Central nervous system - Primary headaches Flashcards
What are the 2 main types of headache
1) Primary - recurrent and benign
2) secondary - associated with underlying cause
What are the types of primary headaches
1) Migraine
2) Tension type headache
3) Trigeminal Autonomic Cephalalgias -
a) Cluster headache
b) Paroxysmal hemicrania
c) SUNCT
4) Other primary headaches
a) Primary stabbing headache
b) Primary coughing headache
c) Primary exertional headache
d) Primary headache associated with sex
e) Hemicrania continua
f) New daily - persistent headache (NDPH) etc
What are critical seconday causes of headaches
1) Vascular - SAH, ICH, CVA, Epidural or subdural
2) CNS infection - Meningitis, encephalitis, cerebral abscess
3) CNS Tumor - Pseudotumor Cerebri
4) Opthalmic - Glaucoma, Iritis, Optic Neuritis
5) Toxic - CO2
6) Drug related - Nitrates, Alcohol withdrawal, MAO inhibitors
7) Endocrine - Pheochromocytoma
8) Metabolic - hypoxia, hypoglycemia, hypercapnia, High altitude cerebral edema, Pre eclampsia
What are the characteristic of Migraine without Aura
- recurrent disorder
- Attacks lasted 4 to 72 hrs
- unilateral location, Pulsating, moderate to severe intensity
- aggravated by physical activity
- association with nausea/ Photophobia and Phonophobia
What are the diagnostic criteria for Migraine without aura
Diagnostic criteria:
A. At least 5 attacks1 fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)2;3;4
C. Headache has at least two of the following characteristics:
1. unilateral location5;6
2. pulsating quality7
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
D. During headache at least one of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia8
E. Not attributed to another disorder9
What do you define chronic migraine
attacks > 15 days/ month - in > 3 months
What is the characteristic of migraine with aura
- Preceded by premonitory symptoms ( Fatique, lack concentration, Neck stiffness Phonophobia,bluured vision, yawning) in an hr to 2 days before a migraine attack
- gradual development duration no longer than an hour
What are the typical auras symptoms
- visual ( most common type) and or
- Sensory and or
- Speech
( mixture of positive and negative symptoms)
What are the diagnostic criteria for Migraine with aura
A. At least 2 attacks fulfilling criteria B-D
B. Aura consisting of at least one of the following, but no motor weakness:
1. fully reversible visual symptoms including positive features (eg, flickering lights, spots or lines) and/or negative features (ie, loss of vision)
2. fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness)
3. fully reversible dysphasic speech disturbance
C. At least two of the following:
1. homonymous visual symptoms1 and/or unilateral sensory symptoms
2. at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
3. each symptom lasts ≥5 and ≤60 minutes
D. Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows aura within 60 minutes
E. Not attributed to another disorder2
What are the differential diagnosis of the migrain with Aura
- Carotid dissection
- AV mulformation
- seizure
What are diagnostic criteria Typical aura without headache
A. At least 2 attacks fulfilling criteria B-D
B. Aura consisting of at least one of the following, with or without speech disturbance but no motor weakness:
1. fully reversible visual symptoms including positive features (eg, flickering lights, spots or lines) and/or negative features (ie, loss of vision)
2. fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness)
C. At least two of the following:
1. homonymous visual symptoms1 and/or unilateral sensory symptoms
2. at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
3. each symptom lasts ≥5 and ≤60 minutes
D. Headache does not occur during aura nor follow aura within 60 minutes
E. Not attributed to another disorder2
What are the diagnostic criteria for familial hemiplegic migraine (FHM)
A. At least 2 attacks fulfilling criteria B and C
B. Aura consisting of fully reversible motor weakness and at least one of the following:
1. fully reversible visual symptoms including positive features (eg, flickering lights, spots or lines) and/or negative features (ie, loss of vision)
2. fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness)
