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S2D: The Symptom to Diagnosis Podcast - Episode 03: Headache
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S2D: The Symptom to Diagnosis Podcast - Episode 03: Headache
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2023-06-03T00:00:00.0000000
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Language: EN.
Segment:0 .
DR. CIFU: I'm Adam Cifu.
DR. STERN: And I'm Scott Stern.
DR. CIFU: And we are back with another episode of the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for common diagnostic medical symptoms. Each episode is divided into four parts. We begin each episode with a case unknown to one of us. We then discuss the five high yield features that help to accurately diagnose the cause of the symptom at hand. We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves and other random pearls of knowledge pertaining to the week's symptom.
DR. CIFU: The cases that we discuss are drawn from our clinical experiences but, because protecting patient privacy is part of our oath, we never discuss actual patients and most cases are composites.
DR. STERN: Well, this is Scott Stern and I love especially the random pearls of knowledge, but let's get on with this. Adam, our topic of the day is headache and you are our expert. Do you have a case to present to me?
DR. CIFU: I do have a case. So this is a case that I saw a couple of years ago. I saw this patient on Tuesday morning. I'll take you through the history and tell you why that's I don't know, somewhat important. Here's a 25-year-old guy who came in with, you'll never guess, a headache.
DR. STERN: Uh-huh!
DR. CIFU: The headache began actually on Sunday night when he was awakened from sleep with the headache, lied in bed for a little while with this headache eventually got up, vomited and then was able to fall back to sleep. He told his wife who's actually a physician about it on Monday morning, she just kind of shrugged and said, "I'm going to work." And then when she got home, the wife got particularly worried about it because it turns out the husband had taken the day off from work.
DR. CIFU: Didn't go into work because the headache was sort of on and off bothering him all day. It was better at that time, but they were able to call and get sort of an urgent appointment with me on Tuesday morning. So he arrives on Tuesday morning and that's kind of where we are.
DR. STERN: Uh-huh, well, there's lots to worry about here. Maybe the first is the fact that his wife went off to work having heard that story and being a physician.
DR. CIFU: We'll get to that later.
DR. STERN: But although the classic approach is to really discern whether this is a new headache or an old headache. There are several features of this that are alarming to start with without even going down that particular issue, which is one, it woke him from sleep. That's very atypical for the primary headaches of you know, migraine and tension and whatnot. And also the vomiting would suggest intracranial pressure that's elevated as could the fact that it had woke him from sleep.
DR. STERN: So all of those are very alarming features to me and would suggest something serious. I mean, in that list would be a subarachnoid hemorrhage. We don't know whether it occurred in a thunderclap fashion. At least we could ask him but he may not know because it had woke him from sleep.
DR. CIFU: Yeah, it's hard to know if you woke up with a headache or if he was awakened from sleep with a headache.
DR. STERN: I'd certainly want to know the rest of his headache history just to see if there's a prior history of the same, but with the vomiting and waking up it's still alarming. So other than a subarachnoid hemorrhage, you'd also want to know about infectious symptoms, in particular, fever and stiff neck and things that might suggest meningitis. Other paths, he's all-- he's young so some of the things we would think about would be less likely temporal arteritis.
DR. STERN: It's not normally acute but rather subacute. We need to know about history of trauma as well in order to look for any sort of subdural or complication of that sort. So those would be my chief concerns hearing this initially, it's alarming.
DR. CIFU: Yeah, great. So those are all amazing points. And to answer your questions, he really does not have headaches. He says, "Oh, I don't know, occasionally you know, a headache but I think it's a tension headache." Usually has a couple of Tylenol or a cup of coffee and that gets better. He is feeling perfectly well otherwise, hasn't been sick at all. No fevers, nothing else bothering him really except this headache.
DR. CIFU: And he also reports kind of no change in his life. He's an office worker. He thinks he's been sleeping well kind of nothing else concerns him except he's really been thrown for a loop by this headache. I'll tell you when I saw him on Tuesday morning, he was actually doing fine. And he said he was actually going to skip the appointment 'cause when he woke up the headache was gone, but then it came back and he said that he should really come in.
DR. CIFU: I examined him, he looked well, vital signs were really normal. He had no neck stiffness at all. I did a really-- quite a good, what I call an internist's neurological exam. And the only thing I found is that he had anisocoria actually. So one of his pupils was more dilated than the other. I cannot remember which one it was.
DR. CIFU: And when I asked him about it, he said, "Oh yeah, you know, I've had that since I was at least eight. I first noticed that I was in a staring contest with my sister and she said, hey, your eyes are different sizes." And he thought she was just trying to win the staring contest. But in fact it was true, went to see a doctor at the time.
