Head and Face Pain Primary Headaches Flashcards
1
Q
What is the “World’s Leading Membership Org for those Committed to Treating Those who suffer from Headaches?”
A
The International Headache Society (IHS)
2
Q
What has the IHS developed?
A
The most comprehensive classification of pain disorders of the head, face, and neck.
3
Q
What does ICHD stand for?
A
The International Classification of Headache Disorders
4
Q
What year was the current, more comprehensive version of the ICHD developed?
A
ICHD-II was developed in 2004.
5
Q
What are the three primary classifications of ICHD-II?
A
Part 1 - Primary HA
Part 2 - Secondary HA
Part 3 - Cranial neuralgias, central and primary facial pain, other HA
6
Q
What are the 4 types of primary headaches?
A
- Migraine
- Tension-Type HA
- Cluster Type and its relatives
- Other Primary HA
7
Q
What are the 8 types of secondary headaches?
A
- Post-Traumatic
- Vascular Disease
- Other Intercranial Pathology
- Substances
- CNS Infection
- Homeostatic Disorders
- Cervicogenic, Eyes, Ears
- Psychiatric
8
Q
What are the types of headaches in Part 3?
A
- Cranial Neuralgias and Neuropathies
- Central and Primary Face Pain
- Other HA
9
Q
What are the types of Migraine?
A
- Migraine w/o Aura
- Migraine w/ Aura
- Childhood periodic syndromes that are common precursors to Migraine
- Retinal Migraine
- Complications of Migraine
- Probable Migraine
10
Q
When and where was the first medical description of headaches?
A
1550 B.C.E. in Ancient Egypt
11
Q
Hemicranial (Migraine) was first coined in what year by who?
A
130-200 C.E. by Galenus
12
Q
Define Migraine
A
Recurrent, chronic, headaches of moderate to severe intensity
13
Q
What percentage does Migraine occur in each gender?
A
6% in Men
18% in Women
14
Q
What is the most important clinical presentation?
A
Aura
15
Q
(T/F)
Attacks occur with and without Aura
A
True
16
Q
(T/F)
Aura occurs up to 1/2 of cases.
A
False
Aura occurs up to 1/3 of cases
17
Q
(T/F) Aura is only visual
A
False
Aura is generally visual but can be somatosensory, aphasic, and/or motor
18
Q
What symptoms can be associated with Migraine?
A
- Anorexia
- Nausea
- Photophobia
- Photophobia
- Osmophobia
- Blurred Vision
- Vomiting
- Diarrhea
19
Q
Which factors contribute to Migraine generation?
A
Genetic and Environmental
20
Q
What are the primary contributors to the manifestations of migraine?
A
CNS
Endocrine System
Autonomic System
21
Q
What percent of Migraineurs have a family history with Migraine?
A
60-70% have 1st degree relatives with migraine
22
Q
What is the risk of developing migraine?
A
45% when 1 parent is affected
70% when both parents are affected
23
Q
Do genetics play a larger role in Migraine with or with aura?
A
Migraine with Aura
24
Q
What is the Migraine Susceptibility Theory?
A
Migraine is a paroxysmal disorder in which a threshold builds between attacks
25
What is the Migraine Threshold characterized by?
Transient or persistent hyper excitation in the cerebral cortex, with the occipital cortex most affected
26
How can the trigeminovascular system play a role in Migraine?
1. Extracranial Neurogenic Inflammation
2. Extracranial Arterial Vasodilation
3. Decreased Central Pain Inhibition
27
Which artery is usually associated with extra cranial artery vasodilation?
The frontal branch of the superficial temporal artery
28
In extra cranial artery vasodilation, pain occurs on the ipsilateral or contralateral side of vasodilation?
Ipsilateral
29
What is Extracranial Neurogenic Inflammation
Increased levels of calcitonin gene related peptide (CGRP) in the external jugular vein resulting in decreased threshold at the site of pain
30
What does central sentiziation in the trigeminal system result in?
Decreased pain threshold at the site of Migraine
31
In Migraine, where is Allodynia found?
In the head, upper trunk, and limbs
32
What indicates central sensitization in Migraine?
The late phase, which is dull and constant
33
What is found in the CSF during Migraines?
Decreased levels of Enkephalin
34
What is Enkephalin?
