Happy Friday, Moffitt!
Thank you to Max for presenting the case of a middle-aged man with headaches. MRI showed a pituitary adenomas. He was found to have a prolactinoma and started on cabergoline! We got a chance to review an approach to headaches, and then talked briefly about pituitary adenomas as well.
❤ TLC (Tim and Laura, your Chiefs) + JV (Jess Valente)
Approach to Headache
Today we reviewed the types of headaches, separating primary vs. secondary headaches:
1. Tension headache (70%)
- Symptoms: Tight band around head. Worse throughout day.
- Treatment: Acetaminophen, NSAIDs, ASA. Amitriptyline can be helpful for prevention
2. Migraine headache (15%)
- POUND: Pulsatile quality, One day duration, Unilateral, Nausea/vomiting, Debilitating (if score 4-5 likelihood ratio of 24 in multiple studies)
- 25% patients experience aura. Does not need to precede headache. Increased stroke risk if aura so avoid OCPs
- Acute: Cochrane review 2013- 400mg ibuprofen 57% effective; 1000mg acetaminophen 39% effective; Excedrin Migraine (acetaminophen 250mg, ASA 240mg, caffeine 65mg), sumatriptan 100mg (careful if on SSRI, CAD or stroke)
- Prophylaxis: If 4-15x per month or HA >12hr, if failing acute tx. Effectiveness only apparent after taking the med for 1-3 months. Propranolol (or other beta blocker), valproic acid, topiramate
- Refer to neurologist: Pregnancy, known structural brain anomalies, chronic daily headache >15x per month, failure of multiple medications, consideration for devices (TENS) or hospitalization (IV dihydroergotamine (DHE))
3. Cluster headache (0.1%)
- Symptoms: Trigeneminal autonomic cephalgias- usually middle-aged men with severe unilateral pain behind eye at night, tearing… weeks of symptoms then remission for months-years. Assoc with structural brain lesions, esp pituitary tumors à Get MRI initially
- Treatment: Acute– Sumatriptan, high flow oxygen. Prophylaxis– verapamil
4. Medication overuse headache (aka rebound headache)
- Drugs that can cause rebound headaches: Fioricet (butalbital, apap, caffeine), 2. Acetaminophen 3. NSAIDs 4. Caffeine 5. Ergotamine 6. Opioids 7. Triptans
- Treatment: Withdraw medication– try reducing 10% every 1-2wk, can give naproxen 500mg BID to relieve residual pain
- Systemic infxn
- Head injury
- Vascular d/o- AVM, dissection, giant cell arteritis, SAH, reversible cerebral vasoconstriction syndrome (RCVS) (1%)
- Posterior reversible encephalopathy syndrome (PRES)- 2/2 malignant HTN, pre-eclampsia, drugs. MRI with posterior white matter edema
- Intracranial hypotension / low CSF volume: Positional- post-LP, POTS, spontaneous. Tx: Epidural blood patching if CSF leak
- Increased CSF pressure: Idiopathic intracranial HTN (psudotumor cerebri)- obese women Tx: acetazolamide or topiramate
- Don’t miss diagnosis: Tumor (0.1%- rare but don’t want to miss!) Red flags– get imaging: SNOOP– Systemic symptoms, Neuro signs, Onset sudden particularly >40yr, Oof- Precipiated by cough/lifting/sex (signs of increased ICP), Previous headache has changed in quality
1. What’s the h/a phenotype?
- PQRSTs – Provocation/Palliation, Quality/Quantity, Region/Radiaiton, Severity & associated Sx, Timing
- Provocation – assoc w/ stress, foods, posture, menstruation, lack of sleep?
