Patient Case

[jmj11]

Okay, my headache cases aren't as sexy as the ER ones, and I haven't seen anything really bizarre lately, but here is one that I wanted to throw out and you may get it immediately.

 

91 year old man is referred for a new onset of headache.

 

HPI: No history of headache whatsoever until about four weeks ago. He was awaken at 3 AM with a moderately severe (8/10) bi-occipital headache. He got up and sat up. It lasted about two hours and he was able to go back to bed and fall asleep.

 

No other problems for two weeks. Then the same thing occurred. It skipped a night and then came back and has been every night since.

 

The headache usually goes away after a couple or three hours but one day it became right sided and lasted more of the day.

 

Headache Character:

 

Location: bi-occipital

Quality: Ache, a little throbbing

Tmax: It seems to come on fairly quickly, awakening him from sleep.

Severity: 5-8/10

Associated Symptoms: None really. Also no autonomic symptoms.

 

Modifying Factors:

Triggers: None except for time of day, 2-4 AM

Aggavators: None

Alevers: Getting up and sitting seems to help.

 

Frequency: Once a day.

Duration: Typically 2-3 hours, one day about 6 hours.

 

Present Tx: Aspirin + cup of coffee, seems to help.

Past Tx: Was given sumatriptan 100 mg tablets by his PCP. Took one every morning (each headache) until he went to get a refill and his pharmacist warned him that he was using too much. It did help somewhat.

 

Work up: His PCP did and MRI brain and a MRA. Both normal except for typical atrophy of aging include central atrophy (large ventricles) but read as normal for age. No labs or other tests.

 

Present Meds: Levothyroxine for many years.

 

ROS: He's notice some mild cognitive decline over the past year. Notice some mild issues with balance. Otherwise feels great.

 

PMHx: Hypo thyroid dx 30 years earlier. Had severe pneumonia while serving in WWII and almost died. Otherwise, he has been healthy as a horse his entire life.

 

Family Hx: No headache or neuro history.

 

Social History: Retired CPA. Active. One glass of wine per day, 3 cups of coffee, never smoked.

 

Exam: Mental status: 28/30 (normal). Neuro: fine intention tremor bilaterally, arcus senilis, trouble with tandem gait but neg Romberg. The rest of the exam was completely normal.

 

Four questions:

 

1) Any other tests you would order?

 

2) What's the most likely present dx at this juncture?

 

3) What treatment would you try (open book:smile:)

 

4) If his self-perceived cognitive decline and gait worsens over the subsequent months and certainly if he developed urinary incontinence, what other dx might your worry about?

[jdenning]

If the size of the ventricles is disproportionate to the degree of atrophy on brain MRI, and ESPECIALLY if he developed trouble with urinary incontinence, I would be worried about NPH. There is nothing in his history that sounds consistent with temporal arteritis, but in anyone over 65 with headache I'd check a sed rate anyway.

 

28/30 on mental status testing is usually nothing to worry about, especially in a guy who is 91, but I'd check thyroid functions and MMA as potential metabolic causes of memory changes.

 

In the context of bilateral occipital headache that gets better with sitting up, I'd like to see what his c spine films and/or MRI looks like. If he has the kind of degenerative changes you might expect in a 91 year old, his headache could be related to DDD of his C spine and maybe he could improve with just good old ibuprofen and some good PT.

[jmj11]

Totally agree with your first couple of paragraphs. NPH is in the back of my mind but wouldn't seriously consider it with his present symptoms. I agree, I always get a sed rate and CRP on anyone over 60 and new headache. His is pending, but I'm doubtful about TA.

 

BTW, one of the most rewarding patients I have ever seen was a "Alzheimer's patient" who was sent to me. This was when I first started here and my headache calendar wash't full. To make a long story short, he had had a rapid onset of "Alzheimers" and I picked up on the ROS and exam a significant gait disturbance, and on ROS was incontinent. He was eventually shunted and his cognitive impairment almost returned to normal.

[deborah212]

Early morning headache that gets better sitting up still makes me worried about increased ICP... At least we know there's no tumor. He's not the typical substrate for idiopathic intracranial hypertension, but wonder if it's worth LPing him. How did his fundi look?

 

Other thoughts... TSH (headache/tremor/synthroid-->hyperthyroid), when does he drink those three cups of coffee (if they're late evening, maybe withdrawal, but less likely unless he changed his intake patters), snoring for OSA but longshot

[marilynpac]

Just stabbing in the dark...can those degenerative changes cause a stenosis that could possibly increase his ICP??? He should have a TSH done, might need to readjust his thyroid hormone.

[jmj11]

I will add that I doubt if it has anything to do with increased intracranial pressure. Body position didn't immediately effect it. I asked carefully about body position and it didn't influence it. I didn't mention this, but some nights he just stayed in bed, but he couldn't sleep, but eventually his headache went away as morning approached. But later he realized that he did better if he got up, took something, sat up for a while and then tried to go back to sleep. When I'm back at work on Monday, I will see if I can upload his MRIs. I have to figure a way to crop his ID off the file. However, the neuro radiologist was quite confident that it was normal for his age.

[marilynpac]

Allright next time I do any stabbing it will be in broad daylight.....

[deborah212]

The same timing every day and improvement with activity would go along with cluster headache... but his pain is bilateral and no associated lacrimation, tearing etc.

[bradtPA]

Some other causes of morning headache are elevated glucose, and obstructive sleep apnea. Anything in the history to suggest OSA? Is the glucose normal?

 

I did see one interesting case two years ago of a headache and the TSH was 85. Patient had an abnormal fundoscopic exam, and high opening pressure on the spinal tap confirmed pseudo tumor cerebri.

[jmj11]

i will check his TSH (at least to make sure it's been done lately), but I think it was last done a couple of months ago and it was fine.

 

To cut to the chase, I'm really confident, at least at this juncture, that he has hypnic headache. I usually see 2-3 cases a year.

[NewtonsApple]

BTW, one of the most rewarding patients I have ever seen was a "Alzheimer's patient" who was sent to me. This was when I first started here and my headache calendar wash't full. To make a long story short, he had had a rapid onset of "Alzheimers" and I picked up on the ROS and exam a significant gait disturbance, and on ROS was incontinent. He was eventually shunted and his cognitive impairment almost returned to normal.

 

Did he have hydrocephalus and you use a cerebral shunt?

[jmj11]

Did he have hydrocephalus and you use a cerebral shunt?

 

I suspected he had NPH, which can be tricky to dx. Rather than me trying to do a cisternagram (which our radiology dept. rarely does) I sent him to the neurosurgery department at U. of Washington. There, they too were convinced that it was NPH and did shunt him and he had significant clinical improvement.

[cobramarty]

That's cool. I never heard of Hypnic HA.

[Scoop5678]

I'm so glad the NPH was diagnosed; so often, it is not. My dad never had incontinence. He did have the typical gait problems and some memory issues.

 

Now three years after shunt, he has more cognitive issues (gets confused), and well as major personality change (was major extrovert; now very quiet person who just wants to stay home). Still working with different docs on paths to improvement.