Headache Case

ghost dog · Sep 7, 2011

Hey Folks.

I saw an interesting headache patient today I thought I would share:

2 month hx of constant pounding headache, which was bilateral occipital and frontal in distribution with associated posterior neck pain.

Prior to this period, she experienced chronic H/A at a frequency at around
15 - 16 days per month x 10 years.

Of note, she is taking the following topical ointments (on a long term basis): Clindoxyl, Stievamycin and a steroid ointment. She also had recently been scripted 4 or 5 courses (in a row) of various oral abx for an "ear infection" by her family physician.

She was quite obese.

I was unable to visualize her fundi, due to the fact that her pupils were very small ( as she was taking 6 percocet / day for the pain). Apart from this, she was neurologically intact (apart from being annoying).

She had a new onset seizure 2 months ago, which was attributed to a combination of Wellbutrin and Elavil (which was d/c'd). She had also been on Topamax, which was also discontinued at this point in time. She received a CT head in the ER, which was negative for masses.

Dx Comments ?

neurodoc · Sep 8, 2011

ghost dog said:
Hey Folks.

I saw an interesting headache patient today I thought I would share:

2 month hx of constant pounding headache, which was bilateral occipital and frontal in distribution with associated posterior neck pain.

Prior to this period, she experienced chronic H/A at a frequency at around
15 - 16 days per month x 10 years.

Of note, she is taking the following topical ointments (on a long term basis): Clindoxyl, Stievamycin and a steroid ointment. She also had recently been scripted 4 or 5 courses (in a row) of various oral abx for an "ear infection" by her family physician.

She was quite obese.

I was unable to visualize her fundi, due to the fact that her pupils were very small ( as she was taking 6 percocet / day for the pain). Apart from this, she was neurologically intact (apart from being annoying).

She had a new onset seizure 2 months ago, which was attributed to a combination of Wellbutrin and Elavil (which was d/c'd). She had also been on Topamax, which was also discontinued at this point in time. She received a CT head in the ER, which was negative for masses.

Dx Comments ?

The unremarkable CT is reassuring...but an MRI or contrast-enhanced CT would have been better to rule out some potential pathology. You need to consider cephalgia medicamentosa and "transformed migraine" in a patient on chronic analagesics (especially narcotics). Posterior neck pain raises the question of a "cervicogenic" HA, such as occipital neuralgia. C-spine x-rays or MRI might help clarify the situation. When faced with "headache" patients it's easy for physicians (including neurologists) to focus on intracranial issues. Yet it's true that C-Spine pathology can produce HA symptoms.

A patient with "seizures" should have an EEG. Elavil and Wellbutrin can lower seizure threshold, but this should prompt a physician to investigate why the patient would have epilepsy...

NC

ghost dog · Sep 8, 2011

neurodoc said:
The unremarkable CT is reassuring...but an MRI or contrast-enhanced CT would have been better to rule out some potential pathology. You need to consider cephalgia medicamentosa and "transformed migraine" in a patient on chronic analagesics (especially narcotics). Posterior neck pain raises the question of a "cervicogenic" HA, such as occipital neuralgia. C-spine x-rays or MRI might help clarify the situation. When faced with "headache" patients it's easy for physicians (including neurologists) to focus on intracranial issues. Yet it's true that C-Spine pathology can produce HA symptoms.

A patient with "seizures" should have an EEG. Elavil and Wellbutrin can lower seizure threshold, but this should prompt a physician to investigate why the patient would have epilepsy...

NC

Thanks for your feedback.

This patient did not provide a very straightforward history.

It was my initial impression that she had chronic migraine, exacerbated by both medication overuse and stoppage of her prophylactic med (i.e. Topamax).

When I thought about it some more, I questioned whether she might have pseudotumour cerebri. Indeed, she has multiple risk factors for this condition:

1. Obesity.

2. Multiple meds which can cause this condition.

3. I think I forgot to mention that her headache was exacerbated on recumbency.

Tenesma · Sep 8, 2011

she needs a boyfriend...

starmoon · Sep 8, 2011

I think there is some thought that some cases of presumed pseudotumor may actually be due to VST. Does she have any risk factors for hypercoagulability? Is she taking OCPs? I would be curious to see an MRI/MRV.

ghost dog · Sep 8, 2011

starmoon said:
I think there is some thought that some cases of presumed pseudotumor may actually be due to VST. Does she have any risk factors for hypercoagulability? Is she taking OCPs? I would be curious to see an MRI/MRV.

