Headache Flashcards
Other term of headache
Cephalalgia
• Pain or discomfort in any region within the head
Cephalalgia
Diffuse pains in various parts of the head with pain not confined to any distribution of a nerve
Cephalalgia
for headache in general
46
for migraine
11
for tension type headache (TTH)
42
for chronic daily headache
3
GBD 2019
Headache disorders 14th among global causes of DALY (disability-adjusted life years);
10h among females; 2nd among young adult female (15-49yo); 10th among young:
adult men
WHO
one of 10 most disabling conditions for the 2 genders and one of 5 most disabling for women
Pain insensitive structures of the head
Brain parenchyma
Ependyma
Choroid
Pia
Arachnoid
Dura over convexity
Skull
Mechanism of Headache
Intra/extracranial artery distention, traction, dilation
• Traction or displacement of large intracranial veins and their dural envelope
• Compression, traction or inflammation of cranial (CN 11, III, V, VII, IX, X) and spinal nerves
• Meningeal irritation and increased ICP
Mechanism of Cranial Pain
- Intracranial mass lesion
-Dilation of intracranial or extracranial arteries (and possibly sensitization of these vessels)
-Cerebrovascular Disease
-Paranasal sinus infection - Ocular Origin
-Meningeal Irritation
— Lumbar puncture and low CSF pressure
- Headache aggregated by lying down
-Exertional headache
Seizures, alcohol ingestion, nitroglycerine and nitrates, MSG
Dilation of intracranial or extracranial arteries (and possibly sensitization of these vessels)
throbbing or steady headache; increased pulsation of meningeal vessels activates pain sensitive structures within their walls or around the base of the brain
Febrile illness
• Dilation of intracranial or extracranial arteries (and possibly sensitization of these vessels)
Effects
• Extremely rapid rises in BP
• Cough and exertional headaches
Most strokes due to vascular occlusion does not cause head pain
vascular occlusio CVD
severe, persistent headache localized on the scalp then becomes diffuse
Extracranial temporal and occipital arteries (giant cell arteritis)
upper neck or postauricular pain
Occlusion and dissection of vertebral artery
projected to occiput
Basilar artery thrombosis
Ipsilateral eyebrow, forehead above
ICA Dissection, MCA Occlusion
Eye
Expanding intracranial aneurysm or PComm and distal ICA
Symptoms of inflamed temporal artery
Headache
Fatigue
Fever
Vision loss
Tear in the intimal layers of wall of carotid artery leading to either
Intramural Hematoma
Aneurysmal dilation of vessel
Both > Stasis > Microemboli > Ischemic CVA
Group of paired air-filled spaces that surrounds the nasal cavity
Sinuses
Excess mucus and sinus infection
Inflamed sinus lining
Sinusitis
Inflammation of the mucous membrane
Rhinosinusitis
Over affected sinuses
• Associated with tenderness
• Paranasal sinus infection or blockage
Paranasal sinus infection location of pain
- ethmoid and sphenoid sinus
— localized deep in the midline behind the root of the nose or at the vertex
Changes in pressure and irritation of pain-sensitive sinus walls
Paranasal sinus infection or blockage
worse on awakening, gradually subsides when upright
Frontal and ethmoid sinusitis
Does not subside when upright
Not worse upon awakening
Maxillary and sphenoid sinusitis
• Pain is ascribed to filling of sinuses and relief to emptying, induced by dependent position of the ostia
• Bending over, blowing nose, air travel intensities pain due to changes in pressure
Frontal and ethmoid sinusitis
located in orbit, forehead, temple; steady, aching type after prolonged use of eyes in close work
Ocular Origin
sustained contraction of EOMs, frontal, temporal and occipital muscles
Hypermetropia (far sightedness) and astigmatism
rapid amelioration after corrective lenses
Error of refraction
Diagnostic exam for Bacterial Meningitis
Cranial CT with contrast
Diagnostic exam for SAH
Plain cranial CT
