Headache - Freitag Flashcards
What are some red flags of headaches that indicate further workup is necessary?
- 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
Among pts who have migraine and a normal neuro exam, what percentage have significant intracranial pathology (i.e. the headache is secondary?)
Very little - 0.18%
Vast majority of headaches are primary and not secondary to intracranial pathology
What are the differences between primary and secondary headache?
- 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
What are the three major types of primary headache?
- Migraine
- Cluster
- Tension
What are some causes of secondary headache?
- 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)
Which intracranial structures are sensitive to pain?
- Meningeal arteries
- Proximal cerebral arteries
- Dura at the base of the brain
- Venous sinuses
- CNs 5, 7, 9, 10
- Cervical nerves 1, 2, 3
When are CT or MRI indicated for recurrent headache?
- Not warranted except when:
- Recent change in headache pattern
- New onset seizures
- Focal neurologic signs/symptoms
Just how common are migraines?
- 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
What percentage of migraine sufferers have not been diagnosed?
~50%
The majority of women with migraines associate their attacks with what?
Their menstrual cycle
What age is most common for the initial onset of migraines?
adolescence to early 20s, though it can range from childhood to 40+
How long to migraines typically last?
At least 4 hours, but usually 24-72 hours
What major feature distinguishes migraines from other headache disorders?
- The presence of concomitant GI and neuro symptoms
- anorexia
- nausea & vomiting
- diarrhea
- photophobia
- phonophobia
- blurred vision
- paresthesias
- aura symptoms
How common is migraine with aura?
What makes up this “aura”?
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)
Even migraine sufferers who do not experience aura sometimes report symptoms preceeding their migraines. What are these symptoms?
- 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
What is a tension headahce?
How does it differ from a migraine?
- 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
Differentiate the episodic and chronic forms of tension headaches.
- 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
Are tension headaches more common in women or men?
When does onset typically occur?
Women > Men
20-40 years old
What are cluster headaches?
Describe the timing, pain, and localization.
- 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
Are cluster headaches more common in men or women?
What is the typical initial age of onset?
Men > Women (unlike migraines & tension-type)
late 20s to early 30s
Describe how a patient with a migraine often acts in contrast to a patient with a cluster headache.
- Migraine
- Prefer to retreat to a dark, quiet, recumbent position
- Cluster
- Will pace the floor, or hold their head and rock violently
Are cluster headaches associated with concomitant symptoms aside from the pain?
- Yes. They are like migraine and unlike tension-type in this way
- However, the specific symptoms differ from those in migraine
What symptoms are noted with cluster headaches other than pain?
- 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
Interestingly, what times of year do cluster headache cycles commonly begin?
In proximity to the summer and winter solstices
How do the symptoms of **chronic migraine **differ from those of episodic migraine?
- 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
What are some risk factors for chronic migraines?
- socioeconomic status
- overuse of acut medication
- coexisting disorders (obesity & depression)
What three symptoms are the best predictors of a diagnosis of migraine?
- Nausea
- Disability
- Photophobia
What symptom, aside from head pain, is most predictive of a diagnosis of tension headache?
Neck Pain
Can be uni- or bilateral
Can also be described as tightness or stiffness
What are some factors that have been proposed as contributing to migraine pathogenesis?
- 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?
- Cortical neuronal excitability
- 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.]
What is cortical spreading depression?
- Proposed as an initiating mechanism of headache
- What is seen:
- Wave of intense cortical neuron activity
- Increased rCBF (regional cerebral blood flow)
- Activation of the trigeminovascular system may trigger this?
- Followed by a wave of neuronal supression
- Decreased rCBF
- Often coincides with headache onset
- Travels at 2-3mm/min
- Wave of intense cortical neuron activity
