Headaches

Perspectives for Better Neurological Care
: C. Robert Adams, M.D.; Board Certified Neurologist

Pitfalls and Pratfalls in Management of Headaches

1- Diagnostic Imaging

A. CT Scanning is the absolute goal standard for identification of hemorrhage.

B. Always add a contrast enhanced image CT scan when not contraindicated in evaluating vague persistent headache and other neurologic symptoms so as to avoid missing obvious aneurysms, vascular malformations such as angiomas, meningiomas, as well as, malignant metastasis.

C. MRI imaging is in order if a posterior fossa lesion is suspect as with vaguely presenting brain stem tumors which are fairly common.

D. Cervical spine imaging is sometimes in order if neck stiffness or unexplained persistent posterior head and neck discomfort is part of the cephalgia.

E. Always note “incidental findings” such as MRI description of small vessel angiopathy especially in young adults, as well as, chronic sinusitis.

2- Migraine the great masquerader

A. Dizziness, especially in children prone to motion sickness.

B. Dysphoria and personality change as apart from the direct cephalgia.

C. Nausea and vomiting of severity to suggest viral illness.

D. TIA’s especially visual scotomas and hemisensory symptoms.

3- Coexistent disease complicates

A. Cervical arthritic disease.

B. Chronic vasomotor rhinitis.

C. Effects of other drugs.

1. Nitrates, Serevent in Advair

D. Temporomandibular joint dysfunction

E. Psychiatric interplay

F. Hypertension

Bottom line: Treat coexistent disease if indicated

4- Prophylactic treatment does not obviate ongoing acute treatment

A. Propranolol

B. Verapamil

C. Amitriptyline

D. Valproic acid (Depakote)

E. Gabapentin (Neurontin)

F. Topiramate (Topamax)