Headache Flashcards
How many people in the world today have headache disorder, how many suffer tension and migraine? What is the the global age-standardized prevalence?
In the world today, 3Billion have headache disorders of which we have:
* 1.89B with tension type headache while
* 1.04B with migraine
For tension-type headache, the global age-standardized prevalence is:
* 30.8% for women and
* 21% for men,
whereas the prevalence rates for migraine are: * 19% for women and
* 10% for men
Most patients presents with primary headache disorder, Migraine, the most common though not the most accurate because its features overlap with secondary causes of headache
What is the pathophysiology of migraine?
Learn diagram
List 8 common headache triggers
What is a primary headache and it’s 3 major categories?
Headache or headache disorder “not caused by or attributed” to another disorder
According to ICHD-3 criteria, we have 3 major categories:
Tension- type
Migraine
Trigeminal autonomic celephalalgias
Make up 90% of headache cases
What is the IHS diagnostic Criteria for tension type headache?
Most common primary headache in the general population:
IHS diagnostic Criteria states two out of follows:
1. Pressing or tightening(non pulsatile quality)/ tightband
2. Frontal-Occipital location
3. Bilateral – mild/moderate intensity—NEVER SEVERE!!!
4. Not aggravated by physical activity
What are the rules of the ICHD-3 classification criteria for migraine?
Before you can classify something as a migraine these are the considerations…
We have the ICHD-3 classification criteria for migraine:
1. At least five attacks meeting the criteria are required for the diagnosis
- No single feature is either necessary or sufficient to make the diagnosis
- The diagnosis requires only two of the pain criteria and one associated symptom criterion
- Patients who meet either the pain criteria or the associated symptom criteria, the diagnosis is probable migraine
What are the subtypes of migraine headache?
- Migraine without aura
- Migraine with aura
- Chronic migraine
- Medication-overuse headache (also known as rebound headache)
ICHD-3 Diagnostic Criteria for Migraine Without Aura (5-4-3-2-1)
A. At least five attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has at least two of the following four characteristics:
1) Unilateral location
2) Pulsating quality
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 phonophobia
E. Not better accounted for by another ICHD-3 diagnosis
ICHD-3 Diagnostic Criteria for Migraine With Aura and Typical Aura
A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms:
1) Visual (Most common- Flashes of light, zig-zag lines, scotomas)
2) Sensory
3) Speech and/or language
4) Motor
5) Brainstem
6) Retinal
C. At least three of the following six characteristics:
1) At least one aura symptom spreads gradually over ≥5 minutes
2) Two or more aura symptoms occur in succession
3) Each individual aura symptom lasts 5-60 minutes
4) At least one aura symptom is unilateral
5) At least one aura symptom is positive
6) The aura is accompanied, or followed within 60 minutes, by headache
D. Not better accounted for by another ICHD-3 diagnosis
Migraine with typical aura
A. Attacks fulfilling criteria for migraine with aura and criterion B below
B. Aura with both of the following:
1) Fully reversible visual, sensory, and/or speech/language symptoms
2) No motor, brainstem, or retinal symptoms
ICHD-3 Diagnostic Criteria for Chronic Migraine
A Headache (migraine like or tension-type–like ) on ≥15 days/month for >3 months, and fulfilling criteria B and C
B Occurring in a patient who has had at least five attacks fulfilling criteria B-D for migraine without aura and/or criteria B and C for migraine with aura
C On ≥8 days/month for >3 months, fulfilling any of the following :
1 Criteria C and D for migraine without aura
2 Criteria B and C for migraine with aura
3 Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
D Not better accounted for by another ICHD-3 diagnosis
Questions noteworthy to ask to diagnose medication-overuse headache
- How many days per month do you have a headache of any type or how many days per month are you completely free of headache (crystal clear) from morning until night?
- How many days per month do you take something, including prescription and over-the-counter medications, to alleviate a headache?
ICHD-3 Diagnostic Criteria for Medication-Overuse Headache
A Headache occurring on ≥15 days/month in a patient with a preexisting headache disorder
B Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
C Not better accounted for by another ICHD-3 diagnosis
> 10 DAYS FOR TRIPTANS, OPIOIDS, ERGOTAMINES, COMBINATION ANALGESICS >15 DAYS FOR PCM, NSAIDS,
Caution/Premonitory symptoms of Migraine
Though not part of the diagnostic criteria, they are also common symptoms in patients
They occur maybe hours or days before onset of pain
neck stiffness
yawning
Sinus pain/pressure
increased urination
Irritability
changes in mood
fatigue (most common)
impaired concentration.
PREMONITORY/PODROMAL SYMPTOMS (HYPOTHALAMUS) – AURA (CORTICAL SPREADING DEPRESSION) – ICTUS/MIGRAINE ATTACK (TRIGEMINOVASCULAR SYSTEM) —POSTDROMAL PHASE
What are TRIGEMINAL AUTONOMIC CELEPHALALGIAS and examples?
These share clinical features of unilateral headache and usually prominent cranial parasympathetic autonomic features (mediated by the superior salivatory nucleus) e.g conjunctival injection, tearing, nasal congestion, rhinorhea, horners syndrome, forehead/facial sweating
The are lateralized and ipsilateral to the headache:
- Cluster headache- (15-180mins, occur in clusters)
- Paroxysmal Hemicrania (at least 20attacks, 5 or more/day, lasting 2-30mins, indomethacin Rx)
- Hemicrania Continua (daily&continuous, gritty eye sensation, 3/12, indomethacin-responsive)
- SUNCT (Short Lasting Unilateral Neuralgiform headache with conjuctival injection and tearing)
- SUNA (Short Lasting Unilateral Neuralgiform headache with autonomic symptoms)
What is a Secondary headache?
New headache occurring in close temporal relation to another disorder that is a known cause of headache
Coded as “attributed to” that disorder
Suspicion of a secondary cause of headache can be effectively raised by identifying historical and examination red flags
The mnemonic SNOOP4 is a guide to these red flags
Head CT has a limited role in evaluation of secondary headache disorders but best used(without contrast) to eliminate intracranial blood in patients suspected of having subarachnoid hemorrhage, skull fractures in patients with trauma epidural or subdural hematoma or intraparenchymal hemorrhage
Important to know that there is increased cancer risk associated with CT scans performed during childhood
Disorders Associated With Thunderclap Headache
Vascular
◆ Subarachnoid hemorrhage
◆ Arterial (vertebral, carotid, intracranial artery) dissection
◆ Cerebral venous sinus/cortical vein thrombosis
◆ Reversible cerebral vasoconstriction syndrome
Nonvascular
◆ Spontaneous intracranial hypotension
◆ Pituitary apoplexy
◆ Colloid cyst of the third ventricle
◆ Acute hypertensive crisis
Why is MRI the imagin of choice for headache?
This is the imaging of choice, avoids radiation and enables comparison with follow ups easily unlike CT scan
It helps to increase yield and resolution for identifying secondary causes\
Best visualized areas by MRI are
* Pressure abnormalities: intracranial hypertension (idiopathic intracranial hypertension and secondary), intracranial hypotension (CSF leaks)
* Infection: meningitis, encephalitis, cerebritis, sphenoid sinusitis
* Neoplastic disease: parenchymal and extraaxial neoplasms (especially posterior fossa), meningeal carcinomatosis, pituitary tumor, brain metastases
