Lecture: Headaches and Visual Symptoms: When to Worry, When to Image

>> Hello, everyone. And welcome to today’s Cybersight webinar. My name is Dr. Rudrani Banik. I’m a neuro ophthalmologist based out of New York City in the United States. I’m an associate professor of ophthalmology at Mount Sinai School of Medicine where I teach and do research. And I love to educate. So today, we’re going to be talking about headaches and visual symptoms, when to worry, when to image. So I would like you all to first imagine this scenario. It’s Friday afternoon about 4:30 p.m., it’s a very, it’s been a very long week and you can’t wait for the weekend and all of a sudden you see an emergency patient that’s been added to your schedule. And this patient comes in and they’re clumping your headache because they’re having so much pain. And you worry, okay, why is this patient who seems like they’re having a headache in my clinic. Why are they sitting in my chair. You start to talk to them and they tell you that along with the headache, they also had some visual symptoms. For example, maybe they’ve lost some vision or they’ve seen some flashing lights or perhaps they have some droopy eyelids with their headache. Or they have unequal pupils or they’re seeing double with their headaches and they never had this problem before. So you’re very much taken aback by this headache patient. You don’t know what to do. And you know this patient’s come to you instead of going to the emergency department because they’re having a visual issue. What this webinar today is intended to do is to help you sort through these patients and really develop an approach, an algorithm you can follow to help manages these patients that come into the eye clinic with headaches and also visual symptoms. So let’s begin with our first polling question. How confident are you in the approach to headache patients and their management? So one, extremely confident. Two, confident. Or three, not confident. And please be honest here. This is an anonymous poll. So please be honest. All right. So let’s take a look at our results. So the vast majority of you, over 52 percent said you felt confident which is amazing. Congratulations to you. 41 percent not so confident but that’s okay, that’s what we’re here for today to show you some tips and strategies. And then 7 percent said you feel extremely confident. Kudos to you as well. Let’s proceed with the presentation today. So we have a few objectives for today’s webinar. No. 1, I’m going to be sharing with you the main types of headache syndromes. The first objective is to be able to understand the various different headache syndromes. No. 2, is to identify any red flags on the eye exam in headache patients. Any red flags that may warrant a workup for example. And objective No. 3 is to develop a structured approach to headache evaluation. Here, hopefully you can stay until the end of the webinar but I will be providing you with an algorithm that you can follow for how you should approach these patients who come in with headache. And also as an added bonus, I hope you can, again, stay until the end, I do have an invitation I would like to extend do you all for a free event happening in a few months. So please stay until the end and I will share with you that invitation to this event which hopefully will be transformative in eye care to many patients around the world. Let’s first talk about headaches. Just to put this in perspective, headaches are very common. They are amongst the most prevalent neurologic conditions worldwide. Not only do they impact an individual’s quality of life, they can also cause significant morbidity and even sometimes mortality. And associated with headaches, of course, are socioeconomic burdens. For example, missed days at work, missed days at school, lack of productivity, lack of engagement. Headaches are a worldwide, a global issue. If you think about the breakdown of how many individuals in the world have headaches, it’s estimated the global prevalence is about 52 percent of individuals around the world get regular headaches. This is not just a one-off headache. 52 percent get regular headaches. Of this 52 percent, 26 percent have tension type headache, TTH. And 14 percent of the world’s population has migraine. And there are various other headaches syndromes which are not as common as these two but tension and migraine make up the vast majority of headache patients. There are a subset of patients who have not just episodic headaches but chronic daily headaches. The definition of daily headache is basically headache greater than 15 days per month. Some patients have 18 days, 25 days. Some people have 30, 31 days of headache every single day. And luckily, this portion is very small, about 4.6 percent of individuals have chronic daily headache. So keep these numbers in mind, headaches have very common. When we think about headaches in general, it’s useful to separate headaches into two categories, two large categories, primary headache syndromes and secondary headache syndromes. So this chart is quite busy. It’s got a lot of text on it. I apologize for that. But it basically breaks down the two main category, prior mare and secondary. Primary as we all know, primary means there is no specific underlying etiology. And within primary, you have the more common types of primary headache syndromes which is what I mentioned earlier, tension type headache, migraine and various, variants of migraine. There is migraine without aura and migraine with aura and we’ll talk a little bit about that. Those are the common types of primary headache syndromes. The more uncommon types affect various branches of the trigeminal nerve. Under this category are cluster headaches and there other trigeminal syndromes called trigeminal autonomic syndromes or the cephalalgias that fall under the primary headache syndrome category. And some of these trigeminal autonomic cephalgias may be associated with autonomic symptoms such as conjunctival injection or tearing or nasal stuffiness or sometimes eyelid or pupil changes can fall under the trigeminal autonomic cephalgia category. Now, the secondary headache syndrome, these are very, very broad. As I mentioned earlier in secondary headache syndromes, usually there is some kind of underlying systemic or neurologic issue going on. So for example, hemorrhage within the brain. If someone has had let’s say a ruptured cerebral aneurysm and they have subarachnoid hemorrhage, that would cause a very specific type of headache that falls under a secondary headache syndrome. Say they had head trauma, had a concussion and they have a subdural hemorrhage. That would be also under a secondary headache syndrome or let’s say they don’t have a hemorrhage, they have had concussion and the imaging is normal but post-concussion would also be a secondary type of headache syndrome. Tumors also fall under secondary headache syndromes and there is a host of other less common etiologies, for example infections, whether it’s meningitis or a brain abscess. Falling under secondary headaches, also idiopathic cranial hypertension which is IIH. Previously it used to be called pseudotumor cerebri. This falls under a secondary headache syndrome because there is a cause for it, meaning there is an underlying neurologic condition. There is increased CSF pressure that is causing the headache. That falls under secondary. As you can see this list is quite extensive. But one thing I want to point out is that visual issues, for example, refractive error, convergence insufficiency, and other refractive issues, like presbyopia are not on this list. This list comes from, there is a classification for headaches called the international classification for headache disorders or ICHD3. And under this categorization, again, visual symptoms like refractive — or visual etiologies like refractive error convergence insufficiency and presbyopia don’t fall under the ICHD3 categorization. What do we do about that? As eye care providers we know that patients come in with these symptoms, how do we classify them. There are two possibilities, you can put them into a secondary headache classification which is headache caused by a vision issue. Or, many of these patients, the type of headaches they get from refractive errors or convergence insufficiency that the symptomatology is very similar to tension headache. So you could put them under tension headache based