Acute onset, severe, generalized, deep seated, constant and associated with neck stiffness especially on forward bending
Headache of meningeal irritation
Causes of headache of Meningeal irritation
increased ICP, dilation and inflammation of meningeal vessels and chemical irritation of pain receptors in large vessels and meninges by endogenous chemical agents (serotonin and plasma kinins)
Chemical agents that causes headache of meningeal irritation
Serotonin and plasma kinins
intense, sudden, associated with vomiting and neck stiffness
Subarachnoid hemorrhage
Headache associated with SAH
Thunderclap headache
Steady occipitonuchal and frontal pain coming on within a few minutes after arising from recumbent position (orthostatic headache) and relieved within a minute or two by lying down
• Lumbar puncture (LP) and spontaneous low CSF
pressure headache
Causes of
• Lumbar puncture (LP) and spontaneous low CSF
pressure headache
Traumatic - persistent leakage of CS into lumbar tissues through the needle tract or a tear of meninges
• Spontaneous - cough, sneeze, strain, athletic injury, result of rupture of arachnoid sleeve along a nerve root
What happens when moving towards an upright position
low intraspinal and negative intracranial pressure permits caudal displacement of the brain, with traction on dural attachments and dural sinuses
Position where the CSF is at the lowest
Lateral decubitus position
How to relieve a spontaneous low CSF pressure headache
Epidural Patch
Headache aggravated by lying down is due to
- subdural hematoma
- brain mass lesion esp in post fossa
- idiopathic intracranial hypertension
Typical increased ICP Headaches
• In all states of increased ICP headaches, they are typically worse in the early morning after long period of recumbency
dull and unilateral, perceived over most of the affected side of neck
Subdural Hematoma
global and nuchal headache generally worse in supine position
Idiopathic intracranial hypertension
Usually benign
Exertional headaches
Exertional headaches may be associated with
pheochromocytoma, AVM and
other intracranial lesions
Primary Headache
Headache and associated features constitute the disorder itself
Pain is the only identifiable disease
No underlying cause
Migraine, Tension-type, Cluster, Trigeminal-
sympathetic variant
Chronic, recurrent
Unattended by other symptoms or signs of neurologic disease
Secondary Headache
Headache results from exogenous causes
Glaucoma, sinusitis, SAH, Meningitis (infections), trauma, vascular disease
Headache due to psychiatric disorder
Only 1% of patients with brain tumor will have headache as sole complaint
Context in which HA begun
Onset
Abrupt vs insidious
chronicity, duration and frequency (single attack and over a period of years); time to maximal intensity; time of day
Timing
sudden onset with maximal severity in seconds or minutes
SAH
gradually over hours or days
Meningitis
onset in early morning or daytime, peaks over several to 30 mins, and lasts for 4-24 hrs or longer
Migraine
occurrence of severe unilateral orbitotemporal pain coming on within 1-2 hrs after sleeping or at predictable times during the day and recurring nightly or daily for a period of several weeks to months; usually an individual attack dissipates in 30-45 mins but may occasionally last for several hrs
Cluster headache
may appear at any time, interrupt sleep, increase ICP
Intracranial tumor
Pulsating/throbbing
Migraine
Essential but may be difficult to describe
• Tightness, aching, pressure, burning, bursting, sharp, stabbing
Quality or character
Laterality
unilateral vs bilateral; side-locked vs alternating
unilateral in 2/3 of attacks, commonly associated with nausea vomiting, sensitivity to light, sound and smells
Migraine
localized to site of vessel
Temporal arteritis
less sharply localized pain but referred to a certain region usually forehead, maxilla or eyes
Paranasal sinuses, teeth, eyes, upper cervical vertebrae
