+ What are the key components of this patient’s history and physical examination, and why?

Relevant History:

• What are the headache characteristics? Describe the onset, context, location, duration, aggravating/alleviating factors.
• Describe the severity and quality of headaches (dull, throbbing, squeezing, sharp, stabbing, etc.)?
• Where are the headaches located?
• Are they constant or intermittent?
• Alleviating or aggravating factors?
• When did these headaches start? Is there a history of chronic headaches?
• Was there trauma/injury?
• Is there pain anywhere else? Any neck pain or numbness/tingling/weakness?
• Any post-concussive symptoms including vestibular dysfunction, vision changes, nausea, mood changes, or cognitive complaints?
• Functional changes?
• What has she done so far to treat the problem? Has there been any workup/imaging?
• Past Medical and Surgical History?
• Medications?
• Social history including school and employment history?

Relevant Physical Examination:

• Vital signs
• General appearance and comfort level with the lights on
• Mental status examination
• Cranial nerves
• Strength, sensation, and reflexes - testing for contralateral asymmetry
• Vestibular signs - saccades, visual motion sensitivity testing, nystagmus
• Cervical range of motion and palpation
• Special testing: Spurling

+ What is your differential diagnosis for this patient's headaches?

• My primary considerations include post-traumatic migraines, chronic migraines, tension type headaches, cervicogenic headaches, occipital neuralgia, or intracranial bleed. Other diagnoses which I might consider include temporomandibular joint injury, trigeminal neuralgia, low cerebral spinal fluid pressure headaches, paroxysmal hemicrania, neoplasm, arteriovenous malformation, cerebral venous thrombosis, temporal arteritis, pseudotumor cerebri, spontaneous intracranial hypotension, and Chiari I malformation.

+ Challenge Question

• How would you distinguish between migraine and tension-type headaches?

+ Challenge Answer

• There is some overlap between these two headache syndromes. Migraine headaches tend to be unilateral and throbbing, while tension-type headaches are often bilateral and described as a dull pressure, tightening, or squeezing sensation. Migraine headaches are often associated with nausea, photo- and phonosensitivity, and worsening with activity, while these features do not occur as frequently in tension-type headaches. Tension-type headaches often slowly worsen throughout the day and are worse at night, particularly after stressful days.

+ Would you obtain imaging or laboratory work in this patient?

• I would consider imaging of her brain such as a CT or MRI in order to rule out intracranial bleed. However, given that two weeks have passed since her injury and she remains alert and cognitively intact without focal neurologic deficit, I would likely defer imaging at this time. I would have a low threshold to obtain imaging if the patient were to develop any cognitive or functional decline. Laboratory work is not currently indicated in this patient.

+ You diagnose the patient with a concussion with associated post-traumatic migraines and vestibular dysfunction. How would you manage this case?

• I would begin by counseling the patient on her diagnosis. I would then describe healthy lifestyle interventions to promote concussion recovery, focusing on diet, hydration, sleep, stress management, and light exercise. As two weeks have passed since her concussion, I would counsel her to avoid “complete rest” and instead engage in activities as tolerated, taking breaks when needed. Especially given her vestibular dysfunction, I would recommend that she avoid returning to gymnastics for the time being and I would educate her on return-to-play protocols for the future.

• Regarding her migraines, I would counsel her to maintain a daily log of her migraines, to avoid triggers, and to avoid over-the-counter medication overuse. I would consider pharmacologic options for migraine prevention including tricyclic antidepressants (such as amitriptyline), antiepileptics (such as topiramate or depakote), or beta blockers (such as propranolol), among other choices. I would also consider prescribing an as-needed migraine abortive (such as sumatriptan). For her vestibular dysfunction, I would refer the patient to physical therapy for a vestibular therapy program.

+ How might you try to implement this?

• I would begin by researching the tool and ensuring that it is validated and supported in the literature. I would then reach out to local high schools, perhaps through athletic trainers or through contact information on the schools’ websites. I think that the best approach would be to see if the schools are already using some type of tool for a similar process, rather than coming in and immediately demanding that they start using my tool. If possible, I would try to adapt to whatever processes are currently in place. If no tool is currently in place, I would be understanding that implementing a new tool would require costs and planning from the school. I would be prepared to explain the benefits of implementing such a tool and would make myself available for any questions from the schools. This could be a large undertaking requiring coordination between multiple schools and physician offices, so I would be sure to delegate where possible.

+ How would you counsel her?

• A good response would be: “I am very happy to hear that your symptoms are getting better. You are doing a good job managing your symptoms and giving your body the resources that it needs to recover from your concussion. While you do seem to be recovering, you are not completely healed from your concussion yet. One way that we track recovery and readiness to return to sports is monitoring symptoms, both at rest and with activity. Before you go back to competing, you should be entirely symptom free or else you risk a repeat injury significantly worsening your symptoms and delaying your recovery. I recommend that you continue daily light aerobic activity until you can do this activity without any symptoms. The next day, you may progress to moderate exercise, and if you remain symptom-free you can then progress to heavy exercise the next day. After you can do heavy exercise without symptoms you may return to practice. You should not compete until you can practice without any symptoms. As you can see, we still have work to do before you can compete and I do not believe that you will be ready to safely compete in the next four days. I know that this process can seem slow and frustrating, but I thank you for being understanding and patient as you follow these necessary steps towards recovery.”