DR. CIFU: And that's sort of been the same ever since. So, what are you thinking now? What would you do with the guy?
DR. STERN: Well I also forgot to mention but I want to know about any history of drug use cause certainly drugs and in this age group needs to be considered, especially if he's drinking alcohol, happened to wake up with a headache and vomiting maybe he's just hung over.
DR. CIFU: [chuckles] Terrific.
DR. STERN: I'd want to know about a cancer history and anticoagulation use because both of those would increase the risk for CNS processes although it's unlikely. I certainly would worry about a sentinel bleed in this situation. A small aneurysm that's bled enough that he had an headache initially and then improved. Is the anisocoria related or not? Did he have an aneurysm that's pre-existing to long-longstanding and it was creating pressure on one of the third cranial nerve somewhere such that it's been abnormal all this time, but then was dilating and expanding.
DR. STERN: It's conceivable, of course, some patients just have anisocoria and it's a red herring, so, you know--
DR. CIFU: But for this case to freak you out, as much as a red herring could ever freak you out, right?
DR. STERN: This certainly would, I mean I would go at this point immediately to imaging.
DR. CIFU: Great. You're very good at this.
DR. STERN: Oh, thank you.
DR. CIFU: So that's really along lines, but I was thinking the other questions you asked, really nothing he does not drink, does not use any drugs, really nothing interesting in the guy's history, he has no past medical history at all, let alone a history of childhood cancer or more recent malignancies. And I did just what you said. I sent him directly from clinic down to the CT scanner. He had a non-contrast head CT, which did not show bleed, but it did show interestingly some asymmetry in the cavernous sinuses or in the cavernous sinus and the radiologists, I called the radiologist and the radiologist said, "So there's no bleed but this asymmetry could represent an aneurysm which conceivably could be causing the anisocoria maybe chronically." And so at that point I was already behind in clinic.
DR. STERN: Of course.
DR. CIFU: I called our good neurologists and said, you know, "Will you take this over from here?" And maybe we'll get back to the case after some more discussion.
DR. STERN: Sure, that sounds great. Well, why don't we do some deep dives in a headache right now. And Adam, why don't you give us five key points about diagnosing headache before we go back to the details of the case.
DR. CIFU: I would love to give you five.
DR. STERN: [chuckles] Please.
DR. CIFU: So point one, you actually-- a lot of these points you actually already mentioned. So point one is the whole old versus new thing. And probably anything-- has any time anyone has ever read about headaches. This is how the differential would be broken down. And it really is useful. I always say you see someone with an old headache, you're going to take it seriously, but you can kind of sit back in your chair and get a good history.
DR. CIFU: Old headaches are not something that's going to be life-threatening. They tend to be primary headaches, meaning that they're a syndrome kind of unto themselves. And you just have to figure out, does this sound like a tension headache? Does this sound like a migraine headache? Does this sound like cluster headaches? So you can make an appropriate diagnosis and treat them.
DR. CIFU: New headaches, very, very common symptom. Also generally benign, usually something silly like I don't know, eye strain or URI or influenza, but they at least have the potential of being something bad, subarachnoid hemorrhage, brain tumor or whatever. And so those people, those are secondary headaches. And so in those people we're often thinking about diagnostic tests to diagnose the underlying cause of the headache.
DR. CIFU: Number two, it's always a tough one. My second key point is that if you're thinking about an old headache, you have to consider if the patient needs CNS imaging. And the answer is generally not, right? Headaches are incredibly common. They are rarely, rarely, rarely something concerning, but you do have to be aware that they can occasionally be. And so you need to think about, do I need to evaluate this person.
DR. CIFU: For me there are a few things to think about. And there are reasons in all these cases that you might not need imaging, but you should at least go through these in your head. So any headache with new abnormalities on the neurological exam, it's hard to come up with a reason you would not image that patient, a migraine with an aura, but more that's atypical, maybe dizziness, maybe vertigo, maybe lack of coordination, maybe paresthesias things that might tell you that this isn't actually a migraine but something else.
DR. CIFU: Scott, I know you looked into the whole issue of vertiginous migraines a lot, right?
DR. STERN: Right, so vertiginous migraines one has to be careful about making that diagnosis because vertigo is common and migraines are common. But vertiginous migraines aren't terribly common. And one would have to have a crystal clear association repeatedly of episodes of vertigo that are associated with migraine. They can be before, during or after the migraine but there really needs to be a very clear temporal association to be confident about that diagnosis.
