Compile a complete case history for patients with headache

Read sidebar: How to evaluate the paranasal air sinuses

Optometrists estimate seeing between three and five patients per week who present with headache as their chief complaint, according to Primary Care Optometry News sources.

Len Koh, PhD, OD, is one of these optometrists who sees patients with headache weekly. He told PCON that more than 400 subtypes of headaches are listed in the latest edition of the International Classification of Headache Disorders.

“Usually each referring specialty does their best to differentially diagnose headache and come up with potential etiology and management; however, it is very challenging to pinpoint the exact cause and effective treatment,” he said.

The single most important part of the headache evaluation is the case history, according to Richard B. Mangan, OD, FAAO. “An accurate differential diagnosis can be made 90% of the time from case history alone, if you know what to look for,” he said.

Optometrists need to allocate more time for a patient presenting with headache, Koh said. The primary goal of the first encounter is to rule out secondary headache. Once that is complete, a patient can be brought back for further testing for possible ocular or visual etiology.

“If we do not have the time or expertise to do a thorough headache and binocular vision evaluation, we can send the patient to a colleague who devotes their specialty to binocular vision or refer to a headache specialist,” Koh said.

Providers must approach headache efficiently, with a detailed history and comprehensive ocular examination to rule out the malignant headaches that may blind or even kill the patient, he said.

Identifying potential red flags associated with secondary headache is essential in learning a patient’s history, Koh continued. Red flags can include: First or worst headache ever, acute or sudden onset, onset after 50 years old, worsening headache, headache associated with systemic symptoms, changes in pain patterns, always in the same location, pain that awakens the patient from sleep and neurological symptoms and signs.

Diagnostic tools and tips

Patient questionnaires are invaluable in diagnosing a cause of headache, according to Mangan. Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, and Mangan both utilize the PQRST criteria.

P – Provocation/palliation. Provocation is factors that bring on the headache such as relative hypoglycemia, bright lights, loud noises or various odors like cologne and gasoline. Palliative is any treatment that improves the head pain.

Q – Quality/quantity. What is the character of the pain? Is it a pounding, throbbing (vascular), tightness (tension) or a pain behind the eyes (sinus headache)?

R – Region/radiation. Pain on one side or one area of the head.

S – Severity scale. On a scale from 1 to 10, with 10 being the most severe, how would you grade your pain?

T – Temporal/time. When did the pain start and at what age? How often does the patient get these headaches? The frequency of the headaches guides the treatment protocol.

James L. Fanelli, OD, FAAO, said it is easy to differentiate a refractive etiology from a medical origin. Myopic patients do not usually complain of headache unless they are overminussed, he said. Uncorrected or under-corrected hyperopes will complain of periocular pain when reading or doing near tasks.

“Astigmats, when uncorrected, will have visual difficulties at all distances, and the strain associated with trying to see clearly by squinting will tend to be more constant,” he said.

Mangan said it is important to understand the basis of head pain and what structures are pain sensitive and not pain sensitive.

“Ultimately, the brain isn’t a pain sensitive structure,” he said. “What is painful is the nerve and blood vessels that run through the brain and peripherally. If there is an abnormality with a blood vessel or nerve, it tends to send a more localized pain.”

Mangan said to think of the brain as an insensitive organ surrounded by a pain-sensitive capsule consisting of the outer dura and the surface vessels.

Stress/tension headache

Julie Rodman, OD, MS, FAAO, said the type of headache she sees most commonly is tension headache. Patients will complain of a band-like sensation across the forehead, and the pain can switch sides. She said an important differentiator is chronic pain (more than 15 headaches per month) or episodic pain, which lacks the associated photophobia, smell sensitivity and ringing in the ears.

“Although tension-type headaches are at least three times as common as migraine, we know far less about them,” Mangan said.

When taking a patient’s history, Mangan will look for a usual age of onset between the teens to late 30s. He is suspicious of headaches beginning earlier or later in life, as it may represent disease.

He will ask a patient about body postures at work, in the home and when driving to rule out postural muscle strain.

He also suggests looking for symptoms of depression (low mood, sleep disturbance, impaired libido) and anxiety (irritability, preoccupation, sleep disturbance, somatic symptoms such as palpitations and sweating, and general angst).

“People with chronic tension-type headaches are usually significantly encumbered with anxiety or depression, notoriously prone to excessive use of analgesic medication and very difficult to treat,” Mangan said. “I refer them to a psychiatrist to get them on antidepressants.”