- Palliation – what meds tried, how often meds taken, what was response to tx
- Region – UNIlat vs. BIlat
- Radiation – from neck or jaw
- associated Sx – n/v, photo/phonophobia, lacrimation/rhinorrhea, aura
- Timing – Frequency (including # of h/a per month), duration, onset (gradual or thunderclap)
- Age at onset, FHx of migraine
- Changes in vision
- Recent Trauma
- Relationship with food/alcohol
- Recent changes in sleep, exercise, weight, diet, in work or lifestyle
- Change in meds
- Association with environmental factors
- Effects on menstrual cycle & exogenous hormones, or change in birth control
2. Is it old or new?
- Old and recurring without changes is generally more reassuring
- New or changing/worsening are more concerning, esp in older or immunocompromised patients
3. Is it a Primary h/a or Secondary? Red flags?
- Is this a Primary h/a disorder? (ie. Tension, Migraine, Cluster, Trigeminal autonomic cephalgias)
- Is this a Secondary h/a disorder? (Some key questions: any systemic sx? Neuro sx (weakness, numbness, focal neuro sx)? Pulsatile tinnitus? Positional? Etc)
- BP & HR
- Listen for bruit at neck, eyes & head (and signs of AVMs)
- Palpate head, neck, and shoulder
- Check temporal & neck arteries
- Examine spine & neck muscles
- Neuro Exam: Mental status, CN exam, funduscopic exam (!), reflexes, coordination, gait
Do I need imaging?
- Indications for imaging:
- Focal neuro signs or sx
- Onset of h/a with exertion, cough, etc
- Orbital bruit
- onset of h/a after age 50yr
- Recent significant change in pattern, frequency, severity of h/a
- Progressive worsening of h/a despite appropriate tx
- MRI is preferred(better to detect metastases, edema, vascular lesions, other intracranial pathology)
- Get CT quickly if concerning for a Thunderclap Headache(ie. Subarachnoid hemorrhage)
BONUS: Also, from the Chief Blog archive I found this awesome Approach to Headache in the Primary Care Setting Evernote from Chris Sha!
This patient was found to have a pituitary adenoma, which may cause mass effect, hormonal hypersecretion, or hyposecretion. Here is a quick review
1. Mass effect: Headache, visual changes (bitemporal hemianopia bc compression of optic chiasm)- don’t forget to get the visual field testing
2. Hormonal Hypersecretion: Excess hormones secreted by pituitary.
- Prolactin: Prolactinoma- Galactorrhea, amenorrhea/infertility, early menopause
- Dx: Elevated prolactin. Differential diagnosis for elevated prolactin also includes other causes, such as consider pregnancy, hypothyroidism, psych meds, verapamil, opiates, cocaine. JV’s pearl today: If is only mildly elevating, ask the patient to do a fasting prolactin and make sure they’re resting 15min prior.
- Tx: OCPs or dopamine agnoists (bromocriptine/cabergoline), NOT surgery.
- GH: Acromegaly: large tongue/hands/feet, cardiomegaly, thyromegaly, DM
- Dx: 1. IGF1 elevated 2. Oral glucose suppression test- can’t suppress GH 3. Pituitary MRI
- Tx: Transsphenoidal tumor resection, octreotide suppresses GH
- TSH: Very rare, usually co-secrete TSH and prolactin or GH, cause hyperthyroidism
- ACTH: Cushing disease (vs. Cushing syndrome with from exogenous steroids) Dx: Dexamethasone suppression- can suppress if central but ectopic sources of ACTH cannot be suppressed. Also do biopsy. Tx: Resection
- ADH: SIADH
3. Hypopituitarism: Fewer hormones secreted. Tumor, XRT, Sheehan sydndrome (pregnancy), pituitary apoplexy (macroadenoma bleeds) infiltrative (sarcoid, hemochromatosis), head trauma, cavernous sinus thrombosis. Hormones typically lost in this order:
- LH/FSH: Infertility, amenorrhea, impotence Tx: Depends on fertility goals
- GH: Fatigue, fasting hypoglycemia. Isolated GH deficiency rare- only eval if other hormones missing too.
- TSH: Hypothyroidism Tx: Levothyroxine
- ACTH: Fatigue, but NO hyperpigmentation/skin bronzing, hypoK, eosinophilia. Dx: ACTH stimulation.
- Tx: Replace missing hormones, esp steroids/T4. If pituitary apoplexy- emergency! Stress dose steroids
- Pan-hypo pit: Hydrocortisone, desmopressin, testosterone, somatripin (GH replacement), levothyroxine all needed