3. fully reversible dysphasic speech disturbance
C. At least two of the following:
1. at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
2. each aura symptom lasts ≥5 minutes and < 24 hours
3. headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows onset of aura within 60 minutes
D. At least one first- or second-degree relative has had attacks fulfilling these criteria A-E
E. Not attributed to another disorder1
What are diagnostic criteria for sporatic hemiplegic migraine
A. At least 2 attacks fulfilling criteria B and C
B. Aura consisting of fully reversible motor weakness and at least one of the following:
1. fully reversible visual symptoms including positive features (eg, flickering lights, spots or lines) and/or negative features (ie, loss of vision)
2. fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness)
3. fully reversible dysphasic speech disturbance
C. At least two of the following:
1. at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
2. each aura symptom lasts ≥5 minutes and <24 hours
3. headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows onset of aura within 60 minutes
D. No first- or second-degree relative has attacks fulfilling these criteria A-E
E. Not attributed to another disorder1
What is the diagnostic criterias for Basilar-type migraine
A. At least 2 attacks fulfilling criteria B-D
B. Aura consisting of at least two of the following fully reversible symptoms, but no motor weakness:
1. dysarthria
2. vertigo
3. tinnitus
4. hypacusia
5. diplopia
6. visual symptoms simultaneously in both temporal and nasal fields of both eyes
7. ataxia
8. decreased level of consciousness
9. simultaneously bilateral paraesthesias
C. At least one of the following:
1. at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
2. each aura symptom lasts ≥5 and ≤60 minutes
D. Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows aura within 60 minutes
E. Not attributed to another disorder1
What is the diagnostic criteria for the Retinal Migraine
A. At least 2 attacks fulfilling criteria B and C
B. Fully reversible monocular positive and/or negative visual phenomena (eg, scintillations, scotomata or blindness) confirmed by examination during an attack or (after proper instruction) by the patient’s drawing of a monocular field defect during an attack
C. Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the visual symptoms or follows them within 60 minutes
D. Normal ophthalmological examination between attacks
E. Not attributed to another disorder1
What are the important aspects of history in diagnosis of Migraine
1) Prodrome
2) Aura
3) Characteristic of Headache
4) Associated symptoms
5) Resolution and postdrome
Aspect of history of migraine - Prodrome
- occurs in 50 - 80% of cases
- occurs hrs to days prior to headache
- variable manifestation - photophobia, phonophobia, yawning,drowsiness, irritability
- 15% preceededby visual symptoms
Aspect of history of migraine - aura
- 10 to 20% of cases
- 10 to 20 minute duration
- Visual aura most common
- Somatosensory less common
- Motor disturbances
- confusional state in children
Aspect of history of migraine - headache
- Unilateral in 60%
- 40% bilateral
- frontotemporal
- 30% throbing, > 50% non throbbing
- onset over minutes to hrs
Duration - 4 to 72hrs
Aspect of history of migraine - associated symptoms
- anorexia, nausea, vomiting
- Photophobia, Phonophobia
- blurred vsion
How do you diagnose migraine
POUNDing P- pulsation O - duration 4 to 72 hOurs U - unilateral N - Nausea D - Disability 4 criteria - LR 24 3 criteria - LR 3.5 < 3 criteria - LR 0.41
Consider alternative diagnosis if -
- Sudden onset, first or worse
- different from usual headache
- Progressively getting worse
- onset with exertion or intercourse
- Reduce LOC
- Fever
- Focal neuro deficit/ meningism
Features suggesting benign aetiology but doesn’t rule out serious headache
- Precipitated by menstruation
- Ameliorated by sleep
- ameliorated during pregnancy
- apear after sustained exertion
- triggers such as food, odours, alcohol
Indications for CT neuro investigation of headache
a) New onset headaches
b) headache with progressive course
c) Changed in pattern
d) headache that never alternate sides
e) any neurological findings or seizure