An endogenous opiod
35
(T/F) Aura can occur without HA
True
36
How long is the recovery usually for Migraine Aura?
20-60 minutes
37
What is Migraine Aura characterized by?
Focal Neurological Symptoms
38
What is Migraine Aura currently attributed to?
Cortical Spreading Depression
39
What is Cortical Spreading Depression (CSD)?
A slow spreading, short duration, of increased neuronal activity followed by inhibition of activity implicated in aura
40
At what rate does Cortical Spreading Depression recover?
At the same rate as the onset
41
What are visual auras characterized by?
Sparkly, scintillating, crenellated shapes in one field
42
What phase is represented by the visual auras?
The excitation phase
43
What phase is represented by the scotoma?
The inhibition phase
44
Define Scotoma
A partial loss of vision or a blind spot in an otherwise normal visual field
45
What does current clinical research draw as the Aura-HA connection?
Aura is not connected to HA, but may be a completely separate event
46
What is the HA of Migraine theorized to be?
An interplay between vasodilation of extracranial arteries, as a result of hemispheric vasoconstriction, and resultant neurogenic inflammation
47
How does blood vessel diameter play into onset of HA?
Vasoconstriction restiling in Vasodilation occurs after the onset of HA
48
What does the timing of changes in vessel diameter show about the Aura-HA connection?
Aura is not associated with the pain generator of Migraine, and is confirmed to be CSD
49
How can an Aura cause HA?
The CSD activates the TVS resulting in vasodilation and neurogenic inflammation.
50
How can an Aura occur w/o HA?
If the CSD fails to activate the TVS an isolated Migraine Aura occurs w/o HA
51
What is the Central Migraine Generator?
An alternative to the CSD/TVS connection; a Brainstem Mechanism (Trigeminal Caudal Nucleus)
52
What is the Brainstem Mechanism in the Central Migraine Generator?
CSD, the aura generator, occurs without any connection to the HA generator
53
What is the Brainstem Mechanism of Migraine Generation based on?
The variability of occurrence between Aura and HA
54
What is the Criteria for Migraine w/o Aura?
1. At/L 5 attacks
2. HA lasting 4-72 hrs
3. HA with two of the following (Unilateral, pulsating, moderate-severe, aggravation by or avoidance of routine physical activity
4. During HA: N/V, Photo/Phonophobia
5. Not attributed to another disorder
55
What is the Criteria for Migraine w/ Aura
1. At/L 2 attacks
2. Aura fulfilling 1 or 2 subforms
- One of the following fully reversible Sx w/o motor weakness
- - Visual Sx
- - Sensory Sx
- - Dysphagic Speech
3. At/L 2 of the following
- Homonymous visual Sx and/or unilateral sensory Sx
- At/L 1 Aura gradually over > 5 min and/or different aura Sx occur in succession over > 5 min
56
Describe the facial pain distribution pattern of a sinus headache.
Pain is usually behind the forehead and/or cheekbones
57
Describe the facial pain distribution pattern of a Cluster HA
Pain is in and around one eye
58
Describe the facial pain distribution pattern of a Tension HA
Pain is like a band squeezing the head
59
Describe the facial pain distribution pattern of a Migraine HA
Pain, nausea, and visual changes are typical of classic form (unilateral)
60
What do childhood periodic HA syndromes include?
Cyclic Vomiting
Abdominal Migraines
BPPV of Childhood
61
What are childhood periodic syndromes shown to be precursors of?
Migraines
62
What are the 4 types of Tension-Type HA?
1. Infrequent, episodic
2. Frequent, episodic
3. Chronic
4. Probable
63
What is the most common type of HA?
Tension-Type HA
64
What is the subjective and objective diagnostic criteria?
Clinical presentation is the sole criteria, no reliable objective testing has emerged
65
What did Tension-Type HA used to be called?
Muscle Contraction HA
66
What is the most consistent clinical finding?
Significantly increased tenderness to palpation of the pericranial mm, proportional to the intensity and freq of HAs
67
What else may cause Tension-Type HA?
Muscle tension in the face, neck, and shoulders
68
What are the Tension-Type Headache Subgroups?
1. Myofascial
2. Psychosocial
3. Mild Migraine
69
What is the myofascial subgroup of TTH?
