Headache Syndromes Flashcards
Primary Headaches defined
● No obvious underlying cause
● Chronic, recurrent and usually no other signs
or symptoms of neurologic disease.
● Can have Familial relationship
Examples include- Migraines, Cluster
Headache, Tension type Headache, etc.
Secondary Headaches defined
● Headache associated with an underlying
cause.
● Headaches that warrant more extensive
work-up
● Neurologic symptoms
● Abnormal Mental status
● Red Flags (More Later)
● Fever
Examples of secondary headaches
- Intracranial lesions, Head
injury, Dental, Ocular disease, Tumors, Infection, Meningitis, Subarachnoid Hemorrhage, Temporal Arteritis, Sinusitis, Carbon Monoxide Poisoning, Alcohol, Hypoxia, Post- Lumbar puncture, TMJ,
Physical Exam for headaches
● Perform and then document a Comprehensive Neurologic Exam
● Fundoscopic exam- Papilledema can be seen with increase in intracranial pressure.
● Intraocular pressure measured with Tonometry- Acute angle closure glaucoma
● Palpate the Temporal Artery- Temporal Arteritis
Diagnostic Studies for headaches
● CT
● MRI
● Labs - CBC, CMP, ESR, CRP
● Lumbar Puncture
○ CSF pressure and Analysis
○ Presence of Blood in CSF
Necessary only when the headache pattern has changed recently, the headache
cannot be clearly defined by the clinician as a common primary headache disorder, or neurologic examination reveals abnormal findings”
Types of Headaches - Benign
1) Tension Headache
2) Cluster Headache
3) Migraine Headache
4) Analgesic Rebound Headache
Types of Headaches - High Risk
1) Subarachnoid Hemorrhage
2) Space-Occupying Lesion
3) Temporal Arteritis
4) CNS Infection
Tension Headache
● Most common type of Primary Headache. Range from 30-78% of population
● Etiology is not completely clear, multifactorial, several theories exist.
● Band-like or Viselike, tightness
● More common in Adults, while onset of migraines is usually in younger patients
● High correlation with Depression and Anxiety
● Diagnostic overlap with migraines, similar to migraine without aura
● Worsened with stress, fatigue, noise, glare
Tension Headache
Diagnosis
Band-like / Vise-like tightness, bilateral, with predominantly frontal or occipital location. Can be
generalized, and not usually characterized by worsening with activity.
Tension Headache
Treatment
● Similar to migraines, often clinicians lump together unless obvious, distinguishing the two can be difficult.
● NSAID, Tylenol
● Dose of Toradol 30-60 mg IM works well in primary care setting
● Amitriptyline prophylactically
● Dihydroergotamine (Problematic) - Pregnancy Cat X, contraindicated in CVD, PVD, HTN, and Macrolides
● Avoid opioids
● Treat comorbid depression or anxiety
● Triptans and Ergotamine not indicated- Why do you think that is?
● Massage, Acupuncture, Improved sleep
● If a person came to ED, we often used a Headache Cocktail
Cluster Headache
● Affects predominantly males ages 20-50 yo
● Severe unilateral headache with a patterned timing and/or clusters
● Pathophysiology mechanism is unknown. Thought to be derived from cell
activation of the ipsilateral hypothalamus, which controls circadian rhythms,
which in turn causes triggering the trigeminal autonomic system.
● Can be triggered by alcohol (surprisingly during attacks, but not during periods
of remission) , histamine, nitroglycerin
Cluster Headache presentation
● Pain is severe unilateral orbital localization- deep around the eye. Can radiate to temple forehead
and cheek.
● Occurs often during sleep (Can occur during the day), “Alarm Clock Headache” -recurrence daily (15
mins - 3 hrs) at similar times (often 1-2 hrs after sleep onset) lasting for days or weeks. Followed
by resolution of symptoms for months or even years.
● Patient often may arises from bed, agitated, paces, and hold hand to side of the head.
