Headache

Question 1

Migraine

Answer 1

unilateral but not side-locked
• pounding or pulsatile quality
• photophobia, phonophobia, osmophobia *light, loud sounds, odor
• nausea with or without vomiting
• typically 4-24 hours
• aura (classic) - begins 5-30 min before HA
– lasts 15-30 min
– scotomata - flashing lights, bars
– sometimes somatosensory
– may be independent (acephalgic migraine)
* if no aura then it is common, not classic

Question 2

Complicated migraine

Answer 2

Will also present with:

• ophthalmoplegia,
• homonymous hemianopsia
• hemianesthesia,
• hemiplegia,
• word-finding difficulty

Question 3

The vascular theory of vasodilation has been debunked, what is the cortical spreading depression

Answer 3

Cortical spreading depression (CSD) or spreading depolarization is a wave of electrophysiological hyperactivity followed by a wave of inhibition.[1] Spreading depolarization describes a phenomenon characterized by the appearance of depolarization waves of the neurons and neuroglia[2] that propagates across the cortex at a velocity of 2–5 mm/min.[3][4][5] CSD can be induced by hypoxic conditions and facilitates neuronal death in energy-compromised tissue.[6] CSD has also been implicated in migraine aura

Complex neurovascular/neurochemical process that
ultimately results in activation of trigeminal pain
pathways • brainstem nuclei (locus coeruleus and dorsal raphe
nucleus  superior salivary nucleus  pterygopalatine
ganglia  pia, dura, and blood vessels, also to trigeminal
nucleus which excretes CGRP (a potent vasodilator)
[calcitonin gene-related peptide] • CGRP stimulates MMP (matrix metalloproteinase) which
releases polypeptide “soup” to blood vessels, involves
serotonin, bradykinin, substance P, neurokinin P & Y, and
prostaglandins, causing perivascular inflammation and
pain

Question 4

Medication Overuse headache

Answer 4

Taking medications more than twice per week in general

Headache occurring on ≥15 days per month in a patient with a
preexisting headache disorder
 Regular overuse for > 3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache, need to switch to preventative measure.

 Caffeine, Excedrin, Fioricet, Fiorinal
(acetaminophen/butalbital/caffeine)
 Triptans (5-HT agonists)
 Ergotamine
 Other analgesics or combination analgesics including opioids
and NSAIDS

Question 5

SUNCT

Answer 5

5 secs - 4 minutes,

up to 200x day

stabs of pain around the eyes and temple - unilateral hemicrania.

Short-lasting unilateral neuralgiform
headache attacks with conjunctival injection and
tearing)

Moderate or severe unilateral head pain, with orbital,
supraorbital, temporal and/or other trigeminal distribution,
lasting for 1–600 seconds and occurring as single stabs, series
of stabs or in a sawtooth pattern

Question 6

Pseudotumor cerebri - idiopathic intracranial hypertension

Answer 6

↑ intracranial pressure
 No structural CNS abnormality
 No CSF outflow obstruction
 Need to rule out other causes of ↑ intracranial pressure
(e.g. sinus venous thrombosis 
 Chronic headache – positional
 Blurred vision – papilledema
 Tinnitus
 Diplopia - cranial nerve VI palsy
 Lumbar puncture demonstrates high opening pressure

Question 7

Low CSF pressure headaches

Answer 7

Spinal headache”, “Spinal leak” after lumbar
puncture (LP)
 Shift and traction on intracranial vessels from ↓
intracranial tension
 Positional – only upon sitting or standing
 Ruptured Tarlov cyst - meningeal cysts in S1 to S2.
 Self-limiting
 Treatment: IV fluids, IV caffeine, epidural blood patch

Question 8

sinus headache

Treatment:
treatment: humidifier, saline nasal spray, breathing in
steam 2-4 times per day, quickly treating allergic and
asthmatic attacks, stretches for head and neck,
relaxation techniques, antibiotics for sinusitis, nasal
corticosteroids or antihistamines or decongestants

Answer 8

.=dull, deep, throbbing in center of head
 **worse with bending down or leaning over
 worse in cold and damp weather
 begins as soon as you get up in morning, mucus has been collecting and draining all night
 may be better in the afternoon
 pressure-like pain behind one specific part of face
 tender to touch on face
 pain worse with sudden movements of head
 headache often starts after a bad cold
 postnasal drip
 yellow or green discharge from nose
 red and swollen nasal passages (nasal congestion)
 mild to moderate fever
 general sense of not feeling well
 fatigue