off of the symptoms. But what I wanted to share with you, we’ll talk a little about these primary headache syndromes and a little about vision related headaches and then go onto more serious things. I wanted to share with you the symptoms of these primary headache symptoms. It’s common for patients to come in with these syndromes. If you can identify it, if you can potentially diagnosis it and get the patient referred to the correct provider, that would be helping the patient’s care and alleviating some of their issues. When I said earlier there are three main types, tension headache, migraine headache and cluster which is again a variant of the trigeminal autonomic cephalgias. What is tension headache? It tends to be neuromuscular and the pain tends to be bilateral. It can be bilateral frontal. It can be bilateral temporal. Sometimes it radiates to the occipital area or go down into the neck or shoulders: It’s typically bilateral and the nature of the pain is typically dull. Patients will feel a dull pressure or a tightening, they feel like a bad tightening around their head or they’re wearing a tight hat or a vice around their head. That is a sensation that many patients describe. In terms of intensity, tension headache tends to be on the mild to moderate side. And in terms of female to male ratio, females are slightly more predisposed to tension headache than males with a 60 to 40 sex predilection. In terms of the duration of a tension headache, it can last a few hours. In some individuals it can last longer, a day or several days. Keep that in mind. Some of these headache syndromes can be prolonged in their duration. People with tension headache can get anywhere from one tension headache a month up to 30 tension headaches a month. This overlaps with the category I mentioned earlier about chronic daily headaches. It’s possible for people to have tension initially and for it to evolve into a chronic daily headache syndrome. In terms of the triggers for tension headache, it’s often triggered by stress, dehydration, hunger. And it is not aggravated by routine activities. If someone had to go take a walk, their tension headache shouldn’t be worse. It may still be presents but it shouldn’t be worsened by usual activities or like reading, it shouldn’t be worsened by reading. Now the second most common type of primary headache syndrome is migraine headaches. Migraine, typically, not always, tends to be unilateral. And it tends to follow the distribution of the trigeminal nerve along V1 and V2. The type of pain that migraine patients get is different than tension headache. Instead of a dull ache, many patients with migraine get a throbbing or stabbing or pulsion sating sensation. And many people describe this sensation coinciding with hair heartbeat. Every time their heart beats they feel a throb or a stabbing like a piercing or ice pick type of sensation. In terms of the pain, it’s much more, it’s stronger than a tension headache. So usually people with migraine will describe moderate to severe intensity and this is also very, very important, there is a distinguishing factor between migraine and other headache syndromes. Migraine tends to have photophobia, phonophobia, nausea, and/or vomiting. And actually, there are very specific criteria for migraine. And these symptoms are part of those diagnostic criteria for migraine. Unfortunately, I don’t have time to go through exactly what those diagnostic criteria are, but you can easily look that up. The diagnostic criteria for migraine. In terms of duration for migraine, it can last anywhere from 4 hours to 72 hours. So about 3 days is the typical duration. There are individuals who have longer headaches, migraine headaches. They may have headaches for up to five days or a week or several weeks or even a month or longer. So again, here there’s overlap between migraine and chronic daily headache if it becomes more persistent. Now, also with migraine, there are different phases of migraine. There are four distinct phases some people may experience with migraine. There is a prodrome or yawning or hunger or sleepiness. There is the aura phase that many people have as visual aura which we’ll talk about. There is the attack phase where they actually have the headache or other symptoms. Sometimes it’s not headache, it’s dizziness or vertigo. There are vestibular migraines that don’t cause a headache but cause other symptoms and a post drone. Four stages of migraine and not every patient goes through the father stages but this is a break down of what migraine patients may experience. Migraine patients may experience one to 30 headache assignment month. And here there is a definite male to female predominance. The ratio is 75 percent female and 25 percent male that have migraine headaches. In terms of triggers, there is overlap with the tension headache category. Triggers may be stress, dehydration, hunger, also certain foods. Certain food ingredients may trigger migraines. For example, MSG which is often time assignment food additive to trigger migraines. Nitrates, nitrites. Fermented foods. Tyramine rich foods. Some examples of food that can trigger minus grin. And many people who are pre-disposed to migraine are triggered by hormonal changes, particularly women when they have their menstrual period, they may get a migraine immediately after their menstruation begins. That is called a menstrual migraine, due to changes in estrogen level. That is what we presume. And bar metic pressure changes can sometimes trigger migraines. Oncoming storms whether it’s rain or snow or a cloudy day can sometimes trigger migraine. In distinction with tension headache, people who have migraine headache are — their headache is aggravated by doing routine activities. They feel a lot worse if they try to do their routine activities. Like for example, working on a screen or going to work or going to school can make it worse. Now, I’ll just say a little bit about cluster headache. Cluster headache is along the trigeminal nerve, typically the V1, sometimes V2 distribution. Many people have a very localized orbital or periorbital pain. Usually it’s unilateral. Similar to migraine, people with cluster can have a throbbing or stabbing or pulsing sensation. Similar to migraine, people with cluster can have moderate to severe intensity in the pain and get photophobia, nausea, vomiting. The interesting thing with cluster is that the duration varies on the variant of cluster or the trigeminal issues. Depending on the variant, it may last just seconds where people have an intense throbbing pain for a few seconds and immediately it goes away and then it can reoccur again. Sometimes it lasts hours. Sometimes even days which we call paroxysmal hem crania which is one-half of the head hurting for days and then it goes away and coming back again. Or hem crania continuous which is continuous but just on one side of the head. Interestingly in cluster, men tend to be more affected than females. And there can be autonomic symptoms like sweating, increased sweating on that side of the face. Facial flushing, pupil changes. Usually, miosis but sometimes mydriasis. Nasal congestion, nasal stuffiness, ptosis and lacrimation. The reason it’s called clusters is they can happen in Clusters. They may have a few weeks of having headaches and then the headaches remit for months or years or decades and then come back again. And often times people with cluster wake up with a headache or severe pain and again, they can get bouts of it during their lifetime. So let’s, I talked earlier about visual issues that may cause headaches. There were a few interesting studies done and I won’t go through all of them in detail, but in terms of the frequency of headaches amongst patients in eye care practices. Depending on the study it ranges from 11.6 percent to 84 percent of eye care practices, patients may come in with headaches as their chief complaint. What are the causes? Based on the studies done, uncorrected refractive error, particularly hyperopia and against the rule of astigmatism and presbyopia. And in terms of one study, this is really interesting, this study looked at, published in optometric journal, included patients between the age of 6 to 85 and of those complaining of a headache, 67.8 percent had a refractive error. What we don’t know after the study is hopefully after their refraction is corrected and they’re complaint with their glasses, if the