Differentiate between primary headache and secondary headache
Examples
Primary
- no causative disorder
Ex. TTH, migraine, cluster
Secondary
- caused by another disorder close by
- Ex. Head/neck, non-vascular, infection,
psychiatric
T/F Chronic daily headache can only result from a secondary headache
False
- both
TTH
Location
Quality
Intensity
Duration
Photophobia/phonophobia (light/sound)
Pain worsen with movement?
Nausea?
Location
- bilateral
Quality
- pressing or tightening
Intensity
- mild to moderate
Duration
- minutes to days
Photophobia/phonophobia (light/sound)
- may be present
Pain worsen with movement?
- DOES NOT WORSEN with physical activity, movement
Nausea?
- NOT present
What characteristics do all TTH have to have? (4)
2 of the following
- Bilateral location
- Pressing or tightening (non-pulsating)
- Mild-mod intensity
- Not aggravated by routine physical activity
Diagnose infrequent episodic TTH
How many headaches/month/year
<1day/month
<12/year
Diagnose frequent episodic TTH
How many headaches/month/year
1-14 days/month for 3+ months
Less than 180 days/year
Diagnose chronic TTH
How many headaches/month/year
15+ days/months for 3+ months
More than 180 days/year
How long do infrequent/frequent (episodic) TTH headaches last?
Chronic?
Lasting 30 min - 7 days
Chronic
- hours to days
- unremitting
What do all infrequent/frequent episodic TTH headaches have to have? (2)
Chronic? (2)
Episodic
- No N/V
- No more than 1 of: photophobia or phonophobia
Chronic
- No more than 1 of: photophobia or phonophobia or nausea
- No mod-severe N/V
Migraine
Location
Quality
Intensity
Duration
Photophobia/phonophobia (light/sound)
Pain worsen with movement?
Nausea?
Location
- Unilateral
Quality
- Throbbing, pulsating
Intensity
- 4 phases to migraines (moderate to severe)
- prodrome, +/- aura, headache, postdrome
Duration
- 4-72 hours
Photophobia/phonophobia (light/sound)
- Yes
- osmophobia
Pain worsen with movement?
- Aggravated by movement
Nausea?
- N/V
Symptoms of prodrome migraine?
When does it happen
24-48 hrs
Tired, drowsy, yawning
Food cravings & thirst
More urination
Diarrhea or constipation
Stiff neck
Anxiety, depression
Euphoria, irritability
*May start to experience sensitivity to light, sound & smell
*Like a yellow light/warning phase for early treatment
Aura symptoms
Duration
Positive
Negative
Duration
- 5-60 min
Positive
active discharge from CNS neurons)
- Often VISUAL: bright lines, shapes, objects
- Auditory: tinnitus, noises, music
- Somatosensory: burning, pain, paresthesia
- Motor: jerking or repetitive rhythmic movements
Negative
absence or loss of function
- Loss of vision, hearing, feeling, ability to move a body part
of attacks
What is the diagnostic criteria for migraine without aura
# of attacks
Duration
Characteristics (4)
Phobias/nasuea
At least 5 attacks fulfilling:
Duration
- Headache attack lasts 4-72 hours (with or without treatment)
Headache has at least 2 of the following:
1. Unilateral
2. Pulsating
3. Moderate-severe pain intensity
4. Aggravated by physical activity
Headache has at least 1 of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
of attacks
What is the diagnostic criteria for migraine WITH aura
Duration
Symptoms (6)
Characteristics (6 sections)
At least 2 attacks fulfilling:
Headache has at least 1 of:
1. Visual
2. Sensory
3. Speech and/or language
4. Motor
5. Brainstem
6. Retinal
Headache has at least 3 of:
1. At least 1 aura sx spreads gradually over 5 or more minutes
2. 2 or more aura sx occur in succession
3. Each individual aura sx lasts 5-60 mins
4. At least 1 aura sx is unilateral
5. At least 1 aura sx is positive
6. The aura is accompanied, or followed within 60 mins, by headache
Chronic migraine
Days per month
15+days/month for 3+ months
Triggers for migraines (6)
Stress
Environmental
- Glare, bright or flickering lights
- strong odours, loud noise,
- weather changes, high altitude, tobacco
Dietary
- Alcohol, tyramine containing foods
- citrus fruits, chocolate, coffee
Menstrual cycle
Sleep
- Sleep disturbances, fatigue, fasting/dieting, strenuous exercise
Meds:
- Nitric oxide, PDEi, alcohol, cocaine, histamine, CGRP
Risk factors for chronic migraine (11)
- Female sex
- Family history
- High baseline attack frequency (>1/week)
- Inadequate acute treatment of migraine attacks
- Overuse of acute medications
- Caffeine consumption
- Obesity
- Allodynia (normal touch becomes painful)
- Head injury
- Low socioeconomic status
- Comorbid conditions (Neurological, CV, MSK, SA)
Cluster headache
Location
Quality
Intensity
Duration
Features
Pain worsen with movement?
Location
- unilateral
- one orbit
Quality
- EXCRUCIATING, penetrating
Intensity
- Severe,
- suicide HA, hot poker, stabbing, alarm clock
Duration
- 15min - 3h
- USUALLY AT NIGHT around spring/fall
Features
- conjunctival features (tearing, lacrimation, nasal)
-
Pain worsen with movement?
- Movement required to manage headache
of attacks
Cluster headache diagnostic criteria
#of attacks
Characteristics (4)
Features (7)
Frequency
At least 5 attacks:
- Severe unilateral
- supra-orbital
- temporal pain
- Occurs at the same time each day - usually at night
Features
At least one of:
- Conjunctival injection and/or lacrimation
- Nasal congestion and/or rhinorrhea
- Forehead and facial swelling
- Miosis, ptosis, eyelid edema, sense of restlessness (pacing, rocking, holding the head)
Frequency: 1 every other day to 8 per day
- 1-2 attacks per year
- can have remissions of months
What are cluster headaches precipitated by (5)
- Alcohol
- Naps
- Stress
- MISSED meals
- Vasodilating drugs
What is chronic daily headache defined as
days/month
15+ days/month for 3+ months
of days of drug use
MOH
Location
Quality
Intensity
Duration
Location
- uni or bilateral
Quality
- depends on medication
Triptan: migraine like attacks
Triptan + analgesic: Continuous HA
Intensity
- mild-mod
Duration
- Depends
Drug use
- Triptans, Egos, opioids = 10+ days
- Acetaminophen/NSAID/non-opioid analgesics = 15 days+
Diagnostic criteria for MOH (2)
Headaches occurs on 15+ days/month in patient WITH pre-existing headache disorder
Regular overuse for 3+ months of 1+ drug that can be taken for acute and/or symptomatic treatment for headache
Pathophysiology of TTH
Peripheral activation or sensitization of myofascial nociceptors (central)
Central
- inc general pain sensitivity in CNS
Peripheral
- myofascial trigger points
- inflammation
