Headache Flashcards
What are the three major primary headache disorders?
- Represent 80-90% of headaches
- entirely diagnosed by history
Migraine, tension-type headache, and trigeminal autonomic cephalalgias
Has the feature of being unilateral, but not side-locked with a pounding or throbbing quality
Migraine
Three phobia features of migraines are
Photophobia, phonophobia, and osmophobia
Migraines can have nausea with or without vomiting and typically last
4-24 hours
Begins 5-30 minutes before migraine and typically lasts 15-30 minutes
Aura (classic presentation)
Characterized by flashing lights/bars (scotomata) and is sometimes somatosensory
Aura
Worsened by activity and patients prefer to sleep off the headaches in a dark, quiet room
Migraine
Very common when there is familial history and patients with a history of motion sickness
Migraines
What is a comorbidity of migraines?
Anxiety and depression
Migraines can occur at any age, but prevalence increases steeply at ages
10-14 until 35-39
Migraines are 2-3 times more common in
Women
Incidence declines greatly in women following menopause
Migraines
Mediates pain from cerebrovasculatureand craniofacial region
Trigeminal ganglion
Symptoms of a migraine suggest origin in the
Brainstem, hypothalamus, cortex, or limbic system
Cortical spreading depression
Neurobiology migraine aura
In a migraine, behind zone of activation is zone of depression (depolarization), which correlates with the onset of
Headache
Usually starts while flow is diminished
Headache
Isn’t severe enough to cause ischemia
Oligemia
What are the 4 abortive treatments of migraines?
NSAIDS, anti-emetics, Triptans/ergots, or combination
A major pharmacologic preventative medication for migraines is
CGRP inhibitors
Hunger, dehydration, and lack of sleep are known triggers of
Migraines
What are two forms of migraines of higher severity?
Status migrainosus and transformed migraines
Migraine lasting longer than 72 hours
Status migrainosus
Migraines that move into chronic daily headaches
Transformed migraines
Typically a bilateral pressing or tightening in quality and of mild to moderate intensity
-Most common headache type
Tension headaches
Lasts minutes to days and lacks migrainous features
Tension headache
You can see increased pericranial tenderness by manual palpation with a
Tension Headache
Affects 0.5-5% of the population and is slightly more prevalent in women than men
Tensions headaches
Tension headaches are more common in those with
Depression and generalized anxiety disorder
1/4 of patients with fibromyalgia had a prior diagnosis of chronic
Tension Headaches
Characterized as cluster headaches
Trigeminal Autonomic Cephalalgias
What are the two forms of trigeminal autonomic cephalalgias
SUNCT and SUNA
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing
SUNCT
Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms
SUNA
Has autonomic features ipsilateral to the headache
Trigeminal autonomic cephalalgias
1-8 attacks per day and attacks occur in series lasting for weeks or months
Cluster headaches
Separated by remission periods usually lasting months or years
-Maximal orbitally, supraorbitally, and temporally
Cluster headaches
With cluster headaches, patients have a sense of
Restlessness or agitation
Cluster headaches are more common in
Men (302) than women (20s or 60s)
Cluster headaches are different than a migraine because they have no
Prodrome or aura
Cluster headaches last
15 minutes to hours
Often awaken patients in the middle of the night and are periodic, occurring at the same time of day/same time of year
Cluster headaches
55% of patients with cluster headaches have contemplated
Suicide
With cluster headaches, we see activation in the
Ipsilateral posterior hypothalamic gray matter
Inherited cases of cluster headaches makes up about 5% of cases. The inheritance pattern is
Autosomal dominant
The autosomal dominant cluster headaches are due to mutations in the
Hypocretin receptor 2 gene (HCRTR2)
The headache often begins in sleep and is linked to sleep apnea with
Cluster headaches
Severe, strictly unilateral pain which is orbital, supraorbital, temporal, lasting 2–30 minutes and occurring several or many times a day
Paroxysmal Hemicrania
Non-stop > 3 months; incessant, sometimes severe, sidelocked headache that will only respond to indomethacin
Continua Hemicrania
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
SUNCT
Attacks last 7 days to 1 year, separated by pain-free periods lasting at least 1 month
SUNA
Should be used initially to treat hemicrania
Indomethacin
What is the daily dose of indomethacin used for hemicrania?
150 mg daily but can be increased to up to 225
Indicated for the following headaches: paroxysmal hemicrania, cough-induced, ice pick (stabbing), SUNCT
Indomethacin
What are the three main types of trigeminal autonomic caphalgias?
Cluster, Paroxysmal hemicrania, and SUNCT
Commonly called the “ice pick headache”
-Jabs and jolts
Primary stabbing headache
Headache attributed to external application of cold stimulus or ingestion/inhalation of a cold stimulus
Cold-Stimulus headache
It is important to focus on cranial nerve examination and fundoscopy (optic discs) for
Secondary headaches
Dull, deep, throbbing in center of head –forehead, nasal bridge, upper cheeks
-often starts after a bad cold
Sinus headache
Worse with bending down or leaning over and worse in cold and damp weather
Sinus headache
Pressure-like pain behind one specific part of face, postnasal drip and red and swollen nasal passages
Sinus headache
Taking abortive medications more than twice weekly in general can cause headaches occurring more than 15 days per month. This is called a
Medication overuse headache
Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
Medication overuse headache
What are some of the common causes of medication overuse headaches?
Opiods, caffeine, and Triptans
Elevated/high intracranial pressure with no structural CNS abnormality and no CSF outflow obstruction
Idiopathic intracranial hypertension (Pseudotumor Cerebri)
What are three common signs we would see in a patient with Idiopathic intracranial hypertension (Pseudotumor Cerebri)
Overweight, blurred vision with papilledema, and high opening pressure in lumbar puncture
Cranial nerve VI palsy is also a common symptom of
Idiopathic intracranial hypertension (Pseudotumor Cerebri)
“Spinal headache”, “Spinal leak” after lumbar puncture (LP)
-Only occurs upon sitting or standing
Low CSF pressure headache
A ruptured Tarlov cyst can cause a
Low CSF pressure headache
Downward displacement of cerebellar tonsils at least 3 mm into upper cervical canal
-Common syringomyelia (syrinx) (hydromyelia) cervical > cervicothoracic
Chiari I mlformation
What are two treatments for a Chiari I malformation?
Suboccipital craniectomy, C1 ring laminectomy
Has the clinical features of occipital or upper cervical headache with Valsalva [bending over, laughing, coughing and sneezing]
Chiari I malformation
Also characterized by down-beating nystagmus
Chiari I Malformation
Neuropathic pain in the distribution of a cranial nerve
-Sharp, brief, and lancinating
Cranial Neuralgias
Inflammatory arteritis of the temporal artery causing headache, monocular visual loss and jaw claudication
Temporal Arteritis
Temporal arteritis is characterized by
Increased Erythrocyte Sedimentation Rate (Greater than 100 mm/hr)