Sinus headache

Sinusitis is the single most common health care complaint in the U.S., according to Mangan.

Because a sinus headache frequently triggers pain or pressure around the eyes, it is not uncommon for sufferers to contact an eye care professional, he said. One out of three patients with sinus headache will have at least one sinus infection each year, and 300,000 patients will require surgery for sinusitis.

“The evaluation of the patient with sinus-related headache is straightforward and certainly within the wheelhouse of the optometrist,” Fanelli said.

Sinus-related headaches are easily diagnosed in the optometric office following a three-step sinus evaluation, consisting of articulation of facial bones, percussion and transillumination of the sinuses, he said.

“When treating patients with sinusitis,” Mangan said, “it is important to emphasize the importance of good hydration. Products like Mucinex [600 mg guaifenesin, Reckitt Benckiser] in conjunction with sinus irrigation (ie, neti pot) can be helpful in breaking up chronic sinus congestion. You want to avoid antihistamines in these patients and if you suspect that the sinusitis is infectious in nature, monitor your patient closely. If the patient does not respond to treatment within 7 to 10 days, consider a referral to an ear, nose and throat specialist. Infectious sinusitis from a resistant bug can have severe, if not fatal, consequences, especially in patients with previous sinus or orbital surgery.”

Migraine

Approximately 37 million Americans suffer from migraine headaches, and women are affected two to three times more often than men, according to Migraine.com. More than 11 million patients suffer from moderate to severe disability. The loss of productivity in the U.S. is estimated to be between $5.6 billion and $17.2 billion per year because of missed work.

Of those with migraines, 90% have a family history, according to Mangan.

He said that age of onset is important. Typically, migraines start in adolescence or early teens and peak in the 20s, 30s or 40s, and by the 50s the migraines start to fade.

“When we talk about age of onset it’s important to differentiate migraines from something that might be more medical,” Mangan said. “If they say they have headaches for the first time at age 50, that should be a red flag that something medical is going on.”

One-fourth of patients report a certain food as a trigger for the headache. “Keep in mind that sometimes this is not the trigger, but associated with the prodrome craving prior to the headache,” he said.

Mangan often suggests that patients keep a food diary, to record what they eat, when migraine symptoms present and in what area they feel pain. The following can adversely affect patients with migraine: chocolate, cheeses and dairy, alcohol, citrus fruits, nuts, caffeine and skipping meals. Chemical additives such as monosodium glutamate, nitrates and aspartame can also trigger a migraine.

The classic migraine sufferer will have a visual prodrome prior to the onset of the headache, Fanelli said.

“In complicated migraines, the patient has a variety of concurrent neurological symptoms that may affect the afferent or the efferent visual systems, depending on what vasculature is involved,” he said.

Patient history and an optometric neuro-ophthalmic evaluation can often diagnose migraine, although many patients also need neuroimaging, Fanelli said.

“It’s the patient who presents with headache and who has no refractive findings that would correlate to the headache history, where medical origins become likely,” he said.

“If I’m convinced it isn’t an urgent condition,” Mangan said, “I may watch them for a bit. If I know these patients are going to need chronic help, I will refer to neurology or pain management.”

Headache emergencies

“The important approach to history-taking in patients with headache is to identify red flags associated with secondary headache that warrant neuroimaging and further investigation,” Koh said.

The most common reason Skorin receives headache referrals is due to temporal arteritis or giant cell arteritis. Typically, “this patient is someone who has seen an optometrist, medical doctor or emergency room,” he said. “They have severe headaches, it’s new onset and it’s always in an older person. It is almost exclusively seen in people over 55 years old.”

The pain could be anywhere on the head, but often it presents in the temporal or occipital regions, Skorin said. “Sufferers will often not tell eye doctors about temporal or occipital pain, because they think the pain is not related to the eyes,” he said.

“I teach my interns to palpate the temple by putting their fingers over the blood vessels over the temple,” Skorin said. “If you push on it, the patient will get such severe pain that they almost jump out of the chair, that’s how bad it hurts ... this disease isn’t just in the temporal arteries, it’s in all the cranial vessels of the head.”

“Patients are typically out of it, have lost a ton of weight, may have a high fever and have a very specific pain on the temporal side of the head,” Rodman added. These patients need to be sent to the emergency room, she said.

The tests to run are erythrocyte sedimentation rate (ESR) and C-reactive protein, which detect inflammatory markers, Skorin said. The disease is secondary to an inflammatory process that occurs in the blood vessels.