What are the management of migraine
1) abortive management
2) Prophylaxis
Describe the abortive therapy
Mild to moderate
- Paracetamol - 500 to 1 gm qid
- Aspirin -650 to 1gm tds
- Ibuprofen - 600 to 800mg tds
- Naproxen - 275 to 550mg tds
Moderate to severe
- dihyroergotamine - 1gm IV or IM – repeat 1hr
- triptan ( sumatriptan) - 6mg SC – repeat 1hr if resp
- Prochlorperazine - 5 to 10mg oral or 12.5mg IV
- Metoclopramide - 10mg IV or IM – repeat
- Ketorolac - 10mg IV
- Meperidine - 30mg IV or 30 to 60mg IM
Status migrainosus
- Dihydroergotamine - 1mg IV q8hrs
- Steroids - Various regimens
- Narcotic analgesia
What are the prophylaxis treatment options for migraine
- Indicated if more than 2 to 3 episodes per month
- or attacks lasting more than 48hrs
- or attacks are more severe and debilitating
- However prophylaxis only 55% to 65% effective
Eg
1) Propanolol
2) TCA
3) Calcium channel blocker
4) Sodium valproate
5) MAOI
What is tension type headache
- Previously known as stress or contraction headaches
- Most common variety of headache
- Mechanism - not clear
- Sustained contraction of masseters or deep neck muscles
- Frequently co exist with migraine
- 4 main classes base on chronicity + 9 sub classification
Diagnosis criteria of tension headache according to IHS criteria
a) Headache lasting 30 min to 7 days
b) At least 2 of the following
- bilateral location
- pressing, non pulsitile quality
- mild to moderate severity
- not aggrevated by routine physical activity
c) Both of the following
- no nausea or vomiting
- no more than one of photophobia or phonophobia
Treatment of tension headache
- NSAIDs / Asprin
- Paracetamol
- Chlorpromazine
- metoclopramide
Cluster headaches is grouped under what type of primary headaches
Trigeminal Autonomic cephalalgias
How do you define Trigeminal Autonomic cephalalgias
- share the clinical features of headache and prominent cranial parasympathetic autonomic feature
3 types activate the Tg autonomic - parasympathetic reflex + signs of cranial sympathedic dysfunction
1) Cluster headache
2) Paroxysmal hemicrania
3) SUNCT
What are the features of cluster headache
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated1
C. Headache is accompanied by at least one of the following:
1. ipsilateral conjunctival injection and/or lacrimation
2. ipsilateral nasal congestion and/or rhinorrhoea
3. ipsilateral eyelid oedema
4. ipsilateral forehead and facial sweating
5. ipsilateral miosis and/or ptosis
6. a sense of restlessness or agitation
D. Attacks have a frequency from one every other day to 8 per day2
E. Not attributed to another disorder3
What are the features and diagnostic criteria of Paroxysmal hemicrania
A. At least 20 attacks fulfilling criteria B-D
B. Attacks of severe unilateral orbital, supraorbital or temporal pain lasting 2-30 minutes
C. Headache is accompanied by at least one of the following:
1. ipsilateral conjunctival injection and/or lacrimation
2. ipsilateral nasal congestion and/or rhinorrhoea
3. ipsilateral eyelid oedema
4. ipsilateral forehead and facial sweating
5. ipsilateral miosis and/or ptosis
D. Attacks have a frequency above 5 per day for more than half of the time, although periods with lower frequency may occur
E. Attacks are prevented completely by therapeutic doses of indomethacin1
F. Not attributed to another disorder2
What is the diagnostic criteria for Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
A. At least 20 attacks fulfilling criteria B-D
B. Attacks of unilateral orbital, supraorbital or temporal stabbing or pulsating pain lasting 5-240 seconds
C. Pain is accompanied by ipsilateral conjunctival injection and lacrimation
D. Attacks occur with a frequency from 3 to 200 per day
E. Not attributed to another disorder1
What are the differential diagnosis for cluster headache
- Migraine
- Trigeminal neuralgia – pain peaks within seconds and lasted only a couple of minutes.
- Chronic Paroxysmal hemi crania – induce by rotation or tuning of the head by the pressure on the cervical spine.
Describe your treatment of cluster headache
Acute management - 1) Sumatriptan 6mg SC - 2) High flow oxygen - 3) DHE – 1mg IV or IM Prophylactic management - 1) Prednisone 60mg od for 10 days - 2) Verapamil - 3) lithium
