Uncovering Uncommon Causes of Secondary Headaches

Headache medicine relies heavily on the patient’s history, perhaps more than any other field in neurology. A systematic approach to history taking is critical in evaluating patients with headache.

In this episode, Katie Grouse, MD, FAAN, speaks with Deborah Friedman, MD, MPH, FAAN author of the article “Approach to the Patient With Headache,” in the Continuum April 2024 Headache issue.

Dr. Grouse is Dr. Grouse is a Continuum® Audio interviewer and a clinical assistant professor at the University of California San Francisco in San Francisco, California.

Dr. Friedman is a neuro-Ophthalmologist and headache specialist in Dallas, Texas.

Additional Resources

Read the article: Approach to the Patient with Headache

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Full Transcript Available

Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the Show Notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the Show Notes. AAN members: Stay tuned after the episode to hear how you can get CME for listening.

Dr Grouse: This is Dr. Katie Grouse. Today, I'm interviewing Dr Deborah Friedman on approach to the clinic patient with headache, which is part of an issue on headache. Dr. Friedman is a neuro-ophthalmologist and headache specialist in Dallas, Texas. Deborah, I'd love if we could just start by you telling us more about you. How did you become interested in the diagnosis and treatment of headache?

Dr Friedman: I guess one of the lessons in life that I have learned regarding this question is, “never say never.” I started as a neuro-ophthalmologist - that's what I did my fellowship in. My very first job was in Syracuse, New York, at Upstate Medical University, and there was no headache specialist in Syracuse at the time. And I started seeing neuro-ophthalmology patients and specifically told the person who did my scheduling for me, “Do not schedule headache patients. I am not a headache doctor; I'm a neuro-ophthalmologist.” Well, these people just snuck in the door. They got referred in for their visual disturbances, right - we know what that was - or for their, you know, transient loss of vision or some type of visual manifestation of migraine or eye pain, right? So, I started seeing the patients and I figure, “Well, I did a neurology residency; I can treat headache as well as anybody else.” And so I started treating their headaches. and they would come back to see me in follow-up and say, “You gave me my life back,” and I was pretty blown away by that. This was a few decades ago, and we didn't give very many people “their lives back” at the time in neurology, so I decided I should go learn more about headache medicine. And I started attending national meetings of what is now the American Headache Society. I found that I really, really loved treating headache, and it has a natural marriage with neuro-ophthalmology. As my career progressed, I ended up doing more headache medicine and less neuro-ophthalmology, but I still love both.

Dr Grouse: Yeah, absolutely. I think the treatment of headache can be so satisfying and I'm so happy to hear that you were able to discover that love of treating headache in your own career. Why do you think it's important for neurology clinicians to read your article?

Dr Friedman: Well, headache is the most common disorder seen in general neurology. It is actually the most common neurological disorder overall, by a factor of ten. And it is one of the most common causes of neurologic disability worldwide - like it's in (routinely in) the top five. So, it's an important problem, and patients are going to come see us, and we need to know how to effectively interview them so we can effectively manage them. I think, in a nutshell, that's why.

Dr Grouse: You mentioned in your article the importance of making time to discuss the headache - so much so that, actually, you said that if they mentioned it offhand at the end of the visit that they have a headache, you really should be scheduling time for them to come back, to prepare and organize the information, and to have the time to really talk with them. I find this is such an important point and, in my mind, really gets to the heart of what you're trying to tell us in your article - that the way you take the history can make or break your ability to diagnose and treat the problem. Can you talk more about that?

Dr Friedman: Sure. The history is absolutely the most important part of the office visit with headache medicine. I mean, they always say, “In medicine and in neurology, ninety percent of the diagnosis is made by history.” And that is more than true in headache medicine. So, you have to really get a good history. And it's a skill, but there's also kind of an art to it. So, there are certain questions you want to have answers to, but there's also this art of how to relate to the patient and how to really get them to tell you what you need to know, right? When I wrote the article, I really tried to convey that, because I think a lot of it can be learned. But there are a lot of nuances to taking a headache history, and I think that, for many people, it's helpful to have a guide to do that.

Dr Grouse: Following up on what you just said - you mentioned, of course, the art of taking the good history for headache, which I completely agree is absolutely true. However, in your article, you also mentioned that things like various questionnaire tools, AI, can also be really helpful for diagnosis, which seems to be the opposite of the art of medicine. Tell me more about how you can incorporate that into taking your history.