- occipitonuchal pain; ipsilateral if one-sided lesion
Intracranial lesions in posterior fossa
frontotemporal pain that approximates the site of lesion
• Supratentorial lesions
Ocular disease, dissection of cervical portion of ICA
• Periorbital and supraorbital pain
Subjective
• Reflects patient’s temperament, attitudes and customary ways of experiencing and reacting to pain
• Degree to which pain has incapacitated patient
• Propensity to awaken from sleep, prevent sleep, autonomic reactions to pain (sweating, tachycardia)
• • Severity/Intensity:
Disability and interference with
activities, propensity to awaken from sleep
different pattern from prior headaches
Change
sensory hypersensitivity, N&V, visual changes, numbness/tingling of face or extremities, focal motor weakness, speech impairment, light-headedness/vertigo, cognitive dysfunction
Associated symptoms
lacrimation, conjunctival injection, periorbital or facial edema, ptosis, pupillary changes, nasal congestion or rhinorrhea, aural fullness or tinnitus
Cranial autonomic features
symptoms experienced days to hours prior to headache attack
Premonitory features
menstrual cycle, skipping meals, lack of sleep or oversleeping, stress or relaxation from stress, altitude or barometric changes, position changes, Valsalva maneuvers, physical exertion, bright lights, smells, alcohol, caffeine and certain foods
Triggers (precipitating factors):
generalized, mild, occurring regularly in premenstrual period
Catamenial migraine
intense after a period of inactivity, first movements are painful and stiff
Cervical Spine disease
headache or face ache upon awakening or midmorning, worsened by stooping and changes in atmospheric pressure, associated with midfrontal or maxillary tenderness
Sinusitis
often occurs several hrs or a day following a period of intense activity and stress (weekend or letdown migraine); allodynia of the scalp
Migraine
nitroglycerin and dipyridamole, MSG
Medication
diet, caffeine use, sleep, work and personal stress
Lifestyle features
Bruits of head and neck
• Temporal artery tenderness and pulsations
• Pupillary size and symmetry
• Funduscopic examination
• Visual field testing
• EOMS
• Facial sensation
• Motor function
• Dentition and bite, TMJ
• Cervical and shoulder musculature
• Complete PE and NE
Acute, recurrent
• Migraine (with or without aura)
Chronic,
nonprogressive
•• Tension type HA (TTH)
• Anxiety
• Depression
• Somatization
Chronic, progressive
• Brain tumor / space occupying lesion
• Benign
intracranial hypertension
• Hydrocephalus
• CNS infections
Acute or chronic, non-progressive
• TTH with coexistent migraine
• Periodic, commonly unilateral, usually pulsatile (throbbing) headaches
• Highly prevalent and largely familial disorder
• F>M
• May have onset in childhood but usually begins in adolescence or young adulthood; onset before 30yo in 80%
• Diminishes in severity and frequency with age but may actually worsen in some postmenopausal women
Migraine
fully reversible set of nervous system symptoms, most often visual or sensory, that typically develops gradually, recedes, and is followed by headache accompanied by nausea, vomiting, photophobia and phonophobia
Aura
• Sudden disturbance of vision consisting usually of unformed flashes of white, or silver, or, rarely, of multicolored lights
Photopsia
• May be followed by enlarging blind spot with shimmering edge
Scintillating scotoma
formations of dazzling zigzag lines
Teichopsia
Migraine
Visual/Neurologic symptoms usually last
< 30 mins
Migraine spreading
Cortico depression from posteriorly to brain surface
Ushered by a disturbance of nervous function, most often visual, followed in a few mins or hrs by a hemicranial (some bilateral) headache, nausea vomiting
Migraine with aura
(classic or Neurologic)
• Unheralded onset over minutes or longer of increasing hemicranial headache or, less often, by generalized headache with or without nausea and vomiting, which then follows the same temporal pattern as migraine with aura