DR. CIFU: Right, thanks. So, headache with new abnormalities in the neuro exam, probable migraine but with an atypical aura headaches that awaken people from sleep, very uncommon, the worst headache of a life or an abrupt onset headache. Those are kind of the thunderclap headaches. Headache associated with loss of consciousness, certainly very abnormal and then exertional headaches, headaches that come on with exercise, especially when that exercise is valsalva.
DR. CIFU: But I have to say as an aside there are caveats to all of these. I once had horrible headaches that woke me up from sleep. My daughter, who is now 15 was a horrible sleeper when she was born. And in about month three of her life, I wasn't sleeping at all. And I vividly remember getting up two o'clock in the morning and washing down 800 milligrams of Motrin with a caffeinated coffee.
DR. CIFU: And I was like just about to schedule my MRI when I, when she started sleeping my headaches miraculously went away.
DR. STERN: Thank goodness.
DR. CIFU: Yes! Okay, so we've got point 1, point 2, point 3 is that it's really helpful to think about categories if you're thinking about new headaches. So someone with a new headache, I like to think is this a thunderclap headache, which might be-- might carry the diagnosis of a subarachnoid hemorrhage, cough headache, exertional headache, sexual headache. Is this a new headache in an older person then I'd want to think about subdural hematomas or temporal arteritis.
DR. CIFU: Are there infectious symptoms? Could this be related to an upper respiratory tract infection, influenza? Or more concerning meningitis or encephalitis? Are there visual changes associated with the headache? You might think about temporal arteritis again, idiopathic intracranial hypertension, that pseudotumor cerebri or is it substance related? So many substances can cause headaches either with acute use with withdrawal or with chronic use.
DR. CIFU: My fourth point and fifth point are about the same actually, it's just a recommendation to spend a little time. One is spend some time with the International Headache Society website. It's an incredible website better than any social media. Like it has an organized list of every described headache with their diagnostic criteria and you'll get the sense of all of the chronic headaches that have been described. Things like scrim goggle headaches, hotdog headaches, ice pick headaches.
DR. CIFU: And you'll be able to recognize these described headaches that maybe you didn't know about. And then my last point is spend some time with someone who has migraines. Migraines tend to present in a very stereotypical way. And if you really get a sense of what a migraine sounds like, of what the aura sounds like, you won't be confused or fooled when someone comes in with very atypical symptoms.
DR. STERN: Well, that's terrific. That's a great set of lists. I especially like the third point where you identified so many things that should make you worried from the thunderclap nature to the elderly, to visual changes and infectious changes. I think that's terrific. You did say the International Headache Society, a website was better than any social media site. So I think that speaks maybe a little to your age, but I'll just leave that there and let's get back to the case.
DR. CIFU: Okay, we won't argue about that. Okay, so when we left off talking about the case, I had just called the neurologist to rescue me after this person with an acute headache had undergone a CAT scan which showed no bleed, but had showed some asymmetry in the cavernous sinus. The neurologist decided that the patient should be admitted, which seemed like a good idea, but asked that the patient go through the MRI scan or basically on his way to his bed had an MRI MRA.
DR. CIFU: which was a very good study and was actually completely normal. It turns out this whole asymmetry of the cavernous sinus was not actually true. They were able to visualize the vessels and the circle of Willis well. They saw no abnormalities or aneurysm there and they were actually able to get a pretty good look of the third nerve which looked pretty good as well.
DR. CIFU: So they admitted to the service by the time they got to the floor sort of late afternoon, his headache was better and he was discharged the next day. So my question to Dr. Stern is what diagnosis do you think they gave him?
DR. STERN: Headache NOS I would think.
DR. CIFU: That was pretty much it to be honest with you. Their suggestion at the time was maybe this was a first migraine, which both the patient and I, I have to say we sort of shook our heads that, he was a 25-year-old man would be a strange time to start having migraines. Yes, there's some things about it which sounds migrainous. It was severe, it was associated with nausea. It was kind of waxing and waning, but we were not convinced.
DR. CIFU: And interestingly two weeks later, the patient went out to dinner, had a couple of glasses of red wine, got home. And when he was sitting in bed reading, he developed the most perfect aura of scintillating scotoma in his left visual field, lasted about 20 minutes, resolved and it was followed by a throbbing headache associated with nausea. And he's gone on to have infrequent but chronic migraines, so it was a surprise to me.