Characterized by MFTPs and pain referral patterns (WDRN)
70
Describe the quality of pain in the myofascial subgroup
Similar to myofascial pain in other areas in the body
71
What is the myofascial TTH pathogenesis thought to be?
Unabated myofascial pain lead to central sensitization resulting in inc peripheral tenderness of the mm. of mastication and Cx spine
72
What is the basis for Cervicogenic TTH?
Trigeminal pain afferents and spinal afferents to the level of C4 share the same neuronal pathways.
73
What can biomechanics stress create?
MFTPs
74
What are MFTPs?
A hyper irritable spot in muscle
75
What do MFTPs represent?
Dysfunctional motor endplates leading to spontaneous electrical activity
76
What is the Psychosocial TTH pathogenesis thought to be?
Corticolimbic disinhibition, similia to limbic pain augmentation, leading to generalized muscle tissue sensitivity
77
Is pain in the Psychosocial TTH attributed to nociception?
No
78
What happens in Chronic Psychosocial TTH?
They may plasticize the corticolimbic state making them resistant to somatic based treatments
79
What is the Mild Migraine TTH subgroup distinguished by?
Clinical Presentation
80
How does Mild Migraine TTH differ from Migraine?
An individual w/ a Migraine genotype may experience milder HA that are phenotypically TTH
81
How does the pain modulating systems work in Mild Migraine TTH?
They have well functioning pain modulating systems allowing them to dampen the severity of a migraine to a less severe TTH
82
Which muscles are prone to MFTP in TTH?
```
Temporalis
Masseter
Trapezius
Splenius Capitis
SCM
```
83
What are examples of Tx for TTH?
1. MFTP Acupuncture
2. MFTP Injection
3. PT
4. Muscle Relaxers
5. Botulinum Toxin
6. Corticolimbic Subgroup
84
What are examples of Tx for TTH in the corticolimbic subgroup?
1. CBT
2. Biofeedback
3. Antidepressants
4. SSRI/SSNRI
85
What are Trigemincal Autonomic Cephalgias? (TAC)
Primary HA pain with lacrimation, ptosis, rhinorrhea, and Horner's Syndrome
86
How long do TAC's typically last?
Short duration with severe intensity
87
What conditions are associated with TACs?
1. Cluster HA
2. Paroxysmal Hemicrania
3. SUNCT
4. Hemicrania Continua
88
What does SUNCT stand for?
Short Lasting Unilateral Neuralgiform HA w/ Conjunctival Injection and Tearing
89
How do TACs present?
With Trigeminal based pain and Sx of Parasympathetic activation. Sympathetic activation is less common
90
What is the hypothesized Trigeminal-Parasympathetic connection?
A brainstem connection links the Trigeminal system to the Parasympathetic system at the level of the CN VII and the Sup Salivatory Nuc, containing Preganglionic Parasympathetic Neurons
91
What is the evidence for the Trigeminal-Parasympathetic connection?
Elevation of CGRP and Vasoactive Intestinal Peptide (VIP) in the jugular vein during attacks of cluster HA and Paroxysmal HC
92
Which is a Trigeminal marker?
CGRP
93
Which is a Parasympathetic Marker?
VIP
94
How is it hypothesized that the sympathetic system is involved?
Pain is excitatory to the IML, which stim adrenal release of plasma NE/E, also ICA dilation from Para activation stim the sympathetic plexus on the ICA
95
What is the primary generator of TACs?
Hypothalamus and the HPA Axis
96
What is the regulating system for the body?
The HPA Axis, along with the sympathetic system
97
Which are the most severe of all the HA syndromes?
Cluster HA
98
How long does it take a sufferer to be Dx with a Cluster HA correctly and why?
6.6 years due to misdiagnosis as a Migraine or Sinus HA
99
Describe a Cluster HA
1. Episodic and Frequent
2. Short Duration
3. Severe
4. Unilateral
5. Autonomic Symptoms
100
What are Cluster periods?
The cycle in which they have daily attacks
101
How often and how long do cluster periods last?
2-12 weeks
| 2x a year
102
What is Cluster HA remission?
6 months
| 2 years
103
What is the intensity of Cluster HA
Always Severe
104
What is the pain distribution in cluster HA?
