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Diagnosing, treating patients with the ‘very important problem’ of headaches

SAN DIEGO – The nonspecific nature of headaches can make diagnosis challenging, but some specific questions and clinical signs can help point the clinician in the right direction, according to a presentation at the ACP Internal Medicine Meeting.

“This is a very, very important problem in emergency medicine, the management of these patients,” Martin A. Samuels, MD, DSc (Hon), MACP, chair, department of neurology, Harvard University and neurologist, Brigham and Women's Hospital, Boston, told attendees.

He said asking some medical history questions is one way to determine if a patient is suffering from migraine headaches. Specifically, he or she should be asked if they were colicky as a baby, if they or a member of their family had episodic abdominal pain or an appendectomy, when was the onset of menarche, if they experience sensitivity to certain things, if they have motion sickness and if they have other kinds of headaches.

Samuels also recommended that patients keep a record of all headaches.

“Headaches can have a pattern. If [the patient] keeps a headache diary they will see that pattern .... ” he said. “Those people with migraines, have them keep a diary for a few months and see if you don’t see a pattern.”

A head exam, including looking, feeling, listening and touching the person’s head is an important component of the diagnosis too, Samuels said.

“Can you imagine going to a doctor for abdominal pain, and the doctor never looks at, listens to or feels your abdomen? Would you believe that the doctor knew what he was doing?” he said.

He provided other examples of what to look for when trying to pinpoint the source of a headache.

“If there isn’t a red eye, then the eye is not the cause of the headache, no matter what the patient tells you about eye pain,” Samuels said. “The same is true with nasal diseases. If there isn’t green [fluid] coming out of the nose, that’s not the cause of the headache.”

He also said the severity of headache pain a patient claims to be experiencing may not always be a true indicator of how severe a patient’s headache is.

“Certainly, do not do what I call ‘pseudo-modification,’ such as asking a patient on a scale of zero to 10, where zero is nothing, and 10 is tolerable how bad is your headache?” he said, adding that if a patient has gone to the extent of making an appointment, he or she may indicate the pain is worse than it really is. “All patients say eight, nine or 10... [Using this scale] will never help you.”

Despite the many different symptoms a patient may present at an office visit, Samuels warned of the dangers of running too many tests.

“A headache is a very common reason to waste money in an emergency department where a lot of tests are done,” he said, adding that average prices for common diagnostic tests can range from $50 to determine the erythrocyte sedimentation rate to $3,600 for a head MRI with contrast.

Other risks include incidental findings, fueling patient fears that something is seriously wrong, and could be a misuse of resources, Samuels said.

Treatment will vary by headache type, he added, noting that when it comes to treating migraines, there are a lot of similarities among the medications that are currently available.

“There’s less difference among these triptans than the drug companies are trying to tell you. They’re trying to differentiate one from the other, but the reality is that is they are almost the same,” he said. Once one of these medications is chosen, “the trick here is to treat early and treat completely.” Prophylactic drugs may be needed if the migraines are occurring more than half of a given month.

Samuels said patients with tension-type headaches should avoid pharmacologic therapy and overusing analgesics, but could likely benefit from relaxation techniques as well as alternative and complementary therapies. He also said patients with cluster headaches often benefit through oxygen treatments, and can prevent future attacks with calcium blockers or lithium. Calcium blockers may also benefit patients with indomethacin-responsive headaches. – by Janel Miller

Reference: Samuels, MA. Session MTP 074. "Approach to the Patient with a Headache". Presented at: ACP Internal Medicine Meeting; March 29-April 1, 2017; San Diego.

Disclosure: Samuels reports no relevant financial disclosures.