Headache - Freitag

Question 1

What are some red flags of headaches that indicate further workup is necessary?

Answer 1

• First or worst
• Abrupt onset
• Fundamental change in pattern
• Cancer, HIV, pregnancy
• Abnormal physical exam
• Neuro sxs >1hr
• headache onset with seizure, syncope, exertion, sex, or valsalva

Question 2

Among pts who have migraine and a normal neuro exam, what percentage have significant intracranial pathology (i.e. the headache is secondary?)

Answer 2

Very little - 0.18%

Vast majority of headaches are primary and not secondary to intracranial pathology

Question 3

What are the differences between primary and secondary headache?

Answer 3

• Primary
  
  • Idiopathic
  • No underlying pathology
  • No diagnostic tests
  • Defined clinically after pathology is ruled out
• Secondary
  
  • Headache is a symptom of underlying pathology
  • Diagnostic tests available
  • Diagnosis based on underlying pathology

Question 4

What are the three major types of primary headache?

Answer 4

• Migraine
• Cluster
• Tension

Question 5

What are some causes of secondary headache?

Answer 5

• Trauma (e.g. traumatic brain injury)
• Vascular (e.g. subarachnoid hemorrhage)
• Infection (e.g. sinusitis)
• Metabolic (e.g. CO poisoning)
• Oncologic
• Inflammatory (e.g. giant cell arteritis)

Question 6

Which intracranial structures are sensitive to pain?

Answer 6

• Meningeal arteries
• Proximal cerebral arteries
• Dura at the base of the brain
• Venous sinuses
• CNs 5, 7, 9, 10
• Cervical nerves 1, 2, 3

Question 7

When are CT or MRI indicated for recurrent headache?

Answer 7

• Not warranted except when:
  
  • Recent change in headache pattern
  • New onset seizures
  • Focal neurologic signs/symptoms

Question 8

Just how common are migraines?

Answer 8

• 75% of headaches seen in primary care.
• 33% of pts in PCP waiting room have migraine!
• 1 in 5 women has migraines
• 1 in 4 households has a migraine sufferer

Question 9

What percentage of migraine sufferers have not been diagnosed?

Answer 9

~50%

Question 10

The majority of women with migraines associate their attacks with what?

Answer 10

Their menstrual cycle

Question 11

What age is most common for the initial onset of migraines?

Answer 11

adolescence to early 20s, though it can range from childhood to 40+

Question 12

How long to migraines typically last?

Answer 12

At least 4 hours, but usually 24-72 hours

Question 13

What major feature distinguishes migraines from other headache disorders?

Answer 13

• The presence of concomitant GI and neuro symptoms
  
  • anorexia
  • nausea & vomiting
  • diarrhea
  • photophobia
  • phonophobia
  • blurred vision
  • paresthesias
  • aura symptoms

Question 14

How common is migraine with aura?

What makes up this “aura”?

Answer 14

10-25% of migraine sufferers report aura

• Distinct neurological warning signs that preceed the headache by 5-60min
  
  • Scotoma (area within the visual field of diminished or absent visual acuity)
  • Photopsia (perception of bright flashes of light)
  • Fortification spectra (scintillating scotoma)
  • Altered perception of size, shape, and color
  • More rare: visual and olfactory hallucinations (seeing distorted figures and smelling noexistent odors)

Question 15

Even migraine sufferers who do not experience aura sometimes report symptoms preceeding their migraines. What are these symptoms?

Answer 15

• Vague disturbances of body function up to several days beforehand
  
  • fatigue
  • restlessness
  • unusual hunger
  • difficulty concentrating
  • lightheadedness
• Despite not being as clear or acute as aura, can still be helpful in managing the headache as a warning sign to patients

Question 16

What is a tension headahce?

How does it differ from a migraine?

Answer 16

• More generalized, constant, and chronic pain than migraine
  
  • Often involves the entire head, but can occasionally be localized
• Persists for widely variable periods of time
• Absence of other symptoms (GI, neuro) that can be seen with migraine

Question 17

Differentiate the episodic and chronic forms of tension headaches.