Always Unilateral
| Same side for entire life
105
How often and how long do Cluster HAs last?
Duration - 15-180min
Freq - 1-3/Day
Peak - 1-2AM, 1-3PM, After 9PM
106
When do Cluster HAs occur in sleep?
In the first REM phase, typically 60-90min into sleep
107
What are the associated Autonomic Symptoms of Cluster HA?
1. Most often unilateral
2. Lacrimation
3. Conjunctival Injection
4. Nasal Congestion
5. Nasal Rhinorrhea
6. Horner's Syndrome
108
Which Sx are comorbid between Cluster and Migraine?
1. Nausea
2. Vomiting
3. Photophobia
4. Phonophobia
109
What are the risk factors for Cluster HA?
```
Gastric Ulcers
GERD
Head Trauma
Cigarette Smoking
Alcohol
```
110
What are the abortive therapy Tx's for Cluster HA?
Sumatriptan
Oxygen
Zolmitriptan
111
What are the short term preventative therapy Tx's for Cluster HA?
Corticosteroids
Dyhydroergotamine
Occipital Nerve Block
112
What are the preventative therapy Tx's for during the Cluster HA cycle?
```
Verapamil
Lithium Carbonate
Valproic Acid
Topiramate
Melatonin
```
113
What other Tx are used for Cluster HA?
Surgery to the Cranial Parasympathetic System
Surgery to the Sensory CN V
Radio frequency Coagulation
Hypothalamic stimulation
114
How does Chronic Paroxysmal Hemicranial present?
```
Rare
Short duration
High freq
Severe rad to neck and shoulder
Autonomic Sx
Does not occur during sleep
Unilateral - orbital, temple, auricular
Mild pain common between attacks
```
115
What do PET studies indicate about Chronic Paroxysmal HC?
Activation of the contralateral posterior hypothalamus and contralateral ventral midbrain
116
How does SUNCT present?
```
Unilateral
Brief
Moderate-Severe
Orbital with rad to temple, nose, cheek, palate
Conjunctival Injection
Tearing
Rhinorrhea
Nasal Obstruction
```
117
What is the age of onset for SUNCT?
40-70 years old
118
How often daily can SUNCT occur?
1-80 episodes a day
119
What does functional imaging indicate about SUNCT?
Hypothalamic Activation
120
What is Hemicrania Continua?
Very rare condition of unilateral severe HA with autonomic and migrainous Sx
121
What are the two most prevalent primary HA in women?
Migraine
| Tension-Type HA
122
Which HA occurs more in men?
Cluster HA
123
What is the gender discrepancy in primary headaches attributed to?
Influence of ovarian steroid cycles on phenotypic expression of HA
124
In which primary HA do ovarian steroids play to most prominent role?
Migrainous HA
125
What are female specific triggers for a Migraine HA?
Falling Estrogen during late luteal phase
| Estrogen withdrawal in postmenopausal women
126
How do you monitor autonomics?
1. General Appearance
2. Skin Inspection
3. Capillary Refill
4. Radial Pulse
5. Eyes
6. Respiration & Lung Expansion
7. Pulse Ox, BP, Auscultation
127
How do you monitor autonomics through skin inspection?
Appearance
Temperature
Moisture
Varicosities
128
Where do you monitor autonomics through capillary refill?
Hands and Feet
129
How do you monitor autonomics through radial pulse?
Look for changes in pulse with head neutral, head left, and head right
130
How do you monitor autonomics through the eyes?
```
Pupil dilation
Pupil Reflexes
Ptosis
Lid Lag
Palpebral Fissure
```
131
In TTH, what is Exteroceptive Suppression (ES)?
The inhibition of voluntary EMG activity by the temporalis m. induced by CN V stimulation
132
In TTH, what is ES2?
ES2 is a multi synaptic reflex subject to limbic and other modulation, is absent in 40% of pts with CTTH, and reduced in duration 87%
ES2 may be absent in more HA prone patients
133
In TTH, what is ES1?
ES1 is a normal oligosynaptic reflex
134
In Cluster HA, what are the 8 clinical features to memorize?
1. Conjunctival Injection
2. Lacrimation
3. Congestion
4. Rhinorrhea
5. Swelling
6. Miosis
7. Ptosis
8. Eyelid Edema