It's possible, although the 2 months period of time would argue against it somewhat I would think (although she certainly should get an MRV).

She's not on OCP, and doesn't have any coag issues apart from being a smoker.

neurodoc · Sep 9, 2011

ghost dog said:
Thanks for your feedback.

This patient did not provide a very straightforward history.

It was my initial impression that she had chronic migraine, exacerbated by both medication overuse and stoppage of her prophylactic med (i.e. Topamax).

When I thought about it some more, I questioned whether she might have pseudotumour cerebri. Indeed, she has multiple risk factors for this condition:

1. Obesity.

2. Multiple meds which can cause this condition.

3. I think I forgot to mention that her headache was exacerbated on recumbency.

Pseudotumor Cerebri is pretty easy to diagnose. You need to have papilledema, and this would be obvious on fundoscopy. Obesity, female gender, and exposure to certain drugs are risk factors for PC, but papilledema is a hallmark for the diagnosis.

ghost dog · Sep 9, 2011

neurodoc said:
Pseudotumor Cerebri is pretty easy to diagnose. You need to have papilledema, and this would be obvious on fundoscopy. Obesity, female gender, and exposure to certain drugs are risk factors for PC, but papilledema is a hallmark for the diagnosis.

I couldn't see her fundus due to her tiny pupils; I even have the fancy pants $500
opthoscope. I don't keep dilating drops on hand in the office.

The pt will be seeing neuro in a few weeks and I sent him my consult note, emphasizing my concerns.

neurologist · Sep 9, 2011

1. Intracranial hypertension is definitely up there as a possibility to r/o (and BTW, you don't "need" papilledema . . .). LP and maybe visual field testing.

2. Cerebral venous thrombosis (headache + ? seizures + ? of IIH) -- Normal CT is reassuring but should get an MRV.

3. Med overuse/rebound (6 Percos/day)

4. Sleep apnea (obese, headache, opioids)

5. Chiari malformation (chronic HA w/neck pain component). God forbid her MRI shows even the slightest cerebellar ectopia . . .

She needs to lose weight, which will help #1 and #4. I'd get her back on Topamax; should help probable migraine element, may facilitate some weight loss, and carbonic anhydrase effect might help IIH.

Mattchiavelli · Sep 9, 2011

2 things-
If she was on 2 different antidepressants, is she having what I'm assuming depression treated? Have you ever thought it might be tension-type headache? I know they're classically not "throbbing" but in people that give poor histories I always give their classification of pain a downgrade because I always wonder if we mean the same thing by "throbbing." Can be associated with depression and can get some relief with tricyclics, which she stopped around the time when her headaches converted from occasional to constant 2 months ago.

Also the (what I'm assuming) is a non-contrast head CT from the ER will clear you from a moderate to large bleed and masses that are shifting landmarks but aren't the best for small aneurysms that may only have a trace of blood or bleed occasionally.

ghost dog · Sep 9, 2011

Mattchiavelli said:
2 things-
If she was on 2 different antidepressants, is she having what I'm assuming depression treated? Have you ever thought it might be tension-type headache? I know they're classically not "throbbing" but in people that give poor histories I always give their classification of pain a downgrade because I always wonder if we mean the same thing by "throbbing." Can be associated with depression and can get some relief with tricyclics, which she stopped around the time when her headaches converted from occasional to constant 2 months ago.

Also the (what I'm assuming) is a non-contrast head CT from the ER will clear you from a moderate to large bleed and masses that are shifting landmarks but aren't the best for small aneurysms that may only have a trace of blood or bleed occasionally.

I don't think starting a patient with new onset seizure activity and a TCA would be a good idea (as a TCA has the potential to lower the SZ threshold).

I'm not sure why her Topamax, an anti-seizure med, was discontinued in the ER; any neuro feedback on this?

I suggested in my consult that neuro consider restarting Topa, as the patient had previously seemed to benefit from it.

Mattchiavelli · Sep 10, 2011

Wasn't saying she needed to be restarted on her TCA, just that it might have been helping with depression/tension headache since it was about the same time when she stopped taking her TCA that the headache got worse. If she has unaddressed depression issues you won't get maximum response from any HA treatment even if she had a tag on the back of her neck with the exact type of HA she had and you were giving her the gold standard treatment. You can always try an SSRI and see how she responds. Depression will feed into and will be fed by pain perception.

Headache Case

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