headaches stopped or not. We don’t have follow up from this study but it’s an interesting number. Approximate in addition to refractive errors, many patients complain of convergence insufficiency particularly when reading or doing near work associated with an exso deviation. And some people may not have any salient findings on their exam but they may just complain of headaches when they’re on a computer. We call this digital eyestrain as an umbrella term. But sometimes this is also associated with headache. Whether it’s due to the light coming from the screen, the back lit screen whether it’s blue light induced or the flicker from the screen causing the headache, we don’t have data to tease that out yet. It’s something to consider in terms of asking patients when they come in with a headache, how much time do you spend on screen every day and are your headaches precipitated by screen time or do they get worse if you’re on screen whether for school or work or personal use. So keep that in mind. Next, in the next part of the talk, we’re going to be moving onto issues that may show up an eye exam that may be red flags: That may indicate the patient doesn’t just have a primary headache syndrome but a secondary headache syndrome that requires a workup. It’s really up to us as eye care providers to correctly identify these patients and to make sure that they’re getting the care and oftentimes it’s urgent care these patients need. And they get referred appropriately in a timely fashion. So these are the ten screening questions eye care providers should be asking their patients during a headache evaluation. Even though you may think that your patient is coming in with refractive error as the cause of their headache, you should still consider asking these questions. Yes, people could have a refractive error, an underlying error and these other warning signs that may prompt a workup. I would suggest you screen shot this. This is the overview and we’ll go through each of these in detail and I’ll give you examples of each. No. 1, is the patient having blurred vision. No. 12, has the patient experienced sudden loss of vision. No. 3, do they have any peripheral visual field problems. No. 4, is their headache associated with any flashing lights or floaters. No. 5, do they have any light or sound sensitivity with their headache. Because again, asking about phonophobia and photophobia can help steer you to a headache syndrome. No. 6, with their headache, do they have any eye pain. This is also very important. Any redness of their eyes. No. 7, is there any change in pupil size that goes along with their headache. No. 8, do they have experience a droopy eyelid with their headache. No. 9, do they have any double vision with their headache. And No. 10, do they have pain in the frontal area, in the bitemporal area, is it one sided, which distribution is it in. It’s really important that you try to tease out some of these questions. Now let’s talk about these questions more in detail. Blurred vision. Yes, as eye care providers our first thought is maybe this patient is experiencing blurred vision. Maybe asthenopia or presbyopia. Other types of blurred vision are important to tease out during screening. If they have some blurred vision and it’s only one eye and they’re having the headache but also having some pain in the eye socket like a dull ache, either directly in the eye socket or in the V1 distribution, you to consider optic neuritis as a potential cause of this patient’s headache. We’re taught that optic neuritis causes pain with eye movement but it can cause headaches. With blurred vision, maybe they have something going on intracranially and perhaps they have chronic papilledema or optic atrophy because of a compressive lesion and they’re having blurred vision. It may raise the read flag for possible an intracranial mass or a late stage of idiopathic intracranial hypertension that can be associated with vision loss. Again, we can start from the very basic questions but sometimes you have to go a little bit deeper. When you evaluate these headache patients, have an open mind. Don’t try to put people into the category refractive error too quickly. Yes, it may end up being that but you don’t want to miss some of these more serious and not just vision threatening but life-threatening issues that cause headaches. No. 2 on the screening questions that you should be asking is have you experienced any sudden loss of vision. When it comes to this question, you want to qualify that by asking them if you have, first of all sit one eye or both eyes. Is it at the same time if it’s both eyes and how long does it last. If someone has sudden loss of vision in one eye and lasts seconds and their vision comes back, we call this a transient visual obscuration. We often see this when there is optic disk edema, papilledema from an intracranial mass lesion or raised intracranial pressure. If patients are complaining of transient graying out or blackening of their vision, one eye or both eyes, this should raise a red flag. One other thing I will add to this is oftentimes in my IIH patients when they have this symptom, it’s triggered by a positional change. For example, I’ll ask when you’re lying down on your bed and you get up too quickly, does your vision go gray or blurry or black. If you bend down to pick something up off the floor and get up too quickly, does that lead to the symptom of transient vision loss. That is important to ask. If the duration of vision loss is longer, say it’s 30 seconds to a few minutes, and it’s one eye, or maybe it’s both eyes, sometimes, rarely it can be both eyes. We call this amaurosis fugax. If they’re older than 65, you might want to ask about giant cell arteritis or ischemia to the optic nerve. If the sudden vision loss is longer, say in the range of 15 to 30 minutes or so and this vision loss is associated with some zigzag flashing lights or shimmering or movement in their vision where they’re not seeing, then we have to be suspicious of visual aura of migraine. However, that’s not the only underlying consider that causes shimmering or zigzag. Sometimes people say it’s like underwater or under fog or under heat. Movement is the key here. It can be visual aura of migraine but I have had patients that had visual seizures with this type of symptom or bleeding in the brain from a bleeding arterial venous malformation causing what seemed like aura but they weren’t aura. Keep your radar up and don’t just immediately attribute it to migraine. The other important thing to recognize about visual area is typically it’s binocular. People experience this zigzag flashing symptom in both eyes at the same time and on the same side of the visual space. The next question to ask your headache patients, do you ever have double vision with your headaches? Here you want to tease out is this monocular diplopia or binocular diplopia. You ask if you cover one eye does the diplopia persist or go away. If they cover one eye, and it goes away, it’s binocular. And that says it’s some kind of strabismus. The eyes are not aligned and in this case you should look on the exam for a cranial nerve palsy or a combination of cranial nerve palsies. Sometimes patients may have dry eye and it’s giving monocular diplopia. If someone says dip lope I can’t recollects the radar should be up this could be something more serious, an intracranial process associated with their headache. Another thing to ask and also the test for is does the patient have any peripheral vision loss or visual field defects. For example, here, in this visual field, there is a left homonomous hemianosmia. The defect is on the left. You don’t necessarily need to do formal visual field testing in all patients. You do a quick confirmational visual field test. One eye at a time, how many fingers do you see. I do four quadrants or three on each side. If you do a proper confrontational visual field, that should help you pick up 70 percent of neurologic type visual field defects can be picked up on a confrontational visual field. It takes 20 seconds to do. It’s a quick test. For example, a patient, you can pick up something like this where the patient has a brain lesion on the right side, in the right parietal occipital area causing a left homonomous hemianopia. If you didn’t do the visual field, you won’t pick up this problem. Sometimes they come in with visual field defects that are bitemporal, you