New Onset Headaches In An Old Man - What Should Be Done?

 

 

In November of 2022, I started to experience headaches that were new and unusual. They would start out as a dull ache behind the left eye to varying degrees and generally persist until I took 1,000 mg of acetaminophen. Acetaminophen (APAP) works like a miracle for me for most kinds of pain and it would reliably knock the headache out in 1-2 hours. Back in my early 20s I experienced more severe headaches that were quite debilitating and most likely cluster headaches. For a couple of years, I would get them every spring and would have to take aspirin (ASA) or APAP and take a nap until they went away.  I make that diagnosis in retrospect after learning quite a bit about headaches and learning how to treat them. The new headache was nothing like those cluster headaches.  I could still read, exercise and function well. I also noticed that sleep alone had no effect on the new headache. I would still wake up with it if I did not take APAP.  Only recently I had an episode where the new retroorbital headache worsened with coughing and that seemed to be an isolated event. The headache could occur at any time of the day, was not related to stress, or any activity.

I was seeing optometrists at the time – initially for an annual eye exam and then for severe dry eyes. I asked both optometrists if any of the eye diagnoses (Meibomian gland dysfunction, ocular rosacea, blepharitis, punctate keratitis, dry eyes, and astigmatism of the left eye) could be causing the headaches and was told it was a possibility but that I should follow up with primary care and neurology. By January of 2023, I tried to get an appointment to see a neurologist – but could not get in until September 2023.  I saw my primary care MD twice during this period and his diagnosis was tension type headaches because I had no other neurological symptoms. The plan was to keep taking APAP.

Digressing a moment to diagnosing and treating headaches as a psychiatrist. As an acute care psychiatrist, I was in the position of diagnosing and treating many people with severe chronic headaches. They were typically admitted because of associated severe depression, suicidal thoughts or behavior, or a complete inability to function at home. Many of those patients started out with migraine headaches that were eventually complicated by medication overuse headaches. Frequent use of medications like APAP, triptans, and non-steroidal anti-inflammatory medications (NSAIDs) resulted in a headache that would not longer resolve. That diagnosis led to a different treatment plan that was moderately successful until a better plan for headache prophylaxis could be established. I had excellent back up by neurology and often consulted with a friend of mine who is a local neurologist and pain specialist.

Diagnosing headaches is not too far removed from making a psychiatric diagnosis in that the phenomenology of the headache it critically important.  What is the pain like, how is it described, does it radiate, are there any associated events or sensory phenomenon?  History is a critical part of the headache evaluation. The physical exam can contribute in the case of autonomic findings, making an underlying diagnosis that is a cause of the headache, or in some cases  a finding that suggests an underlying pathophysiological mechanism.  An example would be tenderness in the facet joints of the cervical spine (C-spine) for cervicogenic headaches.  Associated testing can be diagnostic but in most cases it is supportive.  That is degenerative disk disease and arthropathy of the facet joints of the C-spine supports the diagnosis but other elements need to be there like the characteristic pain distributions associated with this headache. A complete list of the common forms of headaches can be found at the National Headache Foundation and much more detailed discussion in headache specialty texts. The list is not exhaustive since headaches can occur across many settings and can be the general result of chemical alterations (alcohol, alcohol withdrawal, medication side effects, etc) and inflammation (influenza, coronavirus, etc).  As far as I know neurologists have not embraced the transdiagnostic term that we see cropping up in the psychiatric literature, but headaches are both a disease and a transdiagnostic symptom.

An illustration of the complexity of these headaches uses my specific example.  The table below illustrates the onset and frequency of these headaches from October 2022 to June 17, 2023).  Headaches are recorded only if they were treated with APAP.

 

	Generalized Bilateral	Left Retroorbital
OCT	7	1
NOV	8	4
DEC	1	6
JAN	2	4
FEB	5	5
MAR	4	3
APR	3	14
MAY	3	10
JUN (to June 17)	0	5

 

I will attempt to correlate various comorbidities to see if there are any possible explanations:

C-spine disease – I was diagnosed with C-spine disease by clinical exam and MRI about 20 years ago. The MRI showed stenosis but EMG studies were normal and physical therapy resolved the neurological symptoms I had at the time – primarily numbness in the C7-C8 distribution of both arms.  I have been doing the PT exercises for the past 20 years.  From the chart I do get episodic bilateral occipital headaches that radiate up from the neck and I attribute these to C-spine disease.  I typically treat them with physical therapy maneuvers and occasionally APAP.  Cervicogenic headaches have three reported pain distributions - occipital, occipital temporal maxillary, and supraorbital (most common).  Other sources say that the pain can be experienced anywhere on the face (1).  Retroorbital headaches from this cause seem unlikely.

BPPV- my only other MRI of the brain was done when I developed benign paroxysmal positional vertigo about 25 years ago.  Although that brain scan was normal, a polyp was noted in the frontal sinus but no further evaluation or treatment was recommended. I typically have episodes that seem to be improving over time.  Not debilitating.  

Astigmatism- severe in the left eye – causes visual distortion and seems to contribute to vertigo.