Dr Friedman: I find that questionnaires are incredibly helpful. I devised my own - it is one of the questionnaires that's available in the article (there's a link for it). It's not that I just read the questionnaire and I walk in the room knowing exactly what's going on - sometimes that's true - but at least I have a good idea of what I'm going to be facing when I walk into the room and start talking to the patient. The other reason (perhaps more importantly) that I think it's so helpful is because it gets the patient thinking about the details of their headaches and the details of their life and, you know, like, what medications they've taken in the past. And it really prepares the patient for the interview. In a lot of ways, I think that's more important than the information it gives me. But I do look at all the questionnaires, and I'll say, “Well, you know, you checked off this, and what did you mean by that? And you said this or that on your questionnaire.” And I kind of refer to it so they at least know that I looked at it - there's nothing more irritating than filling out a long questionnaire and then nobody ever looks at it - so, I do look at it and I do acknowledge in front of them that I have looked at it and am looking at it. But I think that they help in many ways. There are programs in AI that the patient will just enter information into online and the program will just spit out a narrative, as well as a diagnosis or a differential diagnosis. For clinicians that are really under a lot of time constraints, I think these can help considerably as well.

Dr Grouse: That's really interesting, and that actually brings me to the next question I wanted to ask, which was - do you have any tips for the many busy neurologists out there (many listening to this podcast right now) who really want to do a good job gathering information and taking a careful history but are really limited on time to be able to do this? What other tools out there would you recommend for them, or tips?

Dr Friedman: Yeah, I think that probably the questionnaires and the AI-based programs are very helpful. There is - I have no financial relationship with this company; I just happen to know about it and I know the people that developed it - but it's called BonTriage (as opposed to bon voyage), and it was developed by headache specialists. And I've seen the product and I've seen the output that can be used, and I think that one is incredibly helpful. It was really made for primary care, so that people could do this thing online and then just walk in with a piece of paper, hand it to their primary care doctor, and they'd have the whole history and the differential diagnosis. But it's equally as useful for neurologists.

Dr Grouse: How about in history taking - any tricks to get the history you need and let the patient feel heard without necessarily taking lots of time going down the wrong pathway?

Dr Friedman: Yeah, that can be really hard, and sometimes patients just want to bring you down what you would consider the wrong pathway (obviously, they consider it the right pathway). People have different styles of interviewing and people have different styles of answering the question. I find that it's often very obvious early on whether the patient is going to do better by asking closed-ended questions or asking open-ended questions. I always start with open-ended questions because the research says that that's more helpful, and that getting the patient to describe their headache disability is one of the most important things that you can do, so you should ask it right up front. But some people - when you ask them the questions (as you probably know), they just go on and on and on, and it's really not the way that you might process information. So sometimes I just have to take it back and ask them very specific questions – “Do you have this symptom? Do you have that symptom? How long does this last? What triggers your headache?” - that kind of stuff. It's very, I think, specific to an individual patient.

Dr Grouse: Yeah, that absolutely makes sense. Your article highlights some important and frequently missed causes of headache, including hemicrania continua and intracranial hypotension, and specifically, you have some example cases that you talk about. I have to say, reading those certainly triggers my own latent fear of misdiagnosis of these important causes of secondary headache. Can you highlight some of the important questions to ask or situations to keep in mind in order not to miss these?

Dr Friedman: Sure. You know, those examples in the article came from my practice. I had to alter them a little bit because they're not supposed to sound like real people, but the patient with hemicrania continua was a real - I wouldn't say necessarily “eye opener” - but it really hit home with me. I spent all this time taking the history from the patient. She'd seen numerous doctors beforehand; they all thought she had chronic migraine. I take her history and I think she's got chronic migraine too, but she's trialed several medications; they haven't really worked, so, you know, we kind of ended it. I said, “Well, I think you have chronic migraine.” She came back for her follow-up visit and looked at me and said, “Could I have hemicrania continua?” At which point, I panicked. It's like, “Oh my god - I think I take a pretty good history, but what did I miss?” I'm like, looking through the note from the last visit and trying to figure out where I went wrong. And where I went wrong was, I never asked her, “Are you ever completely headache free?” And that is such an important question to ask because most often, when people come in and they start talking about their headaches, they talk about their worst headaches, right? Those are the ones that are really interfering with their lives. They often will just totally neglect to tell you that they have a headache almost every single day, but it's just mild and they don't pay attention to it. That was like a big lesson for me, and I try - it's even on my questionnaire – “Are you ever headache free?,” because it's just so important to know that. Intracranial hypotension is also one that you really have to be a detective for. A lot of times, the imaging will help us, but about ten, fifteen, twenty percent of people with intracranial hypotension have normal imaging. Then it becomes like this whole quest of making a diagnosis based on your clinical impression, right? So, there are just a lot of different things that you can ask and there are a lot of different symptoms people can have. One of the important lessons I learned in there was asking about orthostatic headache; the common way to ask that is, “Does it get better when you lie down?” Well, with few exceptions, most people with headache prefer to lie down, right? People with migraine prefer to lie down. But their headache doesn't get better just because they were lying down. It gets better because they took medicine and maybe they went to sleep. So, it's not just, “Is it better when you're lying down?” Is not going to sleep is part of it? And conversely, we want to know like what they feel like when they first wake up in the morning before they get out of bed, right? So just asking about, “Well, what's your headache like in the morning?” - that's not going to necessarily get the answer you want. So there are, again, kind of fine points about asking some of these questions to really find out what you need to know.

