Headache disorder Flashcards
Background
- 65-85% of the population has >1 headache annually
- 5-7% of the population seeks medical attention for headache
- Headache is the reason for 2% of doctor’s visits and 3% of ER visits
- 15% of women, 6% of men and 4% of children have migraine
- Annual lost productivity attributed to migraine is $5.5-17 billion
Headache Anatomy: Cranial pain producing structures: structures which are sensitive to pain
a. Pain is a normal response from a healthy nervous system
b. Cranial structures which are pain sensitive
i. Scalp
ii. Sinuses (periosteum)
iii. Meninges
iv. Pial arteries
v. Arteries and major veins
Headache Anatomy: Cranial pain producing structures: structures which are not sensitive to pain
. Cranial structures which are not sensitive to pain
i. Ventricles
ii. Choroid
iii. Brain Parenchyma (exception is small part of the midbrain)
iv. Small parenchymal and dural veins
Headache Anatomy:Anatomic etiologies for pain
a. Vascular
i. Distension/Traction/Dilation of intracranial arteries or major veins
ii. Traction or displacement of a larger caliber vein
b. Nerve
i. Traction or compression of a nerve
c. Meninges
i. Traction, displacement, irritation, or inflammation of the dura
d. Muscles
i. Abnormal contraction, spasm, irritation or inflammation of cranial or
cervical musculature
e. Brainstem
i. Activation of a small area near the dorsal raphe nucleus (high
concentration of serotonin) in the midbrain has been proven to induce
migraine type pain
Migraine: Defined
Migraine is defined as a benign reoccurring primary headache disorder that has
associated symptoms which can include any of the following: photophobia,
phonophobia, nausea, vomiting, worsening with exertion, and/or neurologic
symptoms (including but not limited to vision change, focal weakness or
parasthesia, dizziness/vertigo).
i. Migraine is very common with 15% of women and 6% of men affected
Migraine: Pathophysiology
Migraines were once believed to be caused by constriction
and subsequent dilation of cerebral blood vessels-but this is now believed to not
be the case. The current thought is that migraines begin in the brainstem with
an abnormal instability or activation of certain cells which spread peripherally
and stimulate the trigeminal system (cranial nerve responsible for sensory to
the head and face). This eruption of abnormal activity in the brainstem may
affect other local systems including chemoreceptors (resulting in nausea and
vomiting) and the autonomic nervous system (resulting in pallor, flushing, and
congestion
Migraine without aura
- This is a typically unilateral headache which is often described
as a deep ache or throbbing sensation. Patients often complain
of associated symptoms of phonophobia, photophobia, and/or
nausea vomiting. Symptoms often worsened by exertion and
relieved by rest. - Symptoms will often last between 30 minutes and 6 hours, but
can last longer (as much as 72 hours)
Migraine with aura
Same as migraine without aura but is preceded by an aura up to
30 minutes before headache onset or occurring up to one hour
into the headache. Aura occurs in 60-70% of migraines.
a. Aura is perceptual disturbance experienced prior to
headache onset which can manifest as:
i. Visual disturbance- scintillating scotoma, zig-zag
lines, kaleidoscope, tunnel vision or even
monocular vision loss.
ii. Sensory disturbance - often focal parasthesia
described as pins-and-needles sensation
iii. Motor disturbance - often focal weakness or
even paralysis
iv. Auditory Disturbance- Modification of voices or
sounds in the environment: buzzing, amplitude
modulation. Could manifest as heightened
sensitivity to sound.
Complicated Migraine
Same as migraine with aura but the aura is quite dramatic and
can last for an extended period of time. These can often mimic
the appearance of stroke. Diagnosis is made by exclusion of
other more serious underlying pathology.
Basilar Migraine
- The migraines have associated brainstem and posterior cerebral
circulation symptoms including vertigo, dysathria, ataxia, and
diplopia. Headache onset follows in 20-30 minutes following
neurologic symptom onset as is described as an occipital
throbbing pain. - Bickerstaff’s Migraine is the most severe and dramatic form of a
basilar migraine. It begins with total blindness and is followed
by admixtures of vertigo, ataxia, dysarthria, and/or tinnitus.
Migraine Treatment: Non-Pharmacologic Approach
- Avoid triggers:
a. Red Wine, certain foods (chocolate, some cheeses,
MSG, heavy nitrite containing foods-i.e. highly
processed meats), hunger from missing meals, sleep
deprivation and irregular sleeping patterns, and stress
Migraine Treatment: Pharmacologic Abortive or Rescue Therapy
- Abortive or Rescue Therapy (to be taken with headache onset)
a. NSAIDS
i. Ibuprofen, Naprosyn, Ketorolac
b. 5HT1 agonists (Triptans and Ergots)available in oral,
inhaled and subcutaneous forms (examples below) - Sumatriptan (short onset and duration)
- Zolmitriptan (intermediate onset and
duration) - Frovatriptan (long onset and duration)
ii. Contraindicated in those with history of CAD or
ischemic stroke
c. Dopamine antagonists available in oral and
subcutaneous forms - Metoclopramide (Reglan)
- Prochlorperazine (Compazine)
d. Combinations - Acetaminophen, ASA, and caffeine
(Excedrin Migraine) - Acetaminophen, butalbital, and caffeine
(Fioricet) - Acetaminophen, Isometheptene and
Dichloralphenazone (Midrin)
Migraine Treatment: Pharmacologic: Prophylactic Therapies
Daily medications should be used to prevent migraines when they are severe enough to cause functional impairment and are occurring at least three times per month. None of the drugs is particularly more effective than another. Drug choice is often based on comorbidities (i.e. depression and other psychiatric disease) and/or hypertension) a. β-Adrenergic Blockers 1. Propranolol 2. Atenolol ii. Calcium Channel Blockers 1. Verapamil iii. Tricyclic Antidepressants 1. Amitriptyline 2. Nortriptyline iv. Anticonvulsants (AED’s) 1. Gabapentin (Neurontin) 2. Valproic Acid (Depakote) 3. Topiramate (Topamax) 4. Levetiracetam (Keppra)-not FDA approved) v. Serotonergic Drugs 1. Cyproheptadine (Periactin)
Cluster Headaches
a. Cluster headaches are one of the most painful headache conditions. They are
defined as an episodic headache condition characterized by 1-3 short duration
(15 minutes to 3 hours in length) attacks of severe unilateral stabbing periorbital
or temporal pain. They tend to occur in clusters for approximately 3-6 weeks.
They are typically associated with at least one of the following associated
symptoms: conjunctival injection/lacrimation, miosis, ptosis, eyelid edema,
rhinorrhea/nasal congestion and/or perspiration. They have a remarkable
circadian rhythm as reflected by the tendency to occur at the exact same time
every day during a cluster period. The attack frequency can be from one every
other day up to eight times per day
Cluster Headaches: Pathophysiology
Cluster headaches are believed to be derived in part by the
hypothalamus, especially so in those with prominent autonomic symptoms.
There is then a secondary activation of the trigeminal-autonomic reflex,
probably via a trigeminal-hypothalamic pathway.