Dry eyes – multiple diagnoses as noted

Paroxysmal atrial fibrillation – have had about 20 episodes lifetime.  Much better control recently with a brief episode every 1-2 years. On an antiarrhythmic for 16 years. The main non-cardiac risk is embolic stroke.  I have had highly variable experiences with the physicians I have consulted about this disorder over the years.  There appears to be no consensus on the time frame necessary for cardioversion to prevent strokes.  I have been cardioverted initially in time frames of up to 15 hours both with medications and electrical cardioversion. In one case, I was anticoagulated and in other cases not. I have had patients who were in permanent atrial fibrillation and were not anticoagulated. Primary care seems to have a fairly casual approach to atrial fibrillation possibly because early studies showed there was no difference in outcomes based on rate control or rhythm control (normal sinus rhythm). Since then, studies have shown that people with rhythm control may have a higher quality of life. I decided to start anticoagulation 18 months ago because the pandemic had seriously compromised physician access and I did not want to end up in atrial fibrillation with no access to cardioversion. For the purpose of this post the question is: “Is it possible that a silent stroke occurred and caused this headache?”  At least one reference suggests that silent strokes are common in the elderly but not a cause of headaches, but deep white matter lesions on MRI may be. (2)

ATM and other risk genotypes- In a previous post I explained the ATM genotype and how it significantly increases the risk for pancreatic cancer.  I also have genotypes associated with increased risk for epithelial cells cancers.

Migraine Aura without Headache- I have experienced this in the past but not recently as a single episode of visual phenomenon.  The ophthalmologist I consulted with knew what had happened immediately and no specific treatment was recommended.

 Obstructive sleep apnea (OSA) – Diagnosed 18 years ago and I have been 100% compliant with CPAP/APAP ever since. I get a daily report on hypopneic episodes/hours and they are always well withing the target range.  OSA can be a cause of headaches, typically in the morning (3) but improve with treatment and are unlikely in this case.

Not all these factors were considered by the physicians I consulted about these headaches. The protocol was basically a cursory (or detailed) neurological review of systems and neurological exam.  In all cases I was told that it was a “non-focal” neurological exam.  My primary care physician saw that as a reason for no imaging and continuing the current treatment with APAP for a diagnosis of “tension headaches”.  The neurologist initially said he thought I had a migraine but on further consultation the diagnosis was “inflammatory headache” and I was given a standard tapering dose of methylprednisolone.  I filled the prescription but decided not to take it until after the imaging study.  None of the physicians suggested that it could be pain due to C-spine disease and I have found that unless you are talking with a rheumatologist, a lot of physicians do not spend a lot of time discussing or treating arthritis. The neurologist also ordered an MRI scan of the brain and two of the images are at the top of this post.  It was read as a normal MRI scan of the brain. The headaches persist.

This exercise in the differential diagnosis and treatment of headaches is instructive for several reasons:

1:  It highlights the complexity of medical conditions and everything that needs to be considered.  I could argue that 20 or even 30-minute visits with a generalist or even a neurologist might not result in an adequate assessment just based on the information that needs to be considered.  I described 50 years of medical history as succinctly as possible but it also requires somebody to put that together as rapidly as possible and look for the relevant patterns of disease. There are headache specialists out there who do this – but they are rarer than child psychiatrists and that is rare.

2:  The complexity is compounded by the fact that there can be more than one type of headache present and that each requires a separate diagnosis and treatment. In my case I came in with my own ideas that I had one type of cervicogenic headache and a new headache of undetermined etiology.  There are studies available that attempt to differentiate migraine headaches from cervicogenic headaches by selective injections of various cervical vertebrae.  In some cases that clarifies the source of the headache and in others the patient has both types. Similarities to the psychiatric diagnostic process are noted.  There are some who suggest that there should only be one treatable diagnosis.  If you can have more than one headache I don’t see why you could not have more than one psychiatric diagnosis.  

3:  Testing is a wild card – but should it be?  In this case my primary care physician opted to not order brain imaging but the neurologist did.  The kind of testing done in psychiatry and in much of neurology is non-diagnostic.  In other words, if a lesion is detected there is still a question of whether it is causative. The best example is degenerative disk disease and arthritis of the spine. It is easy to detect degenerative changes but the question is how they relate to the clinical problem. At the same time, the prevalence of serious secondary causes of headaches in the elderly such as tumors, vascular, inflammatory and other space occupying lesions like hematomas is significantly higher than in younger population – making any primary headache diagnosis in an older person - a diagnosis of exclusion.  I have certainly imaged patients in my practice based on various combinations of neuropsychiatric, cognitive, and neurological symptoms for this reason. It is no different in neurology.  In addition to the central nervous system secondary causes of headaches, orbital lesions need to be considered and that list is also extensive.

4:  Are headaches a disease?  With all of the repetitive rhetoric from the anti-science and anti-psychiatry crowd – my mind wandered to this question.  I had also recently encountered the term “Szaszian binaries” in a philosophical paper that was mildly critical of the disease arguments from antipsychiatrists that to this day are based on Szasz’s 60-year-old definition – that diseases must be based on morphology or a known pathophysiological mechanism – like infection from an organism.  It turns out that headaches are indisputably called diseases even though the mechanisms are as speculative and no morphological lesions are seen on brain imaging.  Like psychiatrists – the only positive findings will be the identification of secondary causes and that is no small accomplishment.  As I searched this topic, I found an article written by Ron Pies, MD on this very topic (5).  Szasz never wrote a Myth of Migraine Headache or commented on why headaches were not diseases.  