Dr Grouse: Absolutely - that makes sense, that the intracranial hypotension case was another one that really, you know, makes me go back and think, “Gosh, how many of these might I have missed in my own career?” You know, such an easy-to-miss case based on what was described.

Dr Friedman: I go through the same thing. I think that, early in my career, I could think back to patients that I probably missed that diagnosis. One of them I even sent to (may he rest in peace) Dr Mokri, who described it, and I sent him the imaging. He said, “No, this patient doesn't have it.” But knowing what we know now, I think she probably did.

Dr Grouse: Wow. Transition to some other types of questions - what's the most common misconception you've encountered in treating patients with migraine?

Dr Friedman: I would say that a lot of people think that migraine has to be (as the name implies) hemicranial. A substantial proportion of adults and even a higher proportion of children have migraine headaches that affect both sides of the head. I think that's really the most common misconception.

Dr Grouse: What's the easiest mistake to make (and potentially avoid) when treating patients with migraine, or headache in general?

Dr Friedman: Studies have been done looking at this question in migraine. The first mistake is not giving the patient a correct diagnosis. And it is surprising in real life how many people walk out of the doctor's office and nobody's ever told them, “You have migraine with aura,” or “You have chronic migraine,” right, and giving them a very specific diagnosis. Second most common mistake in treatment is not offering them an acute treatment. So, many people are using over-the-counter medications that are not very effective, or even prescription medications that are not very effective. We have a lot of good treatments out now, and basically every patient with migraine should be offered an acute treatment. We also know that preventive treatment is massively underutilized. Again, studies (mostly by Richard Lipton and his group) have interviewed patients and done population studies, and people who clearly meet contemporary guidelines for offering preventive treatment are never offered it. So, I guess those would be my top three.

Dr Grouse: Going on the theme of patients maybe not being offered the optimal treatments, what's the greatest inequity or disparity you see in treating patients with headache disorders?

Dr Friedman: The first thing that contributes to that is - there is a shortage of headache specialists. There's also a shortage of neurologists, so that's a problem. There are certain groups that are less likely to seek care for headache. If people don't seek care, it makes it harder for us to treat them. African American males, in particular; Hispanics. I think that some of this might be stigma; some of this just might be cultural - I'm not sure. Women are more likely to seek care for migraine than men are. But there are what they refer to as, like, “islands of health-care disparity” throughout our country, where there are just not enough physicians, or even advanced practice providers working with physicians, to be able to take care of all these people. So, it's estimated that there are well over forty million people with migraine alone in the United States (not to mention all the other kinds of headaches), and there are really not enough of us to go around, and there are very long waiting times to get in to see us. So, some people will end up using the emergency room to treat their headaches, which is totally suboptimal and not a good experience for the patient, either. So, I think there are a lot of aspects to disparities in migraine care, and there is a group in the American Headache Society that actively focuses on this issue and has written papers about it. But I think it's multifaceted and it's going to take a lot of effort on both the part of us, as clinicians, as well as patients, recognizing that there is good treatment out there and people shouldn't have to live with these kinds of disorders.

Dr. Grouse: Absolutely. This has been such an interesting article. I just wanted to end with one last question, which is, what do you think is the most important clinical message of your article that you hope our listeners take away from this podcast?

Dr Friedman: I was really happy to be asked to write this article for Continuum. And I'm glad it is the lead article in Continuum because I think that taking the headache history is by far and away the most important part of the headache medicine evaluation. When I was asked to write it, I was specifically requested to write it from the perspective of a clinician seeing adult patients. And I just want to let the audience know that I did not neglect the pediatric patients - that there is a different chapter in Continuum that addresses the specifics of taking a history and what's important to ask from pediatric patients. It was really a joy to write the article. I hope that people read it and learn from it and enjoy it.

Dr Grouse: I really thoroughly enjoyed this article - it was so interesting. Even as someone who does a lot of headache diagnosis and treatment myself, I learned a lot. I think it's such a rich source of information and I hope everyone takes advantage of the opportunity to read it and learn a little bit more about headache treatment and diagnosis. Thanks so much for coming to talk with us today.

Dr Friedman: Thank you so much for inviting me. It was a pleasure.

Dr Grouse: Again, today I’ve been interviewing Dr. Deborah Friedman whose article on Approach to the Patient with Headache appears in the most recent issue of Continuum on Headache. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today.

Dr. Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice. Right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/Spring2024, or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members: go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.