have to think of a lesion of the chiasma. This is a headache caused by a pituitary adenoma. Macro adenoma that is elevating the chiasma and causing a bitemporal defect. Visual field is a cheap and easy way to pick up these types of neurologic issues. It should be done on every headache patient. I would propose every patient that comes into your clinic, it doesn’t take long. You can pick up so much information from that quick test. Okay. Other types of visual field defects, patients may have in large blind spots, a nasal step. Constriction of the visual field. Sometimes the formal visual field is necessary if they’re complaining of vision loss or peripheral vision issues and you’re worried about papilledema, which is what we see here. Do the testing when necessary but not every patient needs to have a formal visual field. Another question is do you have light sensitivity or photophobia associated with the headache. If they do, think about migraine or one of the trigeminal autonomic cephalgias or uveitis can cause pain or eye pain or a headache. So you should be on the lookout if they have photophobia, they’re extremely light sensitive on your exam, look for cell flare in the anterior chamber. Dilate them and look for signs of intermediate or posterior uveitis. And photophobia can be a non-localizing sign of meningeal irritation. If they have severe headache and light sensitivity, they can have irritation from a tumor that is growing and expanding the meninges causing light sensitivity or they may have an infection like meningitis. So it’s important to ask the question. Moving on. If someone has flashing lights, I talked a little about aura before, but I wanted to show you, hopefully this is going to work and I’m going to scroll forward here. This is a wonderful video on You Tube, I believe from the Mayo clinic in the U.S. This is a simulation of what visual aura looks like. I highly recommend that you bookmark this particular You Tube page because often times when patients come in complaining of flashing lights, I will show them this video and ask is this what you experienced. If they say yes, most likely they’re having migraine visual area. But as I said earlier, it may not just be, sorry, let me turn this off here, it may not just be migraine aura, it can be something more serious like intracranial hemorrhage. Rarely, people with uveitis may have flashing lights. But typically, the flashing lights with you’ve rights are pinpoint and brief rather than zigzags that last 15 to 30 minutes. Moving on, screening question No. 7, does the patient have eye pain or redness. This is a very obvious image here showing the patient has 360-degrees of conjunctival infection. We have to think about things in the eye. Chronic angle closure glaucoma or uveitis. And another thing to think of which is not an eye issue but something that can cause eye redness and pain is carotid cavernous fistula. This patient had a CCF fistula. They had corkscrew vessels. If this image were magnified you could see these dilated corkscrew vessels which is pathognomonic for CCF. That would raise a red flag and prompt further work up. Question No. 8, do they have a droopy eyelid to go along with their headache. If they have a mild ptosis and they may not have noticed it but maybe they say, yes, I do think my eye is droopy and lower than it normally is. If someone has a little bit of ptosis, you may have to think about horner syndrome. If they have more severe ptosis, like in this patient, you may have to think about a third nerve palsy that could be causing the headache as well and of courser that would prompt urgent work up and we’ll talk about that in a few minutes. Next, ask them about change in pupil size. For example, in this patient, their left pupil is a little bit smaller than the right and they have a little bit of horner syndrome. The lid doesn’t look that tottic but this patient ended up having a horner syndrome. On the flip side, a pupil may be larger than the other side. And for this type of mydriasis, we have to be worried about various things. Especially if they have a headache that goes along with it. Of course we have to think about if the patient is in an ICU setting or they had head trauma or a concussion, you have to think about intracranial issues like herniation, midline shift, et cetera. Otherwise, you can think about third nerve palsy. You want to check motility and eyelids. There is another rare condition which is a variant of migraine that can cause pupillary mydriasis. Isolated pupillary mydriasis without lid changes. This is called benign episodic pupillary mydriasis and it tends to happen with young women with migraine. All of a sudden their pupil becomes large. They can have a dull ache behind the eye. And then after a few days the pupil goes back to normal. This is a diagnosis of exclusion. If you see someone with this, make sure everything else is okay before you give them that diagnosis. You don’t want to miss something more serious going on that would prompt a further work up. Sorry, I think I missed, I’m missing one slide. Question No. 10. We’re going to come back to that in a moment. I wanted to also give you this mnemonic for other red flags that may indicate the patient needs an urgent work up. This is something that is commonly used amongst neurologist, neuro ophthalmologists and I hope this information gets spread to more ophthalmologists and optometrists but it’s called SNOOP. You want to ask them all the eye questions, but also you want to ask them these specific questions to really determine do you need to send this patient for a work up or not. Are they having systemic syndromes. S is for systemic symptoms. N is for neurological deficits. O is for onset. I will explain each of these in more detail in a few minutes. The first O is for onset. The next O is older age. The P is for pattern change. And so let me give you some examples of these. So for SNOOP, if somebody has systemic symptoms. The first S is systemic, say they have a headache and some underlying systemic disease. For example, cancer or HIV. Or some preexisting infection like tuberculosis. If somebody has predisposing systemic issue, you want to image them. You want to make sure, for example, if someone has cancer, you want to make sure this is not metastasis to the brain causing problems like headaches. If someone has HIV, you want to make sure they’re not having an opportunistic infection that affects the CNS. And the same with tuberculosis, you want to make sure it’s not affecting the brain. Another type of systemic symptom that is a huge red flag that requires a work up is if they have a fever with the headache. If they have a fever, you have to think of infectious meningitis, bacterial or viral. You have to think about brain abscess which is perhaps not so common in the general population but if someone is immunocompromised or they had recent brain surgery or a penetrating trauma to their skull. The N of SNOOP is neurological deficits. This can include weakness, numbness, balance issues, altered mental status and all the visual symptoms that we just talked about fall under neurological deficits. Ask about that. Onset, so if someone has a sudden onset of severe headaches: Say they come into the office and say doctor, I had the worst headache of my life, that immediately requires a work up. Worst headache of their life, if they come in, they can barely function, you need to send them for urgent imaging. You want to rule out acute bleed in the brain for example, subarachnoid hemorrhage from a ruptured aneurysm. If someone has an older age of onset of the headaches, say someone never had headaches and now they’re 58 and getting their first headaches and they’re constant, they’re chronic, you need to work that patient up for conditions like giant cell arteritis or an intracranial issue. The P stands for pattern change. Persistent headaches that are resistant to treatment is one example of a pattern change. Say somebody had migraine, they responded well to their migraine treatment and all of a sudden they stop responding. Maybe something else is going on now. Maybe the person had migraine and now they’re developing a different type of headache because they have raised intracranial pressure either from a mass lesion or from IIH for example. These are all the red flags. There is a lot of information that you need to gather but if you streamline it, it really shouldn’t be