Where does all of this leave me today?  First relieved that there is no life threatening or debilitating brain pathology and that my brain looks pretty good for an old man.  I previously documented a serious traumatic brain injury in my 20s and my C-spine problems are likely the result of playing high school football and compression injuries transmitted through my helmet and head and into my neck. I was also involved in a collision playing third base that resulted in my neck being locked up for several hours that did not help. Second, it adds to my long-term health plan.  Despite that list of health problems, I have exercise and physical therapy plans to deal with most of it. Maintenance measures will take care of the rest.  I have a follow-up with neurology in October and if the retroorbital headaches start to increase in frequency I might try the methylprednisolone, but I don’t have high expectations. I had an asthma flare after a trip to Alaska about 8 years ago and had to take prednisone at a substantial dose and that did not seem to do much for the cervicogenic headaches.  My primary treatment modalities will remain exercise, physical therapy, and APAP.

It may seem like that is a significant list of problems, but after working in the field for 40 years they seem expected to me.  As long as they are manageable and I am tracking them and making necessary adjustments life is good. I also have a high index of suspicion for future problems and hope to identify any that come up, but I am also not fooling myself that I can control everything or that new problems will always be manageable. 

 

George Dawson, MD, DFAPA

Supplementary on Neck Pain:

I did a previous post of the importance of the spine in psychiatric practice largely because of bidirectional considerations.  I was seeing a large number of people who had sleep problems that were either caused by neck pain or had insomnia that seemed to cause neck pain. My interest in the mechanical and neurological spine dates back to excellent neurosurgical rotations in medical school and the associated radiology rounds with the late Sanford J. Larson, MD, PhD.  Even though neurosurgery was a tough rotation for students, residents, and attendings - every Saturday morning Dr. Larson would meet all of us in the Radiology reading room at Froedtert Hospital and would spend the morning reviewing all of the films from the last week.  I say films because all of the images were on large films placed on a device that could rotate them all in order.  The standard film in those days was 35 x 43 cm (14“ x 17“) so each row on that machine held about 8 films.  I was able to continue that practice when I worked at an acute care hospital but outside of that setting - it was always difficult to access films and later digital images. 

Another outcome of that early experience was continuing to read papers on common spinal problems and way to address them.  The epidemiology of neck pain has progressed significantly over time (6.7). In 2015 it was noted to be the 4th leading cause of disability.  Most acute neck pain resolves in a couple of weeks but in 50% of those cases it recurs over the next year. Annual prevalence is estimated to be 15-50% with an average of about 37.2%.  There have also been some studies of the impact of structured exercises on neck pain that typically show improvement.  I have not seen any estimate on the percentage of people with neck pain who have associated headaches but expect that would depend on risk factors and degree of mechanical and neurological impairment. This also seems to be a medical education issue. In my experience very few physicians know how to do a back and neck examination and interpret the findings. 

 

References:

1:  Al Khalili Y, Ly N, Murphy PB. Cervicogenic Headache. 2022 Oct 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29939639.

2:  Fujishima M, Yao H, Terashi A, Tagawa K, Matsumoto M, Hara H, Akiguchi I, Suzuki K, Nishimaru K, Udaka F, Gyoten T, Takeuchi J, Hamada R, Yoshida Y, Ibayashi S. Deep white matter lesions on MRI, and not silent brain infarcts are related to headache and dizziness of non-specific cause in non-stroke Japanese subjects. Intern Med. 2000 Sep;39(9):727-31. doi: 10.2169/internalmedicine.39.727. PMID: 10969904.

3: Verbraecken J. More than sleepiness: prevalence and relevance of nonclassical symptoms of obstructive sleep apnea. Curr Opin Pulm Med. 2022 Nov 1;28(6):552-558. doi: 10.1097/MCP.0000000000000915. Epub 2022 Sep 14. PMID: 36101923; PMCID: PMC9553267.

4:  Vongvaivanich K, Lertakyamanee P, Silberstein SD, Dodick DW. Late-life migraine accompaniments: A narrative review. Cephalalgia. 2015 Sep;35(10):894-911.

5:  Pies RW.  Why Thomas Szasz did not write about the myth of migraine. Psychiatric Times.  July 29, 2021.  https://www.psychiatrictimes.com/view/thomas-szasz-myth-migraine

6:  Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015 Feb;90(2):284-99. doi: 10.1016/j.mayocp.2014.09.008. PMID: 25659245.

7:  Kazeminasab S, Nejadghaderi SA, Amiri P, Pourfathi H, Araj-Khodaei M, Sullman MJM, Kolahi AA, Safiri S. Neck pain: global epidemiology, trends and risk factors. BMC Musculoskelet Disord. 2022 Jan 3;23(1):26. doi: 10.1186/s12891-021-04957-4. PMID: 34980079; PMCID: PMC8725362.