DR. STERN: Well, that's really interesting, but doesn't take away from the take home which is, I think given his vomiting and waking up from sleep and the new headache that the evaluation had to be done, the way that it was done. The other thing I would mention is he's atypical in terms of his gender. But the one thing that could have been missed on imaging would of course be an idiopathic intracranial hypertension. And so we have to remember to look at the fundoscopic exam and make sure that there's no signs of papilloedema or we could miss that even on MRI/MRA.
DR. CIFU: A terrific point. And in fact, if you're suspicious of idiopathic intracranial hypertension, you have to always remember get a good look at the fundus, the fundi. If you don't feel confident in that call your ophthalmology friends, call your neurology friends to do a good dilated exam. But if you see papilloedema and you're thinking idiopathic intracranial hypertension, you have to remember that the first I in IIT is idiopathic.
DR. CIFU: And so the next step is CNS imaging to make sure that it's not secondary increased intercranial hypertension, which would obviously be a bad thing.
DR. STERN: Well, especially before you do a lumbar puncture and cause herniation that will be a particularly bad outcome.
DR. CIFU: I would agree with that.
DR. STERN: All right. So let's move on to our fingerprints, common misconceptions, pet peeves and other random pearls of knowledge. Yeah, Adam, can you start us off with fingerprints?
DR. CIFU: We still haven't come up with a good saying for this part of the show.
DR. STERN: No, we did not.
DR. CIFU: We're still waiting for the people to tag us on Twitter, I guess. So my first fingerprint that I have to say I use all the time in practice is the POUNDing mnemonic, that's P for pulsatile, O for onset and duration, U for unilateral, N for nausea and D for disabling. And if a patient has all four of those points associated with their headache, that has a likelihood ratio of 24 for the diagnosis of migraine.
DR. CIFU: So you still have to think, but as you guys, you go through your history, if the patient satisfies that you can be pretty confident that this is a migraine headache. The studies that have looked at this have used that in distinguishing migraine headaches from tension headaches. So it's really something that one should use in clinic with chronic headaches when you're trying to differentiate a migraine from other types of chronic headaches.
DR. STERN: Oh that's a good point. So I was thinking for fingerprint, it's actually the opposite of a fingerprint, which is how to think about head trauma. As you know, when we talk about fingerprints, we're talking about findings that are very specific for a diagnosis, but what we're often faced with in the emergency room, in the clinics is someone who's hit their head and we have to decide whether to do a CAT scan in every case or when can we not do a CAT scan.
DR. STERN: And in this particular situation, what we want is something that's very sensitive. So if someone fulfills those criteria. We don't need to do a CAT scan. And actually there are head trauma rules for this, that those include patients have to fulfill the following criteria. They can't have evidence of a skull fracture, no surprise or a massive scalp hematoma which would suggest a serious injury.
DR. STERN: They can't have neurological deficits or altered consciousness, or altered behavior, and they shouldn't have a coagulopathy, have persistent vomiting and be older than 65. And if none of those apply then you can safely exclude a CAT scan for those patients.
DR. CIFU: That's great. And it is interesting, I mean there are a lot of clinical decision rules that their goal is 100% sensitivity. And the idea is can we forego expensive imaging safely in a patient? And that I think is a very widely used one. So that's helpful.
DR. STERN: Let's go on to some common misconceptions, Adam.
DR. CIFU: So for me, it's actually that severity of a headache is really less important than the quality of the headache. I think a lot of people spend a lot of time thinking of severity because we're trained from day one of learning about headaches, to think about the worst headache of your life which is like almost pathognomonic for subarachnoid hemorrhage which is not actually true. But really quality is more important.
DR. CIFU: So if someone comes in and they say, this is the worst headache of my life and it's exactly the same as all my previous migraines, that's a migraine and you don't really need to think much about it. If you ask a person, "Boy, you know, is this the worst headache for your life?" And they say, "You know, no, I have migraines and I've really had headaches worse than this but I've never had a headache like this before." That's actually a headache to really take seriously and think hard about because there's probably something new going on in that person with chronic headaches.
DR. STERN: That's really a great pearl. It is a common misconception. One I think about is that I think that we tend to think that subdurals are always associated with obvious trauma. And a lot of times there's no good history of trauma. And so especially in the elderly we have to be very careful.
DR. CIFU: Yeah, boy, I have been burned by that a lot. And sometimes you're seeing people who-- a symptom of their subdural is a little bit of mental status change in which case your history is even less reliable than usual.
DR. STERN: Right, exactly.
DR. CIFU: That's great.
DR. STERN: Okay, let's go to pet peeves. Adam, I know you're going to have pet peeves for me.
