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
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.
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.
