Family Medicine Clerkship

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Headache

OVERVIEW

Headache is one of the most common presenting problems encountered by family physicians and other primary care physicians. Most headaches are either tension headaches or migraine headaches. Although these headaches are not life threatening, they can lead to significant pain and disability. Some headaches can be the sign that a life-threatening condition such as a subarachnoid hemorrhage or a brain tumor is present.

Students need to be able to distinguish the type of headache that a patient is having by performing a focused history and physical exam. They need to pick up the red flags in the history or physical exam and not miss a condition that could be fatal. Additionally, they need to learn to treat the pain that comes with the more common causes of headache. Patients who do not respond to the usual treatment modalities can develop chronic pain. Dealing with patients suffering with chronic pain is a very challenging condition for students and physicians. Students need to be able to approach a patient with chronic or recurrent headaches in a manner that helps the patient get help and maximize life functions.

TOPIC LEARNING GOALS AND OBJECTIVES
(Organized by ACGME Competencies)

Patient Care

GOAL: Students will accurately assess signs and symptoms of headache.

OBJECTIVES: Students will be able to:

• Perform an appropriate neurological examination of a patient presenting with headache.
• Obtain a complete focused history on a patient presenting with headache.
• Compare and contrast the key features of the most common types of headaches, using the International Headache Society's classification system.

GOAL: Students will appropriately discuss headache with patients.

OBJECTIVES: Students will be able to:

• Explain the most likely cause of the headache to their patients.
• Develop a management plan with each patient.

GOAL: Students will be sensitive to individual and cultural differences in their development of treatment plans.

OBJECTIVES: Students will be able to:

• Discuss with patients and families the importance of lifestyle changes in the management of headache (for example changes in sleep patterns, stress management, and dietary changes).
• Develop treatment plans in the context of each patient's life and environment.

Medical Knowledge

GOAL: Students will understand the pathophysiology of the common and life-threatening causes of headache.

OBJECTIVES: Students will be able to:

• Describe warning signs of dangerous causes of headache (e.g., "thunderclap" headache, vomiting, and positive neurological exam).
• Discuss the initial evaluation of a patient with headache.

GOAL: Students will understand the rationale for treatment plans for headache.

OBJECTIVES: Students will be able to:

• Describe the appropriate therapy for various types of headaches.
• Discuss the evidence for the role of lifestyle changes, such as stress management.
• Discuss the side effects and costs of commonly used medications, including analgesic rebound.

Practice-Based Learning and Improvement

GOAL: Students will demonstrate evidence-based decision making in the diagnosis and management of headache.

OBJECTIVES: Students will be able to:

• Identify gaps in their own knowledge and frame appropriate clinical questions in regard to headache.
• Use best evidence to answer clinical questions about headache.
• Recommend radiographic studies appropriately.

Interpersonal and Communication Skills

GOAL: Students will understand the importance of effective communication with patients and families in the management of headache.

OBJECTIVES: Students will be able to:

• Describe the treatment plans for headache.
• Demonstrate effective listening skills and empathy to improve patient adherence.

Professionalism

GOAL: Students will demonstrate the ability to care for patients with headache from diverse patient backgrounds and at different points in their illness.

OBJECTIVES: Students will be able to:

• Reflect on personal frustrations when patients are not adherent to plans or headaches persist despite efforts to treat them.
• Maintain a positive caring attitude toward patients who have chronic headaches.

Systems-Based Practice

GOAL: Students will understand the impact of health care systems on the management of headache.

OBJECTIVES: Students will be able to:

• Describe cost-effective strategies for diagnosis and treatment of headache (limiting use of inappropriate expensive technology and high-cost medications).
• Identify barriers to patient access to imaging, medications, or referrals.
• Consider the role of other disciplines (e.g., neurologists, pain management specialists, and psychological counselors) in the treatment of headache.

EDUCATIONAL METHODS AND RESOURCES

Clinical Experience

• Observed evaluation of patients with headaches
  
• SP cases (UTHSCSA) ( Rich Usatine, MD )

Small-Group Learning

• PBL case ( Caryl Heaton, DO)
  
• Doctoring case ( Rich Usatine, MD)

Problem-Based Learning

• PBL case ( Caryl Heaton, DO) Electives

Learning Units

• Headache / malpractice subarachnoid case with videotape of the trial ( Rich Usatine, MD)

Web Sites

• National Institute of Neurological Disorders Web site on headache
  http://www.ninds.nih.gov/
  
• International Headache Society
  http://216.25.100.131/
  
• National Headache Foundation Web site.
  http://www.headaches.org/
• Resources:
  http://www.headaches.org/professional/educationindex.html
  
• Organization for Understanding Cluster Headaches Web site.
  http://www.clusterheadaches.org/
• Offers such resources as how to chart triggers of cluster headaches:
  http://www.clusterheadaches.org/triggers.htm
  
• about.com is a patient-oriented Web site, with medication and self-help information.
  http://www.headaches.about.com/
  
• Trigeminal Neuralgia Association Web site
  http://www.tna-support.org/
  
• National Headache Foundation Web site.
  http://www.headaches.org/
• Resources:
  http://www.headaches.org/professional/educationindex.html
  
• Organization for Understanding Cluster Headaches Web site.
  http://www.clusterheadaches.org/
• Such resources as how to chart triggers of cluster headaches:
  http://www.clusterheadaches.org/triggers.htm
  
• American Pain Society Web site
  http://www.ampainsoc.org/
  
• American Academy of Orofacial Pain
  http://www.aaop.org/
  
• The American Academy of Pain Medicine
  http://www.painmed.org
  
• American Headache Society
  AASH is a professional society of health care providers dedicated to the study and treatment of headache and face pain.
  http://www.ahsnet.org
  
• American Society of Addiction Medicine
  http://www.asam.org/
  
• American Society of Regional Anesthesia and Pain Medicine
  http://www.asra.com/
  
• The Center for Shingles and Postherpetic Neuralgia
  Harvard Medical School
  This site offers information on diagnosis and treatment of shingles; a glossary of terms related to shingles and postherpetic neuralgia; information on current clinical trials; frequently asked questions; and links to useful resources.
  http://www.shingles.mgh.harvard.edu

Contact People

• Headache center (Thomas Jefferson University)
  
• National Headache Foundation and STFM Project (Helping Educators Address the Development of Appropriate Curriculum for Headache Education (HEADACHE) Demonstration schools. Contact person: Ardis Davis

ASSESSMENT STRATEGIES

Standardized Patient Cases

• UTHSCSA SP cases (Rich Usatine, MD)

Clinical Assessment

• Direct observation of history, exam, and management counseling

Lead Authors: David Schneider, MD, Richard Usatine, MD, and Alexander Chessman, MD
Clerkship/Post-Clerkship Workgroup members: Ann O'Brien-Gonzales, PhD (Chair), Alexander Chessman, MD (EC Liaison), Caryl Heaton, DO, Janice Nevin, MD, MPH, Lauren Oshman, MD, Deborah McPherson, MD, Mark. E Quirk, EdD, David Schneider, MD, MSPH, William B. Shore, MD, Richard Usatine, MD

Family Medicine Curriculum Resource (FMCR) Project HRSA Contract 240-00-0107.

For questions or comments, please contact Webmaster or Ardis Davis

This page last updated November 6, 2004