Episode 16: Snoop That Headache

The sun rises over the San Joaquin Valley, California, today is June 12, 2020. 

The results of the DAPA-HF (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure Trial) were presented in November 2019. If you haven’t heard about it, here you have it: In patients with Heart Failure with reduced Ejection Fraction, both WITH and WITHOUT Type 2 Diabetes, dapagliflozin plus standard therapy reduced the risk of worsening Heart Failure events and Cardiovascular death and improved symptoms. 

Did you hear that? It improved heart failure outcomes in patients WITH and WITHOUT diabetes. This certainly opens a new window for potential use of SGLT-2 inhibitors in patients WITHOUT diabetes.

On May 8, the CDC reported a significant decline in childhood immunizations since March. Let’s remember to prioritize well-child visits for patients who need vaccinations. As family physicians, we play an essential role in prevention, and we need to avoid the resurgence of preventable communicable diseases.  

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

“The roots of education are bitter, but the fruit is sweet” –Aristotle.

Going to school and learning requires effort, patience, and perseverance, but the consequences of your determination will be well worth it. Dear residents, you will learn something new every day of your lives, even if you don’t realize it. Today we will learn even more from one of our sweetest and smartest residents. Welcome Monica Kumar, thanks for being here with us. I understand you were working nights, but now you are rested and refreshed. Who are you?

1. Question number 1: Who are you?

My name is Monica and I am a second-year family medicine resident at the Rio Bravo Family Medicine Residency Program. So, a little bit about me, I was born in Malaysia, a small country located in Southeast Asia. In 2004, my parents and I moved to Bakersfield, California, a place I now call home. I went to Bakersfield High for high school and then graduated from UC Berkeley with a major in Integrative Biology. 

After undergrad, while trying to plan out the rest of my life career wise, I worked as an air testing chemist for a year, which made me want to run as far away as I can from being stuck in a lab, so I ran all the way to the beautiful island of Saint Marten to pursue a career in Medicine. 

After finishing medical school, I was very fortunate I was able to return home to learn and serve the community that has given me so many opportunities. For fun, I love playing badminton and ping pong, flying kites, walking my dog, gardening, going on adventures, and binge watching romantic comedies and horror movies on Netflix. 

1. Question number 2: What did you learn this week?

So, after working multiple shifts in the ED while wearing the N95 for about 7-9 hours consistently and walking around with a daily headache, I thought it was only appropriate for me to talk a little bit about headaches, particularly the indications for imaging, assessment and management of headaches in the outpatient setting. 

I have had numerous patients who have come to clinic repeatedly complaining of headaches and, though we all have gotten headaches in our lifetimes, we often forget how debilitating it can be for patients who cannot find an appropriate treatment regimen to control their symptoms. 

There is a fine balance about when to treat headaches. We should not overuse medications because overuse can worsen migraine and tension headaches, but at the same time not controlling repeated headaches can result in central sensitization and transformation to chronic headaches that are intractable and difficult to treat. 

When to treat headaches 

First, we should perform a thorough interview of the patient presenting with frequent headaches. We have to ask about 

•   Associated symptoms: nausea, vomiting, photophobia, neck tenderness

•   Duration of episodes and frequency

•   Aggravating and alleviating factors (if the headache is worse with activity or light, or if there is any improvement with noise avoidance)

•   Inquire about the intensity, location and quality of the pain 

•   Medications utilized and its effectiveness

Next, we have to perform a thorough, focused physical exam carefully examining head, neck, eyes including fundoscopy, evaluating extraocular movements, visual fields, assessing sinus tenderness and gait 

Some labs to consider: CBC, CMP, ESR to evaluate for temporal arteritis

The next big question is when is imaging indicated. Being family physicians we do not want to expose our patients to excessive procedures and radiation but we have to find a fine balance by considering the pros and cons. The American Headache Society and American Academy of Neurology recommend the use of the mnemonic SNOOP to guide in the decision of obtaining further imaging 

The mnemonic SNOOP can be used to think about secondary causes of headaches and the need for imaging. 

S in snoop stands for Systemic symptoms and Secondary risk factors. You want to inquire if the patient has been experiencing fevers, chills, weight loss OR if they have a history of HIV or cancer.

N in snoop is for Neurologic symptoms. Ask the patient if they have experienced any confusion, impaired alertness or alteration in consciousness of mentation. The presence of neurologic symptoms should prompt immediate evaluation for focal nervous system lesion.

O stands for Onset: is the headache sudden, abrupt.

O in snoop is for Older. A new onset or progressive headache in an older patient >50 years of age requires further investigation.

P in the mnemonic stands for Papilledema.

Per the American Headache Society and the American Academy of Neurology, if imaging is indicated at the outpatient setting always order an MRI without contrast instead of a CT. A CT should mainly be used in an emergent situation to r/o hemorrhage. 