DR. CIFU: Man, do I've got pet peeves. I have like a font of pet peeves. [both chuckle] So one of my common ones, which is actually kind of complicated is thinking about brain tumors. Whenever someone comes in with a headache and people don't have cancer, I, you know, I've been practicing for, I don't know, whatever 25 years, right?
DR. CIFU: And I've diagnosed a fair number, unfortunately, of brain tumors, even primary brain tumors in my clinic. Interestingly enough, none of those people have presented primarily with a headache. They've presented with seizures. Sometimes even very atypical seizures, they've presented with new neurological findings. But the fact is that brain tumors in people without underlying cancers are very rare.
DR. CIFU: And that headache is actually not the most common way that those present. You should think about brain tumors 'cause I think more often than not someone who's coming to their doctor with headaches, it's probably thinking that they have a brain tumor, but don't get too distracted by that diagnosis.
DR. STERN: Right, provided they don't have a primary tumor else where.
DR. CIFU: You've got it. Yes, I always say, if someone comes into your clinic and thinks they have a brain tumor, they probably don't. If you're on the hematology oncology service and a patient you're taking care of wakes up with a new headache, you shouldn't even think about it. That person just needs to be scanned.
DR. STERN: Great. Well, one of mine is going to I'm afraid show my age. So my pet peeve is that rarely do clinicians try to perform a fundoscopic exam. I think many folks have decided in third year with the first time they looked at the eyes since they couldn't see the fundus that they've given up and they don't even try. And as we've already talked about pseudotumor cerebri and other conditions are rarely diagnosed this way, but really there's no good reason for not trying to learn this skill.
DR. STERN: So I'll leave it at that.
DR. CIFU: I'll support you on that.
DR. STERN: Okay.
DR. CIFU: Mine is I think actually maybe a corollary to yours, it's not doing a neurological exam when you have a patient with headache. When you're evaluating someone with the headache, you absolutely need to do a neurological exam. And you may not be confident in your neurological exam, you don't think it's going to add something. I got to say not only with headache, but in other parts of evaluating patients, I've seen people make the mistake of not doing an exam much more frequently than I've seen people miss a diagnosis because they've done an exam poorly.
DR. STERN: Absolutely. And so the only thing I would add to that as my final pet peeve is being told by various clinicians that the neurological exam was normal. And then I ask the patient, "How did you do when you walked?" And they said, "Oh, no one ever walked me." How can you do a neurological exam and not walk a patient? Is that a complex thing you need to do for a patient?
DR. CIFU: And you know even if you're busy, the patient has to leave your office. If you remember it or you haven't done it yet, just walk the patient to the waiting room and you'll add that part of your exam. And if something comes up, maybe you need to turn around and walk the patient back into the room and think about what you're doing.
DR. STERN: Excellent. All right, well, let's close with clinical pearls. Adam, do you have a clinical pearl for us?
DR. CIFU: Yeah, I guess my only clinical pearl, which is a very general medicine outpatient pearl, is if someone comes to you with chronic headaches and they tell you that those chronic headaches are making them miss work, they almost certainly have migraine headaches. Migraine headaches are the one at least common chronic headache that's so severe that people really need to like take to bed and miss work because of it.
DR. CIFU: I guess the only other differential is that the patient just hates their job. [chuckles]
DR. STERN: Right, which might be a bit too common.
DR. CIFU: Yeah, true.
DR. STERN: All right, I'll close my last clinical pearl, which is actually pretty funny, which is if you have a patient who reliably gets headaches on just Sundays or on vacations, it's probably caffeine withdrawal, even if it's a bad headache. So I asked people about that when it occurred.
DR. CIFU: I love that. I actually may have the opposite problem myself because often when I'm on vacation I love coffee and I hit like multiple coffee shops wherever I am. And I often come back to work and just go back to my usual, one cup of bad coffee in the morning. And then I get sort of like post vacation headaches.
DR. STERN: All the way going to show that we approach it differently again.
DR. CIFU: I know it's probably also the headaches are from getting back to sitting next to you in clinic.
DR. STERN: That must be it.
DR. CIFU: So we hope you found this episode of the Symptom to Diagnosis podcast useful and a bit enjoyable. As a reminder, our textbook, "Symptom to Diagnosis: An Evidence-Based Guide" takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print through all the usual places and also available and fully searchable via the Access Medicine website available worldwide from McGraw Hill and also available on your iPhone or other handheld device.
DR. STERN: Thank you very much.
DR. CIFU: Thank you. The music for the S2D Podcast is courtesy of Dr. Maylyn Martinez.