51. Primary and secondary headaches

Question 1

What is primary headaches?

Answer 1

Idiopathic headaches. More common

• Migraine (most common)
• Tension-type
• Cluster

Question 2

What is secondary headaches?

Answer 2

May be the result of serious underlying diseases/conditions:

• Brain tumors
• Aneurysms
• Infl. diseases
• Abnor. of spinal fluid

Question 3

Diagnosis

Answer 3

Primary: Neurological exam. and imaging tests are usually completely normal in these disorders, no matter how severe the symptoms.

Rule out underlying causes to diagnose primary headache; SNOOP

Question 4

SNOOP

Answer 4

For 2ndary headaches:
SYSTEMIC symptoms/2ndary risk factors
- E.g. weight loss in eldery => giant cell arteritis; ESR & CRP
NEUROLOGIC symptoms/signs
- E.g. CN palsies; imaging
ONSET that is sudden/abrupt/split-second
- E.g. aneurysm (if sudden); imaging
OLDER patients (> 50 y.o)
PREVIOUS headache history
- Changing in preexisting heaches

Question 5

Symptoms

Answer 5

Migraine: Moderate to severe pulsating /throbbing pain (4hrs-3days) located on one or both sides of head; nausea, maybe vomiting, sensitive to light and sound, occur periodically

Tension: Mild to moderate dull or aching pain (30min-hrs) tightness or pressure across head; no nausea or vomiting, multiple times within a day

Cluster: Short ep. (15-180 min) of severe sharp/stabbing pain, usually around one eye, w/autonomic symptoms (tearing, red eye, nasal congestion)

Question 6

Treatment

Answer 6

Migraine:

• Lifestyle changes, relaxation training, electromyographic feedback and cognitive behavioral therapy + medication
• Preventive medications (>4 attacks per month, dur. > 12 hrs, or headaches are very disabling) => beta blockers, antidepressants, anticonvulsants and NSAIDs.
• Abortive therapies: Oral, if mild to moderate => NSAIDs +/- metoclopramide. Oral triptan when severe, if w/nausea and vomit –> parenteral triptans and metoclopramid.

Tension: NSAIDs, if chronic, amitriptyline
Cluster: Treated w/triptans and prevented w/prednisone, ergotamine or lithium

2ndary: Treat underlying cause.