9/29 Headache - Bhise Flashcards
primary headache disorders
- migraine
- tension-type headache
- trigeminal autonomic cephalalgias
- others
represent 80-90% of headaches
migraine headaches
- unilateral but not side-locked
- pouding or throbing
- photophobia, phonophobia, osmophobia
- nausea w/wout vomiting
- typically 4-24 hours
- aura that begins 5-30 min before headache
aura
seen with classic migraines
begins 5-30 mins before
- last 15-30min
- scotomata (flashing lights, bars)
- sometimes somatosensory
- maybe independent (acephalgic migraine)
history, prov/pall, and complications with migraines
history
- v common to have family history
- history of motion sickness
- comorbid anxiety, depression
provocation/palliation
- worsen with activity
- better when sleeping off in dark, quiet room
complications
- opthalmoplegia
- homonymous hemianopsia
- hemianesthesia
- hemiplegia
- word-finding difficulty
headache triggers
low threshold for external stressors like:
- stress, weather, lack of sleep
- skipping meals
- dehydration
- certain foods
- hormonal changes (menses, birth control, preg)
- medication (ex. nitroglycerin)
neurobiology of migraines
cortical spreading depression
- behind zone of activation, there is a zone of depression (depol) which correlates with onset of headache
- headache usually starts while flow is diminished
- activates trigeminovascular neurons → pain!!!
*oligemia isnt severe enough to cause ischemia
**reactive vasodilation (vascular theory) is not supported
trigeminovascular system involvement in migraines
CN V
- mediates pain from cerebrovasculature and craniofacial region
- handles reflex control of cerebral blood flow
- activated by neurogenic inflammation
major peptide: CGRP (calcitonin gene-related peptide)
neurovascular theory
complex neurovasc/neurochem process activates trigeminal pain pathways
brainstem nuclei (locus ceruleus and dorsal raphe nucleus)
→ superior salivary nucleus
→ pterygopalatine ganglia
→ pia, dura, and blood vessels, and trigeminal nucleus
→ release of CGRP (potent vasodilator)
- stimulates MMP (matrix metalloproteinase) → release of polypeptide “soup” to blood vessels
- serotonin, bradykinin, substance P, neurokinin P&Y, prostaglandins
→→→ perivascular inflammation and pain!
prodrome: suggestive of hypothalmis and/or brainstem origin
headache phase: indicative of trigeminovascular system
treatment of migraine
abortive treatment
- NSAIDs
- anti-emetics
- triptans/ergots
- combo
preventive tx
- pharmaco
- non-pharmaco
lifestyle modification examples
- headache log
- keeping on the lookout for: hunger, dehydration, lack of sleep
- limiting/stopping NSAID use
- rebound headaches when you stop taking a med
- avoiding junk food, caff drinks
high severity migraines
status migrainosus
- migraine lasting over 72hr
- abortive tx: ketorolac, meoclopramide, IV fluid
- secondary option: sumatriptan, DHE, methylprednisolone, valproic acid, MgSO4
transformed migraines
- moved into chronic daily headache
- vulnerable to long term conseqs of headaches!
tension headaches
most common headache type
usually episodic, but can be chronic (chronic? F>M)
typically bilateral
pressing or tightening, squeezing
incr pericranial tenderness on palpation
minutes-days
lacks migraine features:
- pain doesn’t worsen with routine phys activity
- not assoc with nausea
- either photophobia or phonophobia
tension headache pathophysiology
pain mechanisms
- peripheral pain mechs in episodic TH
- central pain mechanisms (sensitization) in chronic TH
- prob sensitized at supraspinal level and spinal dorsal horn/trigeminal nucleus in CTTH
- mood disorders may aggravate central sensitization
- low vitD, elevated IL-1beta levels?
