Headaches

Question 1

Headaches

Headache red flags (SNOOP)

Answer 1

Systemic 
Neurologic 
Onset (sudden) 
Onset (age < 5 or > 40) 
Pattern change

Question 2

Headaches

What are 4 categories of non-migrainous headaches? Describe each.

Answer 2

New Daily Persistent Headache

• daily unremitting from time of onset
• bilateral/pressing/tightening
• mild to moderate intensity
• possibly one of: phono-phobia, photophobia, mild nausea

Tension-Type Headache

• episodic, minutes to days
• mild to moderate
• bilateral/pressing/tightening
• pain does not worsen with activity
• peri-cranial muscle tenderness
• prevalence 31-74%
• age > 40
• possibly one of: phono-phobia, photophobia, mild nausea

Cluster Headache

• episodic or chronic attacks separated by pain-free periods
• pain almost always unilateral
• provoked by histamine, alcohol, nitroglycerin
• ipsilateral sx: rhinitis, eye tearing, peri-orbital swelling
• clusters up to 8/day (20 min to an hour)
• age 20-50 & male

Medication over-use headache
-  variable (migraine --> TTH) 
- peculiar pattern 
- drugs that increase risk 
 • Nitroglycerine
 • Nifedipine
 • Dipyridamole
 • SSRI's
- 20-36% adolescents with headaches

Question 3

Headaches

H&P approach to all headaches

Answer 3

PAMPROSSTI
• Inquire about functional disabilities at work, school, housework, leisure activities during the past 3 months
• Pain assessment (OLDCARTS, PQRST)
• Aura
• Medical history
• Pharmacological & non-pharmacological treatments that are effective or ineffective

Focused physical exam
• Vitals
• Extracranial structure evaluation
• MSK exam of head and neck
Focused neurological exam
• Assess level of consciousness, confusion, memory
• Ophthalmological examination
• Pupil symmetry & reactivity, visual fields, ocular motility, fundus exam (papilledema, retinal hemorrhages)
• Cranial nerve examination to include corneal reflexes, facial sensation & facial symmetry
• Symmetry of muscle tone, strength & deep tendon reflexes
• Gait, arm & leg coordination

Question 4

Headaches

Diagnostic criteria for New daily persistent headache

Answer 4

New daily persistent headache
- daily HA > 3 months 
- At least 2 of: 
 1) bilateral 
 2) pressing/tightening 
 (non-pulsatile) quality
 3) not aggravated by 
 routine physical activity 
- BOTH: 
 1) no more than one photophobia/phonia, nausea 
 2) neither moderate or severe N/V 
- not attributed to another disorder

Question 5

Headaches

Dx criteria for TTH

Answer 5

TTH

• infrequent: > 10 episodes (ever), less than 1 day/month
• frequent: 1-14 days per month for more than 3 months/yr (12 to 180 episodes/yr)
• chronic: >15 days/month for over 3 months
• 30 min to days
• 2 of the following
  
  • bilateral location
  • pressure/tightening, non-pulsatile quality
  • mild to moderate quality
  • no increase with routine physical activity such as walking or climbing stairs
• BOTH: no N/V, no more than one phono/photophobia

Question 6

Headaches

Dx Criteria for Cluster Headache

Answer 6

Cluster 
- at least 5 attacks 
- severe unilateral orbital or supraorbital and/or temporal pain lasting 15-180 min if untreated 
- accompanied by at least ONE of: 
   conjunctival injection/lacrimation 
   rhinitis (ipsilateral) 
   peri-orbital swelling 
   ipsilateral facial sweating 
- restlessness or agitation (pacing) 
- frequency 1 Q2 days to 8/day

Question 7

Headaches

Dx Criteria for MOH

Answer 7

MOH
- > 14 days/month
- regular overuse for 3 or more months of one or more drugs for HA treatment
- developed or markedly worsened during medication overuse
- headache resolves or reverts to its previous pattern within 2 months after D/C medication
medications include:
- ergot
- triptans
- analgesics (tylenol/ibuprofen)
- opioids

Question 8

Headaches

Epidemiology of migraines (age, sex, risks)

Answer 8

• age: 30-49
• female>male
• risks
  
  • fmhx
  • triggers (environmental, lifestyle, hormonal, emotional, dietary, medications)

Question 9

Headaches

Migraine patho

Answer 9

• Broad sensory processing dysfunction, with a prominent perception of pain in the dense somatosensory innervation of intracranial vessels.
• dysfunction of neuromodulator structures in the brainstem and cortical spreading depression (CSD).

Question 10

Headaches

What are the 4 clinical phases of migraines?

Answer 10

1. Premonitory or prodrome phase
   • Up to 1/3 experience this stage
   • Occurs hours or days before onset of aura or headache
   • Tiredness, irritability, loss of concentration, stiff neck, food cravings
2. Migraine aura
   • Up to 1/3 experience this stage
   • May last up to 1 hour
   • Visual symptoms → seeing bright lights, zigzag lines or hallucinations
   • Sensory symptoms → unilateral tingling or numbness in face or limb
   • Motor symptoms (rare) → Unilateral weakness of face or limbs (hemiplegic migraine)
   • Dysphasia
3. Headache phase
   • 4 – 72 hours (typically 24 hours)
   • Throbbing pain usually begins on one side & spreads to entire head
   • Fatigue, N&V, dizziness, sensitive to head being touched
4. Recovery or postdrome phase
   • Hours-days
   Irritability, fatigue, depression

Question 11

Headaches

migraine duration

Answer 11

4-72 hours

begins as episodic and occurs at least 15 days in a month or more than 3 months

Question 12

Headaches

Migraine common signs and symptoms

Answer 12

• usually unilateral
• pulsing or throbbing
• aggravated by activity
• allodynia
• pain severe/can be debilitating
• photo/phonophobia, nausea
• aura common (1/3)
• prodrome common (1/3)

Question 13

Headaches

migraine Dx criteria

Answer 13

2 or more of the following:

  - Unilateral location
  - Throbbing/pulsating 
  - Moderate to severe
  - Aggravated by activity 

PLUS 
1 or both of the following:
	- Nausea/vomiting
	- Photo/phonophobia
& Previous similar headaches

Aura criteria

• 1 or more reversible aura symptoms
• 1 or more aura symptoms develop over more than 4 minutes, or 2 or more symptoms occur in succession
• Symptoms do not last more than 60 minutes
• Headache follows within 60 minutes

Question 14

Headaches

Treatment

Answer 14

1. Nonpharm: diet, hydration, sleep etc…
2. Behavioral: CBT, relaxation techniques
3. Complementary and alternative: acupuncture, vitamins etc…
4. Pharmacological interventions