Migraine without aura
Migraine
Visual disturbance to intensity ratio
1:5
Migraine triggers
• Use of OCP = increased frequency and severity
• May be linked to certain dietary items - chocolate, cheese, fatty food, oranges, tomatoes, onions
• ? Tyramine
• Red wine
• Exposure to glare or strong sensory stimuli, sudden jarring of head or by rapid changes in barometric pressure
• Excess caffeine intake or withdrawal of caffeine
4 phases of migraine
Prodrome, aura, headache, postdrome
irritability depression yawning nausea fatigue
muscle stiffness
problems in concentrating difficulty in sleeping
Prodrome
• Present in about 60% of patients
• Precede HA by hrs or days
• Psychological, neurological, autonomic
• Depression, hyperactivity, cognitive changes, frequent urination, irritability, euphoria, neck stiffness/pain, fatigue, food cravings
Prodrome
irritability depression yawning nausea fatigue
muscle stiffness
problems in concentrating difficulty in sleeping
Prodrome
Few hours to days
visual disturbances temporary loss of sight numbless and tingling on part of the body
Aura 5 to 60 minutes
throbbing pain
sensitivity to light, noise, odors
nausea vomiting giddiness
Insomnia
neck pain and stiffness
burning
Headache 4to 72 minutes
inability to concentrate fatigue
lack of comprehension
Postdrome 24 to 48 hours
Premenstrual headache, taking the form of migraine or a combined tension-migraine headache, usually responds to administration of NSAID begun 3 days before the anticipated onset of the menstrual period
• Drop in estradiol levels during late luteal phase of ovulation
• Sleep deprivation
Catamenial headache
Premenstrual headache, taking the form of migraine or a combined tension-migraine headache, usually responds to administration of NSAID begun
3 days before the anticipated onset of the menstrual period
Catamenial headache drop in
estradiol levels during late luteal phase of ovulation
Rare subtype of migraine with aura characterized by unilateral weakness
• Mostly in infants and children
• Familial or sporadic
• At least one first or second degree relative
Hemiplegic Migraine
occurs when individuals meet criteria for migraine and average 15 or more headache days/month for at least 3 months
Chronic migraine
Chronic migraine risk factor
Coexisting noncephalic sites of pain
• Mood and anxiety disorders
• Medication overuse
• Obesity
• Female
• Lower educational status
Chronic migraine treatment
long term preventive agents, botox injection
Control of acute attack
specific migraine meds
- pain medications
- anti-nausea medications
Prevention
- prescription medications
- injections
Lifestyle modifications
- Headache diary
-avoid triggers - СВТ
- Biofeedback, relaxation training and stress management
Most common type of headache
Tension Type Headache
Bilateral with occipitonuchal, temporal or frontal predominance or diffuse extension over the top of the cranium
Tension Type Headache
• Fullness, tightness, pressure (as though head were surrounded by a band or clamped) or a feeling that the head is swollen and may burst
• Mild to moderate
• Waves of aching pain are superimposed
• Onset is more gradual
• Once established may persist with only mild fluctuations
• Sleep usually undisturbed, headache develops soon after awakening
• May not interfere with AODs
• Present throughout the day, daily for long period of time (Chronic
TTH)
Tension Type Headache
Absent in tension headache vs migraine:
persistent throbbing, nausea, photophobia, phonophobia, clear lateralization
• F>M
• More likely to arise in middle age and coincide with anxiety, fatigue and depression in trying times
•
Tension Headache
About 1/3 of patients with persistent tension headaches had readily recognized
Sx of depression
Pathogenesis of Tension Headache
• Excessive contraction of craniocervical muscles and an associated constriction of the scalp arteries (?)