that difficult. You want to ask about the visual symptoms that would require a wok up. And quickly look at the medical history and ask about the SNOOP questions as well. I’m going to spend a few minutes talking about what type of imaging to order and we’re going to do some case studies. I have six case studies for you and I have some poll questions to go along with that. Hopefully you can take the information I have given you and apply them to the case studies and we’ll open up to Q&A at the end. What type of neuro imaging to order. If you had your choice and had the resources available, if someone has acute severe sudden onset headache where they had head trauma or acute symptoms, start with a CAT scan. It’s the fastest thing to do and on the CAT scan, this is a non-contrast head CT, you can see blood. Here this image on the left, all these spaces, they should be dark but they’re filled, they are bright because they’re filled with blood. This patient had a subarachnoid hemorrhage that is causing their headache. This is easily picked up on a CAT scan, non-contrast. This is another example of somebody who had, this is somebody with a head trauma who had chronic headaches. On this non-contrast CT, you can see blood products here. This person has a subdural hemorrhage, a little midline shift which is concerning: You want to look for papilledema on this patient or other neurologic signs if they have nerve palsy. This can be easily picked up on a regular CAT scan, non-contrast. Moving on, if you have patient who had chronic headaches and they look like they have anatomical changes, bony issues, then you may want to get a bone scan on — a CAT scan with bone windows. The reason is because you’re looking for bony growths. For example, this person here has a lot of thickening of their calvarium and sinuses. This person has a condition known as fibrous dysplasia which is an overgrowth of bony tissues that can affect the orbit and sometimes the frontal region and sinuses. This is a craniofacial issue but it can lead to chronic headaches that would be best picked up on a CAT scan. Or if someone had head trauma and you’re worried about a skull fracture, you want a CAT scan as soon as possible. When to get an MRI. Typically, my default is MRI if I have the time to order something and can get them in quickly, I prefer MRI for the vast majority of headache cases because it gives us good imaging of the soft tissues and helps us to identify things like tumors. For example, this person had chronic headaches and had some loss of smell for several years. And then had vision issues and they ended up having a very large frontal or olfactory groove meningioma causing their headaches. MRI brain with contrast would easily pick this up. And then some other examples of when an MRI may be in order would be in you’re worried about vascular anomalies. Say the patient had some visual aura but it’s not really visual aura, not fitting the pattern or they have a visual field defect, you want to get an MRI to look for arterial venous malformations. This patient here, this is a scan before contrast, you can see all of this irregularity here. These are abnormal blood vessels. So this is a very, very large arterial venous malformation in the parietal lobe. You want to look for something like that and CAT scan may not pick it up as clearly as MRI. If you’re suspecting some kind of inflammation, intracranial inflammation going on leading to a patient’s headaches you want to get MRI brain with contrast. This patient had an inflammatory lesion here and it ended up being biopsied and it was determined to be neuro sarcoidosis. MRI of the brain with or without contrast is useful in the vast majority of headache patients. And whether or not you get — depends on the symptomatologies. In the vast majority of cases, brain will be sufficient. But if you’re worried about orbital pathology causing the headache or optic neuritis, for example, then, yes, get the MRI of the orbits as well. Okay. Now moving onto imaging of the vasculature. In this case, this is a patient who had sudden severe headache. This happened to be after a vaccination. Severe headache, they ended up having a venous sinus thrombosis in their right lateral sinus, transverse sinus and the sigmoid sinus. This was a complication post vaccination that lead to a hypercoagulable state that led to venous sinus thrombosis. In some IIH patients, this is a reason to get MRV or CTV, they may have underlying venous sinus stenosis. Unilateral of bilateral which is quite common. This can be identified on an MRV or CTV. Either is fine. If you’re worried about aneurysm, the test to get is angiogram. Can start with a CT angiogram or MR angiogram or a conventional angiogram. We’re looking for an aneurysm, which is what we see here. This is leading to cranial nerve palsies and headaches. The other reason to get MRA or CTA is if you’re suspecting a carotid dissection. You have to send them urgently for an MRA brain and neck. Sometimes the dissection starts in the neck but it can progress up into the intracranial space. What you’re looking for on the MRA is irregularity of the carotid. This is the string sign. You can’t tell what is real lumen or false. There is a double lumen here for this patient that suggests dissection of the carotid. Now we’re going to do case studies rapid fire. Get ready to answer some polarizer questions and then we’ll open up for Q&A in a bit. Case study No. 1. This is a 28-year-old female. And she had sudden onset of unilateral severe throbbing headache. When you ask her about the visual symptoms, yes, I saw some zigzagging flashing lights before the headache started. I have nausea and vomiting, light and sound sensitivity and you’re seeing her the day after this happened. She told you that all of the symptoms resolved yesterday. It happened yesterday, it resolved yesterday. She woke up this morning feeling fine but because of the visual symptoms and the headache that was so unusual, she came into the eye clinic. Poll No. 2, would you image this patient? Yes or no? Are there any red flags on this patient’s history or exam that would suggest that you should image them? I’ll give it another few seconds. Okay. So the majority of you, 62 percent of you opted not to image this patient and 38 percent of you opted to image this patient. So what I would do is based off of her symptoms, I didn’t mention this but the rest of her eye exam was completely normal. She had a visual field that was normal. So she was diagnosed with migraine. And usually, with a nonfocal exam, normal eye exam, an episode that resolved and everything is back to normal, there is no need for imaging with a first-time migraine patient. Even if they had visual aura. There really is no need to do imaging in these patients. So you can skip the imaging. Instead you can talk to her about lifestyle management. Were there triggers, dehydration, stress, hunger, poor sleep or other triggers. Talk to her about over the counter medications. If the migraine becomes more common, if she has other attacks, refer her to a headache specialist or primary care for further management. Case study No. 2, a 45-year-old female with history of breast cancer and progressive headache for 1 month. Night sweets and mild blurry vision and extremely anxious when she comes in. Very, very anxious. You look and see on her exam pretty much it’s a nonfocal exam. The only thing you see is she has a bit of dry eye. Otherwise, everything else is normal. You’re suspecting maybe her blurry vision can be because of the dry eye. Poll No. 3, would you image this patient? Yes or no? Think about her history. Think about her pertinent positives, pertinent negatives. Would you image this patient? Now, we have the results. The majority of you said yes. 82 percent. And 18 percent said no. So I would say the correct answer here is yes, you should image this patient. Because if you think about the SNOOP screening questions, S stands for systemic. And this patient did have systemic symptoms: She had night sweats and a history of cancer. She has a preexisting medical condition and having some systemic symptoms. We did ends up imaging here. Unfortunately this is what we saw. You see on this MRI of the brain post contrast, there is a lot of enhancement of the meninges, the dura. This is diffuse and all throughout. This is lepto meningeal carcinomatosis. Her breast cancer spread and we referred to oncology for management. Case study No. 3. This is a 68-year-old male with poorly controlled diabetes. Hemoglobin A1C is 10.5 percent. Presents with a new headache and double vision when looking to the right for the past couple of days and mild right facial weakness. You can see his eyes are not perfectly aligned. Also maybe on his right eye, the palpebral fissure maybe more open suggesting maybe a facial palsy going on there. In this case, he has focal neurologic deficits with acute deficits. Two cranial nerves involved, 6 and 7? Student: He meets the SNOOP work up. But the question is what work up would you do. Would you get labs for giant cell arteritis, imaging, or both. This patient is 68 years old. Okay. Let’s see what the results showed. The vast majority of you picked both labs and neuro imaging. 