. Colic, motion sickness, and episodic abdominal pain frequently affect infants and children who will have migraines as adults.
Patients who do not meet the criteria for migraines often turn out to have tension-type headaches. Dr. Samuels has a simple question to distinguish tension-type headaches from migraines. "Ask, 'Ever take a drink for your headache?'" Migraine sufferers will give a definite no (red wine and liquors, particularly dark ones, can cause migraines), but tension headache sufferers often turn to alcohol for relief.
After thorough questioning, the next step is an exam. "We should examine people even if we don't need to. Feeling the head is very therapeutic," said Dr. Samuels.
After touching, looking at and listening to the head, physicians should perform a basic neurological exam, including checking visual fields, conducting a funduscopic examination, listening to language, watching the patient walk, and testing reflexes. In the unlikely event that the headache is related to brain tumor or other serious neurological condition, the exam should reveal that, Dr. Samuels said.
For experienced headache diagnosticians, the history and exam usually provide all the information needed. "If you take this on as an interest, you can become very, very good and rarely need tests. If you're not that good, you may need a test occasionally to reassure yourself so that you can properly reassure the patient," said Dr. Samuels.
Emphatic reassurance is crucial to successful treatment. "It's absolutely critical that you get to the point where you can, with great confidence, look people in the eye and say to them, 'This headache is not due to a brain tumor.' If you don't say it, the drugs won't work," said Dr. Samuels.
For patients who are not convinced by his assurance, Dr. Samuels prescribes a CAT scan. "What I look for is the telltale head tilt. If you see it, get a CAT scan," he said. The scans are cost-effective for headaches not because they will provide positive results, but because of the therapeutic value of negative results for worried patients.
MRIs do not work, he said, because they are too sensitive. "You will find things that you don't care about that don't have anything to do with headache."
After testing, examination and history-taking, the diagnosis should be clear and a course of treatment determined (see sidebar). But remember, said Dr. Samuels, the effectiveness of treatment relies heavily on the attitude of the prescribing physician. "Confidence is the best treatment."
Although a definitive diagnosis is often the most effective treatment for headache, there are a number of drugs that can provide relief, particularly to migraine patients, according to Martin A. Samuels, MACP, neurologist-in-chief at Brigham and Women's Hospital.
Most patients suffer from episodic headaches, for which Dr. Samuels recommends episodic treatment. "Why take a drug every day of your life for something that happens four times a year?" he asked participants of the Internal Medicine 2007 pre-course on neurology.
Headache sufferers will usually have self-treated with the first line of drug options—acetaminophen, aspirin or nonsteroidal antinflammatories (NSAID). The next step is the triptans, any of which should be effective if taken during the first 20 minutes of a migraine. "The drug companies will try to say that the drugs [the seven triptans] are very different from each other, but it's an exaggeration," said Dr. Samuels.
Before the drugs, patients should be given metoclopramide to alleviate nausea and make sure that the medication is absorbed. Patients who are experiencing significant nausea can alternatively be treated with non-oral therapies, including subcutaneous and sublingual options.
It is also important that any patient whose headache is treated with an NSAID in the emergency room receive a brief taper of the drug. "Keep people away from analgesic rebound," advised Dr. Samuels, and to that end, make sure that patients do not take daily doses of acetaminophen, aspirin or NSAID.
For patients who have such frequent migraines that they need prophylactic therapy, his first recommendation is tricyclic antidepressants. "Make sure you explain to people that you're not treating depression," Dr. Samuels said. Selective serotonin reuptake inhibitors (SSRI) are fine for tension-type headaches, of which depression may be a cause, but should not be used to treat migraines, he noted.
Migraine sufferers who do not respond to tricyclics have a number of other, more toxic, options, including beta blockers, anti-epileptic drugs and steroids for chronic migraines. Because of the intensity of side effects, Dr. Samuels reserves these drugs for patients who can't use other options. "Migraine people are young, by and large. They don't like feeling tired and having their libido go down," he said.
For the treatment of tension-type headaches, Dr. Samuels advocates avoidance of pharmacological treatment. After reassuring patients that the headache is not a symptom of a more serious problem, he encourages them to try relaxation techniques, like yoga and hypnosis, as long as they are provided by legitimate complementary medicine providers.
"Don't get me wrong. There's no evidence that these things do anything for tension-type headaches, but they keep people away from analgesic rebound," he said.
Whatever treatment is prescribed, patients need to have realistic expectations of the outcome. "100% remission is not a rational goal. The best we can do is get you back to the point where you have the regular headaches that the rest of us have," Dr. Samuels suggested telling patients.
Typical migraine symptoms include:
- nausea or vomiting,
- 4-72 hour duration,
- pounding or throbbing character,
- unilateral head pain,
- disabling for usual activities, and
- photophobia and phonophobia.
Source: PIER module on Migraine
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