• Craniocervical muscles are quite relaxed by palpation with no evidence of persistent contraction by surface EMG
• Pericranial and trapezius muscles are hardened
• Nitric oxide creating central sensitization to sensory stimulation from cranial structures
• Inhibitor of nitric oxide relaxes muscle hardness and pain in patients with chronic tension headache
Treatment of Tension Headache
Analgesics - aspirin, acetaminophen, other NSAIDs
• Persistent or frequent tension headache respond best to cautious use of medications that relieve anxiety or depression
• Amitriptyline ODHS
• CCBs, phenelzine, cyproheptadine
• Ergotamine and propranolol are ineffective
• Massage, meditation, biofeedback mechanisms, relaxation techniques
gradual withdrawal of daily doses of analgesics, ergotamines or triptans
Chronic headaches
Group of headaches classified together as unilateral trigeminal distribution pain attacks, often associated with ipsilateral cranial autonomic features
Trigeminal Autonomic Cephalalgias
Occurs more commonly in men (20-50yo, M:F 5:1)
Characterized by severe consistent unilateral orbital localization
• Pain is deep in and around the eye, intense, non-throbbing
• Often radiates to the forehead, temple and cheek (less often to ear, occiput, neck)
• Nightly recurrence, between 1-2 hrs after sleep onset or several times during the night for several or more consecutive days
Cluster Headache
Regularity each night period, followed by complete freedom
Alarm clock headache
Cluster headache associated with
vasomotor phenomena: blocked nostril, rhinorrhea, injected conjunctivum, lacrimation, miosis and a flush and edema of the cheek lasting on average of 45 min
(15-180 min)
Treatment for cluster headache
• Inhalation of 100% 02 via mask for 10-15 mins at onset of cluster headache
• Verapamil 80mg qid and increasing dose over days with ECG
monitoring
• Nocturnal attacks: single anticipatory dose of ergotamine 2mg PO ODHS or with possibly lesser efficacy, an equivalent dose of serotonin agonist
Intranasal lidocaine or sumatriptan in acute attack
Ergotamine OD or BID before an attack of pain is expected
Short-lasting unilateral neuralgiform headaches
• Severe, side-locked, very brief sharp pains
SUNCT and SUNA
(short lasting unilateral neuralgiform attacks with ipsilateral conjunctival injection and tearing)
• Episodic condition with briefer duration otherwise similar to hemicrania = supraorbital or temporal pain lasts up to 4 min or so and frequent
• Does NOT respond to indomethacin
SUNCT
SUNCT does not respond to
indomethacin
with rhinorrhea and nasal congestion
SUNA
Persistent, lateralized, side-locked headache associated with ipsilateral autonomic features
• Responds to indomethacin
Hemicrania continua
Unremitting generalized headache with a distinct and fairly rapid onset, the inception of which can be clearly recalled
• Follow a viral illness, stressful situation or non-cranial surgery
• Lasts for over 3 months
• Female preponderance
• No special clinical, imaging or CSF features
• Laterality and cephalic autonomic features of hemicrania continua are lacking
• Treatment is unsatisfactory but try anti-epileptics
New Daily Persistent Headache (NDPH)
Most abrupt onset, reaching maximal intensity within a minute
• Severe
• Primary or secondary
Thunderclap Headache
New HA occurring in temporal association with another disorder recognized to be capable of causing it
Secondary Headache
Severe,
chronic, continuous or intermittent HA lasting several days or weeks
separable from HA immediately following head injury
Post traumatic Headache
Deep-seated, dull, steady, mainly unilateral and may be accompanied or followed by drowsiness, contusion and luctuating hemiparesis
• Positional worsening of pain after lying down or leaning head to one side
• Headache of subdural hematoma
with eye pain
Tentorial Hematoma
dizziness, fatigability, insomnia, nervousness, irritability and inability to concentrate
• Persistence = HA for longer than 3 months after injury
• Requires supportive therapy - repeated reassurance and explanations, program of increasing physical activity, antidepressants and antianxiety medications
Post concussion syndrome
Tenderness and aching pain sharply localized to scar of laceration or surgical incision
posttraumatic neuralgia or neuroma
unilateral or bilateral retroauricular or occipital pain, probably as result of stretching or tearing of ligaments and muscles at the occipitonuchal junction or of a worsening of preexisting cervical arthropathy or involvement of cervical intervertebral discs and nerve roots