65 percent of you. And a few for each of the other choices. I would say yes, this patient based on the age and headache, focal neurologic signs, he definitely needs imaging but I would get the giant cell arteritis labs because it’s a risk factor for stroke. This is what the patient’s imaging showed. Initially it was a head CT non-contrast that came back normal. And then he had an MRI and later had MRA. But it showed a very large pontine ischemic stroke here. This ended up being secondary to giant cell arteritis. This patient is elderly, always think about giant cell arteritis, even if you think something else is going on. Case study No. 4, a 35-year-old male presenting with sudden severe headache. Describes it as the worst headache of his life. Has some associate symptoms, nausea, neck stiffness, photophobia. I think most of you would recognize these warning signs here. Yes, you would image this patient. The onset, never had headaches before. We want to rule out ruptured aneurysm, get you are rent CT head and CTA and MRA. Say these were all negative and your suspicion is high enough, you should do a lumbar puncture to look for subarachnoid hemorrhage. Case No. 5. A 75-year-old woman presenting with new dull headache and jaw pain while chewing. Intermittent vision loss in the right eye. This is going on for the past week or two. Tenderness over the temporal arteries. You can see how thickened and tortuous this is. She meets the criteria for O, older age onset. You order giant cell arteritis labs and get labs stat. When should you start steroids. Your suspicious, should you start immediately, after the lab results are available or after the temporal lobe biopsy? Okay. I think we’re ready to see the results. Okay. So the majority of you, almost 60 percent chose immediately, which is correct. If you really suspect a patient has giant cell arteritis, you don’t wait for the labs to come back. Because they had ischemia and episodes of amorosa (ph) that implies the optic nerve is at risk for an arteritic isocheimic optic neuropathy and you need to start steriods right away. Get the steroids on board and plan for the TA biopsy. The TA biopsy can be done even if the patient is on steroids or up to two weeks after the steroids are initiated. We can still see pathologic changes on the biopsy specimen despite the steroids. Always start the steroids. Don’t wait. I apologize, we’re just about over time. I want to finish this and show you the algorithm for how to approach a headache patient. We went quite a few minutes over. Case No. 6, a 30-year-old female with history of migraine. Daily morning headaches that worsen when lying down. And transient visual obscurations. The vision goes out for a few seconds particularly when she changes position. This is highly suspicious for IIH. Bilateral disc edema on her exam. This patient you want to image not only because of a papal edema but also change in her headache pattern. Started off with migraine and now the headaches are different and has other symptoms like sudden vision loss. You want to image someone like this. She fits the criteria of “P” for pattern change. The work up is MRI brain with contrast. MRV to rule out venous sinus stenosis or thrombosis. And lumbar puncture to check opening pressure and CFS contents. This patient got an MRI which shows empty sella. This is common in IIH patients. This is a common soft sign of raised intracranial pressure. There are two diagnosis. She was diagnosed with IIH and also preexisting migraine. You can have both that coexist. So this is what you’ve all been waiting for. This is my algorithm that I created for eye care providers, for all of you basically for how to approach headache patients. I will walk you through this quickly. No. 1, go through those initial 10 questions about visual symptoms and findings. Go through those questions, you want to do the eye exam. You want to dilate them. Definitely, unless of course you’re thinking angle closure, that’s the one exception. But you want to dilate the patient. If you have no red flags based off the history and nothing on exam and their SNOOP is negative, then rule out refractive error, presbyopia, dry eye: Rule out the basic things and treat them for it. Treat them and follow up with them in one month. And if they come back, they have gotten new glasses and say I’m doing great. My headaches are better, great. Then you don’t have to go further. We can say this was caused by their visual issue. If they’re not better, if they’re still having headaches despite being treated for the underlying problem, consider the diagnosis of tension headache, migraine or cluster and refer them to their primary care doctor for further management or a neurologist for management. The other side is the more important side for us as eye care providers. If you identify red flags based off the ten questions that — the vision questions or the SNOOP or you find visual findings on eye exam, let’s take the easy one first, if their ocular findings such as uveitis or angle closure, go ahead and treated that. Hopefully, once you treat, you will get the issue under control and the headaches will improve. Otherwise, in the other category, these patients require urgent and when I say urgent, I mean within 24 hours. Not this week or next weekend. Urgent is within 24 hours. A combination of imaging plus or minus labs. If you have a 55 year-old with amaurosis or double vision, get the giant cell arteritis labs and initiate steroids and biopsy, plan for a biopsy. If they have a sudden severe headache, send for urgent CAT scan of the head to rule out subarachnoid hemorrhage. If they have something that looks like horner’s syndrome, you want to get MRI of the brain, MRA or CTA of the brain and neck, and then afterwards, if all that is negative, you still want to get imaging study of the chest to rule out an apical lung tumor if everything else is negative. If they have bilateral optic disk edema, get MRI. If you suspect IIH, get the MRV as well. Typically they’re done together. We do MRI and MRV for the IIH patients because we want to look at the venous drainage. If the patient has cranial nerve palsy or third nerve palsy, get MRI and MRA or CTA. Say they have a history of cancer or weight loss, unexplained weight loss or late age onset, I would probably get MRI of the brain with and without contrast and based off that, do further work up. As long as they have no other focal neurologic signs. So I know that was a lot of information that I just shared with you all. I’m just going to leave this up if anybody wants to do a screen shot. Please go ahead. But you will get the PDF of the slides. Now that we’re finishing up the talk, poll No. 6, how confident are you in your approach to headache management? Extremely confident, confident, or not confident. I hope I moved some people over into the higher categories. I think we’re ready for the results here. The vast majority of you now said confident which is amazing. I’m so happy for you and proud of you. You’ll get the recording of this to go back and reference. Some of you said extremely confident. Kudos to you. Before we do Q&A, I’m going to share something with you that, an invitation with you. I’m hosting the eye health summit. This takes place May 1 to 7 of this year. Coincides with Healthy Vision Month. This is a public education and awareness campaign to raise awareness of eye issues and geared towards the public to educate them and empower them to get their eye exams to prevent conditions like macular degeneration and dry eye and glaucoma. It’s patient facing. We’re expecting about 15,000 attendees. We’re