Chronic Headache

Concluding our “headache” discussion with “Chronic Headaches,” occurring daily (or almost so), defined as lasting a month or more.  Sometimes years.

We’ve talked about a number of these conditions in prior posts; today we’ll address the others.

**  Mass Lesion  —  When a patient presents for chief complaint of “headache,” invariably the specter of “brain tumor” is on their mind to some extent [pun].  Partly that’s because they don’t know the worse catastrophes which can occur.  We can’t image everybody.

We certainly image anybody with an abnormal neurological exam (see posting “Acute Headache – 2”).  We certainly don’t image the headache that’s continued unchanged for months or years.

As noted previously, we worry mainly about headaches that occur daily and are progressive.  Once again, chronology is the most important of all the symptom delineators.

KEY QUESTION —  For any and every chief complaint or symptom, always ask the patient, “Over the last ___ weeks [months, etc.], is your headache [or whatever symptom] getting better, getting worse, or staying the same?”  If for no other reason, inquire because if the patient answers, “Getting better,” you can smile to yourself with relief & know it’ll be a shorter visit.

So we’re more inclined to image a patient whose headache keeps getting worse in one way or another.  Other red flags that warrant an image:

• Associated with daily nausea / vomiting;
• A softer clue: worsening with valsalvas or bending forward.  Contrary to popular opinion, early morning onset is not a feature;
• Elderly patients, & those taking anticoagulants, who can have occult subdural hematomas  [beware — one expert defined “elderly” as “over 50”].
• People over 50 with a completely new headache are more likely to have tumors (assuming the headache hasn’t been going on for years).

As mentioned in a prior posting, a non-contrast head CT should suffice.  MRI is more sensitive for masses overall, but not necessarily for those large enough to cause headache.  Three times in 20 years, I’ve found relatively small tumors by CT, which undoubtedly were purely incidental and had nothing to do with the patients’ symptoms.

**  Idiopathic Intracranial Hypertension (I.I.H.) —  Commonly known as Pseudotumor Cerebri, this primarily affects obese women of childbearing age.  It’s suspected by finding either papilledema (occasionally unilateral) or objective visual deficits on physical exam.  Neuroimaging is unrevealing, a subsequent a LP spurts out a high opening pressure with a normal CSF analysis, and no other explanation exists for the ocular findings.

The headache is often felt behind the eyes, exacerbated by eye movement, commonly throbbing — but maybe not.  There are usually visual complaints of some sort.  Recent weight gain should raise suspicion.  Address I.I.H. by performing a careful visual exam as described in my 2^nd posting (“Acute Headache – 2”).  If anything’s abnormal, do a head image to R/O masses (which could herniate with an LP), & then obtain the CSF.

I.I.H. is rare, but among obese women ages 15-44, the incidence may be 1 in 5,000.  The condition may become more common as per our obesity epidemic.  Diagnosis is often missed or delayed.  Permanent visual loss occurs in 25%.  If a patient fits the demographic, and there’s no other good explanation for a chronic headache, even if the exam is normal consider a neurology referral.

**  Chronic Sinusitis  –  BEWARE of making this diagnosis, primarily because it’s made way too commonly, & generates an antibiotic Rx [usually for weeks or months], which is invariably unwarranted.  One study found that of 125 patients diagnosed clinically, only 75 had abnormal CT scans.  Only 18 of those had purulent secretions on endoscopy, of whom only 5 cultured out typical pathogens.  The worse the facial pain, the more likely the CT was to be normal!  See Clin Infect Dis 2012;54:62-8.  For the headache patient with lots of nasal symptoms, go for Allergic Rhinitis as your empiric diagnosis of choice.

**  Chronic Cluster Headache  —  This differs from typical cluster headaches in that the attacks persist for over a year, or remission lasts less than a month before recurrence.  If typical cluster headaches might promote suicidality, imagine these.  Here’s where headache specialists earn their dues.

** Chronic Migraine —  This reminds us a lot like migraines; perhaps a unilateral, throbbing component, or maybe nausea and/or photophobia & phonophobia.  But since it occurs every day or almost every day, it lacks the key component of a migraine diagnosis, viz. cyclic recurrences.  The key issue — if anything about a patient’s chronic headache reminds us of migraine, maybe a trial of migraine prophylaxis would help!  [P.S. — problem with this is that numerous candidate meds exist, with varying doses available.  P.P.S. — actually, that helps clinicians, who can always have another option up their sleeve.]

**  Irritating Symptom Elsewhere in Body  —  For example, patients with chronic constipation may complain of headache.  Walking around with a broken ankle can cause a headache.  Usually this correlation is obvious to the patient, but some people present solely for their headache.

**  Depression  —  Depressed patients frequently present with a chief complaint of “headache.”  Sometimes their affect is so flat that the diagnosis seems obvious.  But beware; don’t jump the gun too soon. [unnecessary redundancy]

For one, maybe their depression is secondary, i.e. their whatever-other-kind-of-headache has made them depressed.  So if you pick up right away on the depression, quizzing them with a psychological inventory, you’ll a) miss the main diagnosis; and b) lose credibility [“So you think it’s all in my head ?!?!?”].

Approach the apparently-depressed patient just as you would anybody else with headache.  Go through your differential, history, and exam.  Then inquire about coping mechanisms [“You seem pretty depressed — is the headache really getting to you?”].  If they endorse your observation, explore mood, and ask about suicidality.  Up to 45% of patients attempting suicide visit their primary provider during the preceding month.  Maybe for “headache.”

It’s harder when patients seem depressed, meet clinical criteria, but won’t acknowledge it.  You can’t easily approach potential suicidality [“OK, you’re not depressed, but have you been considering harming yourself anyway?”].  But they might agree that the headache is creating a lot of stress, and in that sense be amenable to treatment.

To conclude, most patients with chronic daily headaches will have tension headaches.  It’s primarily a diagnosis of exclusion; our job is to rule out more specific, and especially more ominous, etiologies.   Chronic tension headaches have been characterized as “featureless.”   Actually, the International Headache Society defines many types of chronic daily headaches.  For those interested, see Cephalalgia 2004;24 Suppl 1:9.

And that’s it for “Headache.”  See also our other postings on “headache”:  Acute H/A – 1 (“worst ever”), Acute H/A – 2 (masses, & the neuro exam), Acute H/A – 3 (other “not to miss”), Acute H/A – 4 (common causes), and Recurrent Headaches.