Question 9

Chiari malformation

Answer 9

downward displacement of cerebellar tonsils at least
3 mm into upper cervical canal
 common syringomyelia (syrinx) (hydromyelia)
cervical > cervicothoracic
 Tx: suboccipital craniectomy, C1 ring laminectomy

occipital or upper cervical headache with valsalva [bending over,
laughing, coughing and sneezing]
 neck, shoulder, back pain
 brainstem or spinal cord dysfunction
 cranial nerve deficits rarely
 sensory or motor dysfunction, urinary incontinence
 Cerebellar: clumsiness, ataxia, cerebellar fits
 Eyes/Vision: down-beating nystagmus, oscillopsia, esotropia,
photophobia, eye pain, floaters, blurry vision, diplopia, field cuts
 Respiratory: sleep apnea from lack of patent airway, respiratory
difficulties
 Speech/Swallow syncope with cough, common diminished gag, vocal
cord paralysis, hiccups
 Hearing: tinnitus, fluctuating hearing loss, vertigo, nausea

Question 10

neuralgia

Answer 10

Neuropathic pain in the distribution of a cranial nerve
 sharp, brief, lancinating
 Trigeminal Neuralgia (tic douloureux)
 Older adults
 Women > men
 Anticonvulsants (e.g., carbamazepine, oxcarbazepine)
 Fancier interventions
 Multiple Sclerosis
 Occipital Neuralgia
 Glossopharyngeal Neuralgia
 others

Question 11

Temporal arteritis

Answer 11

Inflammatory arteritis of the temporal artery (opthalmic is a branch of temporal) > internal carotid
 Clinical features
 Headache
 Monocular visual loss – irreversible!
 Jaw claudication - pain from artery occlusion,
 Loss of temporal artery pulses
 Systemic symptoms
 ↑ Erythrocyte Sedimentation Rate (> 100 mm/hr) - increased inflammation, higher proportion of fibrinogen causes RBCs to stick together,
 Diagnosis: Temporal artery biopsy
 Treatment: Steroids

Question 12

Status migrainosus

Answer 12

migraine lasting > 72 hours
• initial options: ketorolac, metoclopramide, IV fluids
• second options: sumatriptan, DHE, methylprednisolone,
valproic acid, MgSO4

Question 13

Transformed migraine

Answer 13

-moved into chronic daily headache

Question 14

SUNCT

Answer 14

Short-lasting unilateral neuralgiform
headache attacks with conjunctival injection and
tearing)

Question 15

SUNA

Answer 15

Short-lasting unilateral neuralgiform
headache attacks with cranial autonomic symptoms)

SUNA - Attacks last 7 days to 1 year, separated by pain-free
periods lasting at least 1 month

Question 16

Cluster headaches

Answer 16

1-8 attacks per day
 attacks occur in series lasting for weeks or months
 separated by remission periods usually lasting months or years
 maximal orbitally, supraorbitally, temporally
 sense of restlessness or agitation
 excruciating boring pain, unable to lie down, pace the floor
 all ages described – 3 years to 90 years
 men > women 20-40s
 men peak 30s
 women peak 20s or 60s

Difference from migraine 
no prodrome, no aura
 headaches last 15 minutes to hours
 awaken patient in middle of night
 recurs few times per year
 periodic - same time of day, same time of year
 worse with smoking, alcohol
 55% contemplated suicide, 2% attempted
 5-18x higher risk in 1st degree relatives vs general
population

Question 17

Continua hemicrania

Answer 17

Continua – non-stop > 3 months; incessant, sometimes severe, side-locked headache that will only respond to indomethacin

Question 18

New Daily Persistent Headache

Answer 18

Acute onset, chronic headache
 Daily, unremitting
 Bilateral , tightening (non-pulsating)
 May be photophobia, phonophobia, mild nausea
 Headache > 3 months
 Mild-moderate intensity
 Not aggravated by normal activity
 Distinguish from chronic tension-type headache
 Chronic from onset
 Often in patients without prior HA history
 Slightly more common in women
 Preceding trigger in half – stress, illness, medication, surgery

Question 19

Primary Stabbing headache

aka Icepick headache

Answer 19

AKA Ice-pick headache, “jabs and jolts”
 Single stab or series of stabs
 Usually V1 region
 lasts 1-10 seconds, recurs irregularly
 1-many per day
 *No autonomic features
 Can move
 Not always unilateral
 Associated with migraine or cluster
 Indomethacin

Question 20

Thunderclap Headache

Answer 20

sudden onset, severe
 1 hour – 10 days
 may recur within the first week
 young women with history of migraine
 **imaging to rule out subarachnoid hemorrhage and
reversible cerebrovasoconstriction syndrome (RCVS) in
anterior circulation