going to cover 35 plus eye topics and over 30 plus speakers. You’re all invited. And I hope that you will share it with your patients and community. This is going to be hopefully transformational to help educate people about how to be proactive of their vision health. This is a sampling of the topics that we’re going to cover. From the basics to more advanced and lifestyle and nutrition. This is our tentative line of speakers. We will have over 30 speakers but these are the ones that confirmed so far and we’re adding more every week. How do you sign up. Scan this QR code and put in your email. We’re building out the website for the summit. You may not get a confirmation right away but we will have your email. So you can scan the QR code, take a screen shot, scan later or go to the website and register. This will be in the PDF. And finally, please reach out to me if you have any questions. I have a lot of resources on my website. I have a resource called 6 natural ways to concur headaches. If you can download that for free. And I’m also on Instagram. I hope you reach out and connect via Instagram. I’m sorry I went 9 minutes over but in exchange for that, I will stay as long as I can for questions. I think we have a hard stop in 21 minutes. But I will stay for questions and open it up to questions right now. But thank you all so much for your time. So let me take a look here. One question was, do we need to order visual field tests for all patients with headaches or only those with blurry disc margins? Please discuss the visual field defects. Brain tumors and what signs we should be attending to. I hope that — I had some of the visual field defects and the — for example, if you have homonomous hemianopia, if associated with headache, you’re looking for a brain tumor, a mass lesion. Or sometimes an arterial venous malformation or could be inflammation within the brain. Like neuro sarcoidosis. To answer the other question, does every patient need a visual field. At least do a confrontation on every patient. It’s inexpensive and quick and will give you so much screening information. At least incorporate that confrontational visual field exam into your work up. If you don’t do it yourself, fine, have a technician or a nurse do it or a student do it. But it should be done and documented on every single headache patient. Okay. Next, how do you feel about vision therapy to treat headaches? Sometimes headaches can be seen without binocular vision anomalies. I’m not an expert in vision therapy. I believe that vision therapy specialists are best poised to answer this question about whether headaches do improve in their patients. I think as eye care providers our first order of business is to separate out the red flags from the people that don’t have the red flags. If a patients has negative screening questions and negative SNOOP and you think they’re having issues with convergence, give them the glasses and sends for vision therapy and give them a trial of 3 months and see how they do. If they’re not better, definitely send them for treatment to the primary care doctor or a neurologist. At that point it’s probably not just the vision problem that is causing the headache. They probably have other headache syndrome like tension headache or migraine. Give it a 3 month trial, if they’re not better, send them to their primary person. If someone just had refractive error, I would give them a one-month trial only. And see if they get better with that. Maybe they come back, they’re not comfortable with the glasses, you can tweak it or weed out other issues that may need work up. Okay. Next question is of your patients who complain of headaches, how many percent have an ophthalmologic cause for headache? Error of refraction — is an error of refraction a contributor of headaches in the patients you see in your practice. My practice is biased because I’m an neuro ophthalmologist and practice in a tertiary care provider. Again, my bias is towards people who already have seen other providers. I tend not to see the refractive error patients in my practice. Most have migraine or another neurologic cause for their headache syndrome. Okay. The next question, I’m a pediatric ophthalmologist. What are the main causes of headache in children after other etiologies are ruled out. The vast majority of children have tension headache. Triggered by dehydration, there were outside in the sun and playing or lack of, or hunger. Or sometimes school stress can cause tension headaches. That’s the most common type of headache I see in children. That being said, children can get migraine. I have seen quite a number of young patients who have migraine. So it’s important in these patients to go through maybe send them along to the pediatrician to rule out migraine oar at least again, the criteria for migraine are straightforward. You can look them up online. You can really help out a family if you can help to diagnose migraine. It’s common but it’s not a regular headache. It can be gastrointestinal symptoms and it could be useful to start the process and get them diagnosed and refer to the appropriate provide per. How would one identify a bilateral migraine headache? If it’s bilateral, then we have to think, okay, is this tension, migraine, which is it. Ask about the symptoms I mentioned earlier. Is it pulsating or throbbing, stabbing. Is there associated light sensitivity, sound sensitivity, nausea, vomiting. If a patient answers yes to those questions, most likely it’s migraine and it’s presenting bilaterally. Yes. It can happen. There is always exceptions to the rule. If they’re positive, yes, it’s probably migraine. The next question is acephalgic migraine common in your practice? Absolutely. So I’m so glad you brought that up. I believe it’s Dr. Fernandez. Basically, acephalic migraine is when a patient has simply aura, visual aura. But they never get the headache afterwards: And so in these patients, it’s really, really important to ask them about their really dig deep into the history. So do yo have a family history of migraine. Did you ever get headaches as a child. Did you have to go into a darkroom as a child. Even though they may not be getting the headache component now with their visual aura, maybe in the past they had headache syndrome. So it’s important to ask about those questions, again, some of those other questions I just mentioned earlier, light sensitivity, sound sensitivity, nausea, vomiting with the acephalgic migraine, intolerance of flickering lights can all steer us towards acephalic migraine. Yes, it can happen but it’s trickier to diagnosis. And you absolutely need to do, in this case I would do a formal visual field to make sure the patient doesn’t have homonomous defect. If they have a homonomous defect, you need do the extra work up for these patients. Next question. I see many patients who complain of episodes of unilateral retro ocular pain. Most are asymptomatic when they visit the clinic and don’t recall other ocular symptoms or vague in their pain characteristics and the ocular examination that day is normal. How do you suggest to approach these patients? I would ask them what were you doing when you had this symptom? What were you doing the day before or the day of when you had this symptom. For example, some people will have like, I will give you this example, many people will have, will do intense exercise which you would think is good for your health but sometimes it can precipitate this type of headache in the trigeminal distribution behind the eye. Ask them about their activities. You can ask them about whether, if it’s a female, whether, where they are in their cycle when they get this headache. I was just speaking with a friend yesterday who is entering perimenopause, menopause, and she says I get this pain behind my right eye. It just keeps coming and coming. And I asked her when you get it. She said I get it at the start of my cycle. It’s probably a variant of menstrual migraine. But as long as the other ocular findings are negative, you’re not noticing any uveitis or any signs of glaucoma or angle closure, no optic disk edema, you may not have to image these patients unless you notice something like proptosis. We didn’t talk about mass lesions in the orbit that can cause paining. But that’s another thing to look for, proptosis. And yes, work them up with a scan or an MRI of the orbits with and without contrast. In the vast