The third test is a complete blood count (CBC), which looks for elevated platelets and anemia, according to Skorin.

Occasionally patients will present with visual complaints, such as new-onset diplopia or amaurosis fugax, or patients have lost vision, he said.

The definitive test for diagnosis is a temporal artery biopsy, the primary reason for referrals to Skorin’s practice, as he is one of the only surgeons in the area who performs it.

In the procedure, Skorin surgically removes a portion of the temporal artery in the scalp. A pathologist looks at the biopsies under a microscope, and if the blood vessels are damaged due to inflammation, the diagnosis is definitive.

Treatment is a high-dose steroid, he said, which the patient can be on for months or even years.

In May 2017, the FDA approved Actemra (tocilizumab, Genentech), the first nonsteroidal treatment for temporal arteritis, Skorin said. “I think it is going to change how we treat temporal arteritis,” he said.

The injection can be used in conjunction with a steroid, and the patient can cease steroid use much faster while staying on Actemra. Skorin said there is also a lower relapse rate with Actemra. He warned that, currently, only rheumatologists can dispense the medication.

“This will definitely be a sea change in treatment for this disease going forward,” Skorin said.

Pseudotumor cerebri, also known as idiopathic intracranial hypertension, is the second most common reason patients are referred to Skorin.

Rodman said she sees patients with pseudotumor cerebri at her clinic once a week, which she said is likely not the norm for other practitioners.

Patients with this condition are typically younger women with a high BMI who develop papilledema, Skorin said. Vision is rarely affected, and acuity can remain 20/20 even if patients have symptoms.

Rodman said symptoms can include ringing in the ears when patients change position, such as lying down or rolling over; nausea; vomiting; swollen optic nerve and papilledema.

Patients are put on a regimented weight loss program, Skorin said. Studies show that only a 6% body weight loss from time of presentation makes the disease go away. These patients also need neuroimaging, he said. He prescribes Diamox (acetazolamide, Duramed), a water pill and a carbonic anhydrase inhibitor, which usually addresses the papilledema.

“I’ll usually work with a neurologist, who will put them on Topamax (topiramate, Janssen Pharmaceuticals),” he added, “which helps their headache, but one side effect of the drug is it causes weight loss, which is a benefit here.”

Other true medical emergencies in patients that present with headache include: Horner syndrome, migraines with atypical auras, infectious meningitis, cerebrovascular headaches and pituitary apoplexy, according to Mangan.

Skorin said that headaches are ubiquitous and that optometrists must rule out a refractive cause. “It’s the most straightforward and easy thing to do,” he said.

“If something doesn’t seem right, don’t be afraid to refer,” Rodman said. “If it’s a headache that doesn’t seem right, I don’t know what a visual field is going to do, so I usually refer those cases. I think we should try not to treat outside of our boundaries ... for any disease process, do not try to be a hero.”

Patients are good historians and know if something is off, and practitioners should trust them, Rodman concluded. – by Abigail Sutton

• References:
• FDA approves first drug to specifically treat giant cell arteritis. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm559791.htm. Posted: May 22, 2017.
• Friedman BW, et al. Emerg Med Clin North Am. 2009;doi:10.1016/j.emc.2008.09.005.
• The International Classification of Headache Disorders, 3rd ed. Cephalalgia. 2018;doi:10.1177/0333102417738202.
• Migraine Statistics. https://migraine.com/migraine-statistics. Accessed May 16, 2018.

• For more information:
• James L. Fanelli, OD, FAAO, practices at Cape Fear Eye Institute in Wilmington, N.C. He can be reached at: faneleye@aol.com.
• Len Koh, PhD, OD, is on staff at Mann-Granstaff VA Medical Center, Spokane, Wash. He can be reached at: len.koh@va.gov.
• Richard B. Mangan, OD, FAAO, is assistant professor at University of Colorado School of Medicine, department of ophthalmology, in Aurora, Colo., and a PCON Editorial Board member. He can be reached at: richard.mangan@ucdenver.edu.
• Julie Rodman, OD, MS, FAAO, is associate professor at NOVA Southeastern University College of Optometry and a PCON Editorial Board member. She can be reached at: rjulie@nova.edu.
• Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, works at Mayo Clinic Health System in the department of ophthalmology, Albert Lea, Minn., and is a PCON Editorial Board member. He can be reached at: skorin.leonid@mayo.edu.

Disclosures: All sources report no relevant financial disclosures.