Headache + CSF

Question 1

What is the pathophysiology behind symptoms of rhinorrrhea, lacrimation, sinus pressure, nasal congestion and conjunctival injection with migraine?

Answer 1

cross-activation of parasympathetics via stimulation of superior salivatory nucleus (SSN) of facial nerve (CNVII)

Question 2

What comprise the diagnostic criteria of Migraine Headache?

Answer 2

Any two of those four features:

1. at least five headaches, each lasting 4 to 72 hours (unsuccessfully or not treated). It should be noted that in children and adolescents (aged <18 years), attacks may last 2 to 72 hours.
2. Headache characterization includes unilateral location, throbbing/pulsating quality, moderate to severe intensity, 3. Aggravation by routine physical activity

Patients must have one or both:

1. nausea and/or vomiting
2. photophobia and phonophobia

Question 3

What comprise the diagnostic criteria of Tension Type Headache?

Answer 3

At least TWO of the 4 features

1. 10 headaches, each lasting between 30 minutes and 7 days.
2. Headache characteristics include bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate pain intensity
3. it should not be aggravated by routine physical activity
4. Neither nausea nor vomiting present. One of either photophobia or phonophobia

Question 4

What is the pathophysiology of migraine?

Answer 4

Activation of hypersensitive “central generator” (it is debated whether the initiating trigger for migraine occurs in the cortex or in the brainstem, or both). →
Disrupted ion homeostasis, release of neurochemicals, and transient neuronal dysfunction (cortical spreading depression). →
Meningeal blood vessel dilation and activation of trigeminovascular system. →
Release of vasoactive neuropeptides (calcitonin gene-related peptide (CGRP), neurokinins, prostaglandins, substance P, etc.) from activated trigeminal sensory nerves leads to sterile neurogenic inflammation. →
Worsening vasodilation, increasing firing of trigeminal afferents and further release of vasoactive neuropeptides causing pain intensification (the vasodilation itself is no longer felt to be the source of pain). →
Trigeminal nociceptive afferents carry pain signals to trigeminal nucleus caudalis (TNC) for processing and ascent through thalamus to cortex. → Continuous ascending pain signals activate more neurons, leading to associated symptoms such as photophobia, phonophobia, nausea, and vomiting. → Continuous TNC firing leads to central sensitization (allodynia) if activated pathways are not stopped (triptans have minimal to no effect at this stage; thus, the importance of early triptan administration).

Question 5

What are the red flag signs of headache?

Answer 5

• Systemic symptoms (fever, chills, and weight loss) or secondary headache risk factors (HIV and cancer)
• Neurologic symptoms or signs (confusion, impaired consciousness, and focal findings)
• Older: New-onset or progressive headache, especially >50 years of age (temporal arteritis)
• Onset: Sudden, abrupt (thunderclap)
• Progression of headache (change in frequency, severity, or clinical features)