Whiplash injuries of neck
Whiplash r/o
carotid or vertebral artery dissection after head and neck injury
Thunderclap or worst headache of life
• Presence of focal neurologic deficits
• CT scan, MRI with MRA, CTA, LP, angio
Subarachnoid Hemorrhage
Tear in the intima of the vessel wall
• Intramural hematoma
• Aneurysmal dilation
• Can cause microemboli and stroke
• Unilateral headache with ipsilateral neck pain
Cervical Artery Dissection
Unilateral headache with ipsilateral neck pain or
Horner’s syndrome
• Posterolateral
• Accompanied by meningismus
• Vertebral artery dissection
Vertebral artery dissection accompanied by
• meningismus
New-onset headache at >50yo, most older than 65 yo
• Increasing intense throbbing or nonthrobbing HA often with superimposed sharp, stabbing pains
• Unilateral, sometimes bilateral
• Localized to site of affected arteries in scalp
• Temporal artery tenderness, decreased temporal artery pulsation
• Jaw claudication, unanticipated weight loss, fatigue, myalgia
• SUPERFICIAL TEMPORAL and other scalp arteries are thickened, tender and without pulsation
Giant Cell Arteritis (Temporal Arteritis)
Giant Cell Arteritis (Temporal Arteritis) Treatment
High dose corticosteroid
most sensitive but higher risk hence seldom
used
TA
Arteriography of ECA
UTZ of temporal arteries
DARK HALO AND IRREGULARLY
THICKENED VESSEL WALLS
• Temporal artery biopsy
INTENSE GRANULOMATOUS OR GIANT CELL ARTERITIS
• 90% present with headache as most common but non specific symptom
• Seizure, altered mental status, papilledema, FNDs
Cerebral Venous Thrombosis
Thunderclap headache resembling SAH
• Absence of blood in CSF, diffuse cerebral arterial vasospasm
• Benign course with resolution over weeks
Reversible Cerebral Vasoconstriction
Syndrome
Orthostatic headache, occurring in upright position and resolving or improving upon lying supine
• Worsened by Valsalva maneuver especially in Trendelenburg position
• Stiff neck and nausea
Spontaneous Intracranial Hypotension
identify potential CSF leakage sites
CT/MR myelography
Tx for Spontaneous Intracranial Hypotension
bedrest, IVF, caffeine, blood patch
• Oral theophylline as alternative
• Pseudotumor cerebri
• Elevated ICP associated with normal brain imaging and CSF
findings
• Worsening with Valsalva maneuver, awakening from sleep, intractable N&V
• Transient visual obscuration, photopsia and pulsatile tinnitus
• Papilledema or cessation of venous pulsations, diplopia from 6th nerve palsy
• Associated with obesity and women of childbearing age
• But can occur at any age, in males, not overweight
Idiopathic Intracranial
Hypertension
Increase risk of IIH:
• OCPs (estrogen)
• Excessive vitamin A or retinoic acid
• Lithium
Idiopathic Intracranial Hypertension
Tx
• Acetazolamide 250-500mg BID or VP shunt
Dx of IIH
elevated opening pressure on LP with improvement of headache after removal of CSF
• Approximately 30% of patients diagnosed with brain tumor report headache at presentation
• Only 1% present with HA as only clinical symptom
• No specific features but tends to be deep seated, usually nonthrobbing (occasionally throbbing) and described as aching or bursting
• Sudden change in pattern of preexisting headache disorder
• Worsening of headache with Valsalva and exertion
• Nocturnal awakening
• Presence of focal neurologic deficits
• Unexpected forceful, projectile vomiting in later stages particularly in children or as early feature of posterior fossa tumor
• Displacement of major cerebral vessels or block CSF flow
Brain Tumor
HA attributed to use of or exposure to a substance
• Carbon monoxide
• Delayed alcohol induced
• Medication overuse
Triad: fever, stiff neck, Kernig and Brudzinski sign
• Cranial imaging (CT/MRI) followed by lumbar puncture
Meningitis
Headache attributed to disorder of homeostasis
• Hypoxia/hypercapnia
Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure
• Cervicogenic headache
• HA attributed to acute angle-closure glaucoma
• HA attributed to acute rhinosinusitis
Apophyseal (facet) arthropathy, C2 dorsal root entrapment, calcified ligamentum flavum, hypertrophied posterior longitudinal ligament and RA of the atlantoaxial region
• Evidence: systematic injection of anesthetics into cervical structures are effecting complete relief of HA
• Cervicogenic Headache
Reported in 80% of cases
• More insidious onset than SAH
• Elderly
• Diagnosis:
• Cranial imaging
• Tx: Neurosurgery
Subdural Hematoma
