Headaches

Question 1

Primary vs. Secondary Headaches

Answer 1

Primary:

• Genetic disposition, with secondary influences
• Migraine
• Tension
• Chronic daily headache

Secondary: caused by something else

• CNS lesion
• systemic disorders
• structural disorders of the head and neck

Question 2

Headache Red Flags

Answer 2

• Worsening headache: in frequency or severity
• Severe, acute headache: Subarachnoid hemorrhage
• Headache upon awakening, or wakes patient up in sleep: might be related to increased intracranial pressure
• Ataxia or dizziness
• Alteration of consciousness
• Focal neurological findings
• Associated stiff neck: Meningismus, bleed in the brain
• Double vision
• Persistent headache after head injury
• Headaches in the very young: kids under 6 yo

Question 3

Genetic abnormality for Familial Hemiplegic Migraine

Answer 3

• Chromosome 19: abnormality of voltage gated calcium channel

Question 4

Migraine

Answer 4

Must have at least one of the following:

• Nausea +/- vomiting
• Photophobia or sonophobia

2 of the following:

• Throbbing
• Hemicranial (affects only 1 side of the head)
• Increased with movement
• One to 72 hour, intermittent headache
• At least moderately severe

Question 5

Migraine with Aura

Answer 5

Aura: neurologic symptom, (usually visual In migraine)

• Aura can proceed the headache or come on simultaneously
• Aura last few minutes up to one hour
• Positive aura: e.g., shiny shimmery light
• Negative aura: lose a whole visual field
• Can be sensory, e.g., Paresthesias: buzzing around mouth or arm

Question 6

Migraine pathogenesis

- Name the important neuronal circuit

Answer 6

• Basic defect is neuronal hyperexcitability
• Important circuit:
  Cortex – trigeminal nerve (NC) - vascular
• There may be Serotonin (5-HT) or Calcium channel irregularities
• There may also be prolonged VASOCONSTRICTION or formation of local thrombi due to vessel narrowing

Question 7

Tension headaches

Answer 7

• Absent most of the characteristics of migraine
• Intermittent headaches lasting one hour to 5 days
• May be on a continuum with migraine
• Dull squeezing, band-like headaches
• No other explanation for headaches

Question 8

Chronic daily headache

Answer 8

• Clinical definition: At least 15 headache days per month, for at least 3 months
• Often transformed migraine; about 10% are newly onset
• Analgesic rebound: “medicine overuse headache”; commonly due to OTCs: aspirin, Tylenol, ibuprofen)
• Not rare in adolescents
• Look for drug and alcohol
• Rule out psychological factors

Hidden reasons for chronic daily headache:

• Pseudotumor without papilledema: w/ increased intracranial pressure; Dx with spinal tap
• Sleep disorders: not enough sleep, delayed sleep phase, sleep apnea

Question 9

Cluster headache

Answer 9

• Occur in clusters: headache same time everyday; severe, boring headache (can cause people to commit suicide)
• Autonomic symptoms: Ptosis, miosis, sweating (like Horner’s)
• 15 to 180 minutes
• Male predominance: 80-90%
• Usually early adulthood
• Need to move

Question 10

Paroxysmal hemicrania

Answer 10

• 1 to 40 attacks per day (that’s a lot!)
• Female predominance
• last 2 to 45 minutes
• Autonomic symptoms
• Need to lay still in the dark
• Indomethacin: very good response; almost diagnostic

Question 11

Short-lasting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT)

Answer 11

• Rare
• Male predominance
• Last 5 to 250 seconds
• 5 to 10 episodes per hour
• Autonomic symptoms

Question 12

Hemicrania continua

Answer 12

• Continuous unilateral headache

- Autonomic symptoms

Question 13

Acute Severe Headache: “Worst headache of my life”

Answer 13

Sub-arachnoid hemorrhage: very acute boom explosive headache; does not build up over time

• CT of head looking for SAH: sees SAH 90% of time
• LP looking for SAH: performed if can’t see SAH on CT
• Pain management

Could also be:

• Thunder clap headache: migraine variant
• Coital headache: headache during sex
• First migraine

Question 14

Principles of Headache management

Answer 14

• Behavior/Lifestyle changes: avoid triggers
• Use OTC medications first: More effective if used early in headache onset; use proper dose

Secondary management:

• Triptans (abortive medication)
• Preventive medications (not curative): Requires 4-6 weeks to work (e.g., Cyproheptadine, Beta-Blockers, Tricyclic antidepressants, Ca channel blockers, Anti-convulsants)

Question 15

Trigeminal Neuralgia (Tic Douloureux)

Answer 15

• Short headache not associated with autonomic features
• pain in the V1 or V2 distribution on the face
• Responds to anticonvulsants