Non-pharmacologic Treatment

• Reduce stressors, exercise, meditate, keep a headache journal.
• Address lifestyle issues such as poor sleep, lack of exercise, smoking, obesity, caffeine use in triggering headaches
• The US Headache Consortium strongly recommends relaxation training with or without thermal biofeedback and cognitive behavior therapy for the treatment of migraines
• Of note, patients with frequent headaches require both prophylactic and acute pharmacologic treatments.

1. Question Number 3: Why is this knowledge important?

Since headaches are one of the most common complaints we as family medicine physicians encounter, it is very important that we do not miss secondary causes of headaches which can be life threatening. 

1. Question number 4: How did you get that knowledge?

After SNOOPing around AAFP articles pertaining to the treatment and management of headaches in the outpatient setting, I stumbled across the SNOOP mnemonic and thought it would help me and my fellow colleagues remember the indications for imaging and the danger signs that can prevent us from missing a life-threatening diagnosis 

1. Question number 5: Where did you get that knowledge?

The information discussed was condensed from various AAFP articles titled “Frequent headaches: evaluation and management” “Migraine Headache Prophylaxis” as well as UpToDate’s headache article. That’s all for this week, stay tuned for the treatment and management which will be covered during our next episode with Dr Brito, hope you have a nice rest of your week. 

Speaking Medical: Formication or delusional infestation
by Dr Gina Cha

ForMication, with an M, (not to be confused with forNication with an N, which is consensual sexual intercourse between two unmarried people). ForMication is one of the terms used to describe the sensation of small insects crawling on (or under) the skin. 

Formication comes from the Latin word formica, which means ant. A patient with formication perceives the sensation as “real”, they have a fixed, delusion that they are infested by bugs, that’s why we also call it delusional infestation. 

Primary delusional infestation is a psychiatric disorder which cannot be treated only by reasoning with the patient that he or she is not infested by bugs. Delusional infestation is the most common form of monosymptomatic hypochondriac psychosis. 

Formication can also be secondary to substance abuse (methamphetamine, cocaine), or substance withdrawal (alcohol and benzodiazepines). Do not confuse formication with pruritus or paresthesias, which can be explained by an organic cause, but formication has a heavy psychiatric component. 

Espanish Por Favor: Chorro 
by Dr Claudia Carranza

Hi this is Dr Carranza on our section Espanish por favor. This week’s word is cabeza. Cabeza means head, this word comes from Latin root “caput” which literally means head. Patients can come to you with the complaint: “Doctor, me duele la cabeza” or “Doctor, tengo pesadez de cabeza”, which means “Doctor, my head hurts” or “Doctor, my head feels heavy”. You can then continue the interview and ask about timing, duration, exact location, prior trauma, and associated symptoms, just like Dr Kumar eloquently explained before.  

Now you know the Espanish word of the week, “CABEZA”. 

For your Sanity
by Drs Lisa Manzanares, Gina Cha and Alyssa Der Mugrdechian

—What is the medical term for owning too many dogs? A Roverdose

Patient: Doctor, someone decided to graffiti my house last night!
Doctor: So, why are you telling me?
Patient: I can’t understand the writing, was it you?

_______________

Now we conclude our episode number 16 “Snoop That Headache”, Dr Kumar talked about how to determine if a headache needs imaging evaluation. Remember, SNOOP stands for Systemic and Secondary risk factors, Neurologic symptoms, Onset, Older, and Papilledema. ForMication (with an M) is used to describe the sensation of bugs crawling on or under the skin. It is an unusual symptom for a psychiatric or neurologic illness. This week we taught you the spanish word cabeza, which means head, so now you know what your patient is talking about when they said they have pain in their cabeza.

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. 

Our podcast team is Hector Arreaza, Alyssa Der Mugrdechian, Gina Cha, Lisa Manzanares, and Monica Kumar. Audio edition: Suraj Amrutia. See you soon! 

___________________________

References:

1. Zoler, Mitchel L., “Heart Failure, Dapaglifozin Equally Effective for Those with and without Diabetes”, Family Practice News, Vol. 49, No. 12, December 2019.
2. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:591–593. DOI: http://dx.doi.org/10.15585/mmwr.mm6919e2external icon
3. Walling, Anne, MB, ChB, “Frequent Headaches: Evaluation and Management”, Am Fam Physician. 2020 Apr 1;101(7):419-428. https://www.aafp.org/afp/2020/0401/p419.html
4. Ha, Hien, PharmD, and Gonzalez, Annika, “Migraine Headache Prophylaxis”, Am Fam Physician. 2019 Jan 1;99(1):17-24. https://www.aafp.org/afp/2019/0101/p17.html
5. Wootton, Joshua, MDiv and col., “Evaluation of headache in adults”, UpToDate, https://www.uptodate.com/contents/evaluation-of-headache-in-adults?search=headache&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1, accessed on 6/11/2020.