Answer 17

• Episodic:
  
  • Your run-of-the-mill headache. Nearly everyone gets these now and then.
  • Removal of stressful events or simple analgesics suffice for treatment
• Chronic:
  
  • May persist for years
  • May be refractive to analgesics
  • Two forms: 1) with or 2) without tenderness of pericranial / cervical muscles

Question 18

Are tension headaches more common in women or men?

When does onset typically occur?

Answer 18

Women > Men

20-40 years old

Question 19

What are cluster headaches?

Describe the timing, pain, and localization.

Answer 19

• Severe headaches which occur in cycles
  
  • Excrutiating, deep, boring pain
• Attacks last 15min-2hrs. Attacks can occur 1-6x/day during cycles
• Located in the temple or behind the eye
• Always unilateral
  
  • Multiple headaches within the same cycle are all ipsilateral
• ​During a cycle, can wake up a patient after they go to bed

Question 20

Are cluster headaches more common in men or women?

What is the typical initial age of onset?

Answer 20

Men > Women (unlike migraines & tension-type)

late 20s to early 30s

Question 21

Describe how a patient with a migraine often acts in contrast to a patient with a cluster headache.

Answer 21

• Migraine
  
  • Prefer to retreat to a dark, quiet, recumbent position
• Cluster
  
  • Will pace the floor, or hold their head and rock violently

Question 22

Are cluster headaches associated with concomitant symptoms aside from the pain?

Answer 22

• Yes. They are like migraine and unlike tension-type in this way
• However, the specific symptoms differ from those in migraine

Question 23

What symptoms are noted with cluster headaches other than pain?

Answer 23

• Ipsilateral:
  
  • nasal congestion
  • rhinorrhea
  • redness and tearing of the eye
  • partial Horner’s syndrome (myotic pupil, ptosis)
• Unlike migraines, do not present with GI symptoms

Question 24

Interestingly, what times of year do cluster headache cycles commonly begin?

Answer 24

In proximity to the summer and winter solstices

Question 25

How do the symptoms of **chronic migraine **differ from those of episodic migraine?

Answer 25

• Headache frequency increases and approaches a daily occurrence
• Severity of the associated symptoms diminishes for the most part
  
  • May be completely absent much of the time

Question 26

What are some risk factors for chronic migraines?

Answer 26

• socioeconomic status
• overuse of acut medication
• coexisting disorders (obesity & depression)

Question 27

What three symptoms are the best predictors of a diagnosis of migraine?

Answer 27

• Nausea
• Disability
• Photophobia

Question 28

What symptom, aside from head pain, is most predictive of a diagnosis of tension headache?

Answer 28

Neck Pain

Can be uni- or bilateral

Can also be described as tightness or stiffness

Question 29

What are some factors that have been proposed as contributing to migraine pathogenesis?

Answer 29

• Genetic predisposition
  
  • Cortical neuronal excitability
    
    • Enhanced release of excitatory neurotransmitters
    • Reduced intracortical inhibiton
    • Low brain Mg²⁺
    • Altered brain energy metabolism
  • Abnormal brainstem function
    
    • periaquaductal grey (PAG) involved?
• Neurogenic inflammation
• Activation and peripheral sensitization of the trigeminovascular system (TGVS)
  
  • The fibers of CN V that innervate cerebral blood vessels

[This was a clusterf*ck of information. I don’t know if I’d consider all of it high yield.]

Question 30

What is cortical spreading depression?

Answer 30

• Proposed as an initiating mechanism of headache
• What is seen:
  
  1. Wave of intense cortical neuron activity
     
     • Increased rCBF (regional cerebral blood flow)
     • Activation of the trigeminovascular system may trigger this?
  2. Followed by a wave of neuronal supression
     
     • Decreased rCBF
     • Often coincides with headache onset
  • Travels at 2-3mm/min