majority of patients that have periorbital pain with no other findings, I typically don’t image them because the yield is really, really low to pick up anything on imaging. This is a great question. I’m so glad you asked thermodynamic. Does migraine change sides? For example, a patient initially complained of right sided headache and after some years affected the left instead of the right. What are the causes of this changing symptom? I’m glad you asked this question because migraine typically alternates. Yes. So sometimes they have right sided symptoms and sometimes left sided symptoms and sometimes right side and sometimes left side aura. That is a good sign that this is not something pathologic in the brain causing the problem if it’s alternating sides. If it’s always the same side, now, this was not part of the screening questions, is your headache always on the same side or is your aura always on the same side. If that is yes, that would be another red flag and I would image that patient. Why should it be localized all the time. So yes, that would raise a red flag. Okay. So the next question, this is also very important, what is the cause of droopy eyelid with headache and the mechanism? It depends on how droopy the eyelid is. If there is mild ptosis, 1 to 2 mm of ptosis, we’re thinking this patient may have symptomatic dysfunction. Not necessarily a horner’s syndrome but sympathetic dysfunction. The sympathetic fibers ride with the V1 branch of the trigeminal nerve for a short time. Sometimes patients have pain in the distribution with symptomatology. That is why droopy eyelid can be seen in patients with cluster headache or another trigeminal autonomic cephalalgias, they can get this localized pain with a droopy eyelid. Look for all the other signs. If there is not just a droopy eyelid but a horner’s syndrome, I would image them and do the work up. People can have symptoms that come and go. I think someone else asked what if they come in and they’re asymptomatic but have episodes: Have them take a photo. Not a selfie but you want somebody else to take the photo about 12 inches or so or say 33 cm away from their face. And take a full face photo looking right at the camera. You can see what going on. Do they have a little bit of ptosis, do they have anisocoria, anything off about the facial anatomy or change in they’re appearance that may guide you in terms of the diagnosis why they’re having the headaches. If they’re not symptomatic, have them take the photo. It’s helpful to have them come in with the photos or even a video. If it’s something that has movement to it, ask them to do a video. Can cluster headache convert to migraine in due course? It’s a good question. Even times patients can have with these primary headache syndromes, again, tension, migraine, cluster, sometimes they blur. The lines blur. And so, yes, you can have migraine attacks and you can have cluster attacks. And sometimes people who have migraine may also have cluster or vice versa. Say someone had migraine early in life and now they’re older in their 50s or 60s and they’re getting more cluster type. Yes, it can change. If the pattern is changing, you want to image them. Because it’s not normal for the pattern to change from one headache syndrome into another that quickly or that significantly. So I would image those patients. Does headache occur in normotensive glaucoma? That is a great question. I would say based off of the fact that the intraocular pressure is normal, I would not attribute a headache in a normotensive glaucoma patient to their eye issue. I would think it’s a separate issue. And headache is common. Over 50 percent of the population has headaches. They could have independently headache and independently normotension glaucoma. I would not except them to have headache from a normal eye pressure. Okay. The next question, can dry eye cause pupil mydriasis? Typically, no. Unless the patient is putting in a drop, a pharmacologic mydriasis. Typically no. We see many patients with dry eye. It’s something on the ocular surface unless they put something that penetrates the cornea, we should not see a change in pupil size if they have dry eye. For example, if someone accidentally, they have severe pain from dry eye and get their hands on a topical anesthetic but they accidentally put in not a topical anesthetic but a dilating drop, I would think it’s pharmacologic: Okay. Someone is ask, can you please reshare those ten questions, sorry, I missed them. That would mean I have to share the slide show again. But I want to focus on the questions now. What I would say is you will get an email with the webinar replay and the PDF. So hopefully, you can get the questions and take screen shots when you get that PDF. Okay. The next question is thank you very much for this session, do you treat migraines initially or would you rather refer to a neurologist. If yes, what is a preferred medication for migraine. I tried to stay away from talking about treatment but I think it’s something important to discuss. The question of should you as an eye care provider initiate treatment for these patient ifs you suspect tension or migraine. If it’s a lifestyle issue, I would say talk to them about it. Go ahead and talk to them about their eating habits, dehydration, stress level, sleep pattern, et cetera. Foods that may be triggers. Those are simple things that can be aha moments for your patient ifs you just mention it and have them do detective work on their own. That initiates the conversation. But yes, in my practice I do treat all my headache patients. The reason is because when I first started practicing I would send them out to the neurologist or the headache clinic and they came back in three months and never went because the clinic was booked up. They are suffering with headaches for 3 months in the interim. I felt badly and said I have the knowledge and experience to treat this. So I started treating my patients myself. So usually I treat most headache patients whether it be tension or migraine or trigeminal without referring them to a headache clinic. My go-to medications depends. Sometimes I use topiramate and sometimes amitriptyline or beta blockers or calcium channel blockers. Almost everyone benefit, both tension and migraines benefit from supplements, magnesium and riboflavin has been clinically shown as supplements to reduce the frequency and severity of headaches. It’s a simple thing that can change the outcome for patients. It’s easy, doesn’t require a prescription. I start with that and if necessary we treat them with medications. Okay. I’m not quite sure I understand this question. For patient with complaints of headache with a diagnosis of PRES, I’m assuming that means posterior reversible encephalopathy syndrome. Do we need systemic workups, specifically, you’ve uveitic workups. I would say absolutely. If someone comes in with PRES, they have a serious neurologic issue going on. That requires imaging obviously but the question is why did it happen. And in the vast majority of patients, it’s usually due to uncontrolled hypertension or some systemic medication. With respect to uveitis and PRES, I haven’t heard of any specific links there between uveitic syndromes and PRES but maybe there is something I’m not aware of. But yes, these patients absolutely need a systemic work up if they have PRES. So I think I’ve answered most of the questions. There were also quite a few and we have about 2 minutes left. There were quite a few questions that were sent in before the webinar. And I’m trying to think of what, if there is anything from there I didn’t answer. If anybody sent in questions that I didn’t answer right now, please put them into the Q&A box. I don’t see anything. All right. Again, I thank you all for your time and I thank you for spending this time learning about headache management because it’s so important. You will help not just your patients but ultimately along the line because headaches are so common, you will end up helping perhaps a family member, a friend and maybe even yourself with this knowledge. I hope this webinar has empowered you to take better care of your headache patients and also the people in your life. Please, again, the eye health summit is open to all of you. Please register. It’s a free event, 7 days. And please share it with your patients so they, too, can be educated and empowered in their eye health. So thank you so much.