trigeminal autonomic cephalalgias
- cluster headaches
- hemicrania: episodic, chronic, continua
- SUNCT (short-lasting unilateral neuralgiform headache attachs with conjunctival injection and tearing)
- SUNA (short-lasting unilateral neuralgiform headache attacks with cranial autonomic sx)
trigeminal autonomic cephalalgias:
autonomic features
autonomic features ipsilateral to headache:
- conjuctival injection or lacrimation
- nasal congestion and/or rhinorrhea
- eyelid edema
- forehead and facial sweating
- forehead and facial flushing
- sensation of fullness in ear
- miosis and/or ptosis
- Horner syndrome
cluster headaches
- 1-8 attacks per day
- attacks in series for weeks-months, separated by remission periods for months-yrs
- max effect: orbitally, supraorbitally, temporally
- excruciating boring pain, unable to lie down, pacing
- sense of restlessness or agitation
20s-40s: men > women
- men peak in 30s
- women peak in 20s, 60s
diffs between cluster headaches and migraines
cluster headaches have…
- no prodrome
- no aura
- worse with smoking/alcohol
timing
- headaches lasting 15min-hours
- awake pt in middle of night
- recurrent
- periodic: same time of day, same time of year
cluster headaches
mechanism
theories: vascular dilation, autonomic system, circadian effects, histamine release, genetics, autonomic system
- activation in ipsilateral posterior hypothalmic gray matter
- ant cingulate gyrus, bilateral insula
- low testosterone
- pain mediated by trigeminal nerve → vasodilation and edema (histamine, CGRP, substance P, VIP)
- parasympathetic fibers activated (CN VII involved)
sleep association
- often begins in sleep → disturbed circ rhythms suspected
- associated with migraines and sleep apnea
- suprachiasmatic nucleus [sleep pathologies] → parasympathetic pathway
genetic association
- first degree relative → 14-39x incr risk
- inherited auto dom in 5% of cases (HCRTR2 gene)
treatment of cluster headaches
hemicrania
1. paroxysmal: severe, unilat pain (orbital, supraorbital, temporal) lasting 2-30min, several times daily
2. continua: nonstop for over 3 months
- incessant, sometimes severe, side-locked headache that ONLY RESPONDS TO INDOMETHACIN
3. SUNCT: moderate or severe unilat head pain (orbital, supraorbital, temporal, other trigeminal distribution) - 1-600 seconds
- single stabs, series of stabs, sawtooth pattern
- SUNA: attacks lasting 7 days - 1 year spearated by pain free periods lasting at least 1 month
- 2s-10min duration
- freq: daily or more
indomethacin responsive headaches
indicated for
- paroxysmal hemicrania
- cough-induced
- ice pick (stabbing)
- SUNCT
trigeminal autonomic cephalgias
summary table
lasting less than 30min → likely paroxysmal hemicrania
lasting more than 30min → likely cluster
primary headaches
summary table
new daily persistent headache
acute onset, chronic headache - daily and unremitting
bilateral tightening (non-pulsating), mild-moderate intensity
over 3 months
not aggravated by normal activity
distinguishing features from chronic tension-type headache:
- chronic from onset
- often occurs in patients without prior HA history
primary stabbing headache
- aka “icepick headache”
- usually V1 region, 1-10s irregularly between one and many times per day
- assoc with migraine or cluster
- responsive to indomethacin
thunderclap headache
sudden onset, severe
1hr-10days
may recur within first week
esp in young women with history of migraine
require imaging to rule out subarachnoid hemorrhae and RCVS in ant circulation (reversible cerebrovasoconst syndrome)
secondary headaches
sinus headache
dull, deep throbbing in center of head
- worse bending down, leaning over, in cold weather, sudden movement of head
tender to touch on face
yellow/green discharge from nose
postnasal drip
mild-mod fever
fatigue
secondary headaches
med overuse headache
headache occuring on 15+ days per month in patient with preexisting headache disorder
- taking meds more than twice weekly
- regular overuse for > 3months of one or more drugs taken for acute/sx treatment of headache
ex. caffeine, excedring, fioricet, fiorinal, ergotamine, triptans
idiopathic intracranial HTN
aka psudotumor cerebri
- incr ICP
- no structural CNS abnormality
- no CSF outflow obstruction
need to rule out other causes of incr ICP
- chronic headache (positional)
- blurred vision (papilledema)
- tinnitus
- diplopia (CN VI palsy)
- LP with high opening pressure
low CSF pressure headache
“spinal headache” or “spinal leak” after LP
- results from shift/traction on vessels from low intracranial tension
- positional : only on sitting or standing
- self-limiting
tx: IV fluid, IV caffeine, epidural blood patch
when spontaneous: rupturing of Tarlov cyst!
Chiari I malformation
downward displacement of cerebellar tonsils at leas 3mm into upper cervical canal
- commonly see syringomyelia (syrinx)
tx: suboccipital cranectomy, C1 ring laminectomy
occipital or upper cervical headache with valsalva [vending over, laughing, coughing, sneezing]
cranial neuralgias
trigeminal neuralgia (tic douloureux)
- older adults, women > men
- anticonvulstants
- MS
occipital neuralgia
glossopharyngeal neuralgia
temporal arteritis
inflammatory arteritis of the temporal artery
clinical features:
- headache
- monocular visual loss (irrev)
- jaw claudication
- loss of temporal artery pulses
- systemic sx
increased RBC sedimentation rate
dx: temporal artery biopsy
tx: steroids
