Approach to Headache

Question 1

How common is migraine?

Answer 1

20% of women

5-10% of men

Question 2

What is migraine?

Answer 2

Idiopathic headache syndrome (genetic)

May be preceded by aura but over 2/3 are not

Question 3

What is the typical presentation of migraine?

Answer 3

Recurrent, episodic headache

Really bad pain (moderate to severe, building over minutes)

Unilateral

Pulsating

Aggravated by exercise

+ one or both of N+V, and photo- or phono-phobia

Sometimes accompanied by vertigo

Patient just “doesn’t feel right” (distracted, confused, irritable)

Question 4

What changes of brain activity occur during migraine aura?

Answer 4

Slowly spreading wave of reduced activity (cortical spreading depression of Leao; measured in cm/min)

Probably glial rather than neuronal

Often with occipital onset

Question 5

What visual disturbances are often reported with migraine aura?

Answer 5

Scintillating scotoma

Monochromatic patterns (e.g. wavy lines, fortification spectra, water effects)

Creeping hemi or quandrantanopia

Monocular changes rare (but retinal migraine does exist)

Question 6

What kinds of phenomena can be seen with a migraine aura?

Answer 6

Visual

Sensory (e.g. parasthesia)

Motor (e.g. weakness)

Speech centre (e.g. dysphasia)

Brainstem (e.g. in basilar migraine)

Question 7

What causes headache in migraine?

Answer 7

Much less clear

Trigeminal pain (meningeal and facial innervation, serotonin receptors involved)

Almost certainly a brainstem event, but there are secondary meningeal vessel changes, and pain amplification occurs in scalp and head (allodynia; this feedback loop can be broken by botullinum toxin)

Question 8

Describe the typical presentation of tension-type headache

Answer 8

Mild to moderate

Band-like: bilateral, pressing

Not associated with exercise induction, N+V, photo- or phono-phobia

I.e. a “normal headache”

Question 9

What is chronic daily headache? What are the different types?

Answer 9

Headache on most days, most of the day

Chronic migraine (evolves from migraine without aura) or chronic tension-type (individually mild headaches but persistence distressing)

Question 10

What can make a headache chronic?

Answer 10

Bad luck: severe migraine, chronic daily headache as a primary headache

Bad treatment: medication overuse headache

Bad neck: cervicogenic

Question 11

What medications can cause chronic headache?

Answer 11

Opiates

Triptans

Ergots

Possibly paracetamol but probably not NSAIDs

Question 12

Describe the typical pattern of medication overuse headache

Answer 12

More than 10 days a month (twice a week)

Question 13

What is the mechanism of medication overuse headache?

Answer 13

Chronic changes rather than just tolerance; upregulation of pain receptors

Question 14

Mx of medication overuse headache

Answer 14

Medication withdrawal (but have withdrawal headaches for weeks; however patients are often surprisingly compliant with stopping medication)

Question 15

What clinical feature may accompany a cervicogenic headache?

Answer 15

Muscular neck pain (nearly ubiquitous)

Question 16

What features may accompany the thunderclap headache characteristic of SAH?

Answer 16

May have neurological Sx/signs, e.g. weakness/sensory loss, impairment of consciousness (common; depth of coma marks prognosis)

Photo- or phono-phobia

N+V

Can be unilateral headache (headache is meningeal)

Question 18

How can SAH be distinguished from migraine?

Answer 18

Onset is extremely abrupt in SAH

Question 19

DDx for primary thunderclap headache

Answer 19

SAH

Sexual and exertional headaches

Vasospastic headache

Primary thunderclap headache (although not well-described entity)

Question 20

Dx of SAH

Answer 20

Plain CT

Lumbar puncture if CT normal but there is a good story (will be more accurate once xanthochromia develops)

Question 21

Signs/Sx of raised ICP

Answer 21

Diffuse headache, variable in severity but often progressive

Prominent nausea

Papilloedema (peripheral visual loss or transient blindness)

Diplopia (CNVI palsy)

Worsening of Sx with increases in ICP (e.g. valsalva - cough or straining, morning headache) and better with reduced ICP (e.g. when standing)

May also have Sx of underlying lesion

Question 22

26 year old woman with transient, objective L sided weakness and sensory disturbance makes acute presentation to ED, but her sensory and motor Sx then fully resolved

DDx?

Answer 22

Migraine aura (high prior probability)

TIA

Focal seizure

Hypoglycaemia

Vasospastic headache

Functional eurological disorder

Others: non-seizure tumour Sx, periodic paralysis, paroxysmal dyskinesia, mitochondrial disorder, etc

Question 23

Does EEG diagnose seizure?

Answer 23

No, just predicts recurrence (sometimes)

Question 24

Distinguish between migraine, TIA and focal seizure in terms of the typical pattern of involvement

Answer 24

Migraine: cortical, brainstem

TIA: cortical, brainstem

Focal seizure: cortical, mesial temporal (invokes memory phenomena)

Question 25

Distinguish between migraine, TIA and focal seizure in terms of the typical onset

Answer 25

Migraine: acute with sensorimotor march over minutes

TIA: acute, immediate

Focal seizure: acute with sensorimotor march over seconds

Question 26

Distinguish between migraine, TIA and focal seizure in terms of the typical offset

Answer 26

Migraine: gradual, often stepwise, intermixed with new Sx

TIA: gradual

Focal seizure: distinct (Todd’s paresis)

Question 27

Todd’s paresis

Answer 27

Focal weakness in a part of the body after a seizure

Question 28

Distinguish between migraine, TIA and focal seizure in terms of the typical Sx character

Answer 28

Migraine: often active parasthesia, weakness usually varies

TIA: usually negative Sx (e.g. weakness, numbness)

Focal seizure: often active parasthesia, clonus or dystonia prior to weakness

Question 29

Outline some distinguishing clinical features of migraine, TIA and focal seizure

Answer 29

Migraine: N+V, headache (may be mild with fronto-parietal aura), photo- or phono-phobia, more likely in young

TIA: CV Hx (CV RFs, PHx of MI/stroke/PVD), very common in those >65

Focal seizure: dyscognitive phase, previous stereotyped events