Things that differentiate tension headaches from migraines:
+/- photophobia, +/- phonophobia, and without
lateralization of migraines, and typically absent
nausea, vomiting.
Autonomic symptoms during a cluster headache attack
● Ptosis, Miosis - can persist after long standing chronic attacks
● Conjunctival Injection, Lacrimation
● Nasal congestion, Rhinorrhea
Cluster Headache
Treatment for acute attack
● 100% Oxygen
● Verapamil
● Ergotamine - anticipatory dose when attack is expected
● Intranasal Lidocaine- effect on the sphenopalatine ganglion, Implantable nerve stimulator- experimental
● Vagus nerve stimulation
● Intranasal Triptan
Cluster Headache
Treatment - prophylactic
● Verapamil
● Prednisone taper
● Lithium - worry about toxicity
● In intractable cases stimulation of the hypothalamus, and trigeminal nerve ablation has been tried
Migraine Headache
● Very common condition, begins typically in adolescence, or childhood and can
improve in advanced years. Can be triggered by stress, certain foods, alcohol,
beverages, noise, menstrual cycle
● Intense, typically unilateral recurrent headache
Pathophysiology of Migraine headaches
● Pathophysiology not totally clear. Considered to have strong genetic relationship
to autosomal dominance has been seen. Thought in the past thought to be
related solely to distention of the intracranial arteries. This idea has diminished
over time with newer neuroimaging technology
● Currently the relationship to dysfunction of the trigeminal system causing release
of neuropeptides such as calcitonin gene-related peptide (CGRP), which leads to
an inflammatory cascade. Leads to neurogenic inflammation into vessel walls
● Role of serotonin (5-HT) as a mediator of migraine propagation, hence use of
serotonin agonist eg. sumatriptan (Imitrex) reducing neurogenic inflammation
Two main Categories of migraine headaches
● Migraine with Aura - Traditionally referred to as “Classic Migraine”
● Migraine without Aura - “Common Migraine” appropriately named, as it is more common. 5:1
Phases of a migraine headache
● Prodrome- 60% of people will report pre-symptoms- Light, Sound sensitivity, Fatigue, Food cravings, Mood changes, Excessive thirst, Anorexia, etc.
● Aura- For those who get it. Usually visual disturbance, but can be sensory (numbness to face hands, etc.) or motor (Sense of heaviness in the limbs, Speech Disturbance). Associated with scintillating scotoma (enlarging blind spot with shimmering edge.)
● Migraine Phase- The actual headache
● Postdromal Phase- Up to 24 hours of feeling tired, or euphoric, weakness, food cravings, anorexia
Migraine Headache
Diagnosis
● Headache, usually pulsatile, typically lateralized throbbing
● Recurrent- To diagnose, must have repeated attacks, lasting 4-72 hrs, not attributable to secondary cause
● Characteristic nausea, vomiting, photophobia, phonophobia
● Patient often will want to lay still, in a darkened room
● Can be preceded by an Aura ( often described as a visual disturbance).
● Headache can build gradually and last for hours
● Important to note, that migraines for some can be somewhat individualized and predictable.
Migraine Headache
Abortive Treatments
● The earlier the better, prodrome phase
● Various categories eg. Triptans, NSAIDs, Ergots, CGRP, 5HT1F agonists
● Headache Cocktail- various combinations of meds, that can be given to treat migraines,
varies w/ facility- Hospital based vs Outpatient setting
● Darken the room, limit noise
● Acupuncture - Some consider as nearly effective as medication use.
● May take some trial and error to find what works best
Headache Cocktail
○ IV Normal Saline 1 liter
○ Diphenhydramine (Benadryl) 25 mg IV
○ Metoclopramide (Reglan) 10 mg IV, or you can substitute
■ Phenergan 25 mg IV or Zofran 4-8 mg IV
○ Ketorolac (Toradol) 30 mg IV
○ +/- Magnesium 2 mg IV
○ Oxygen
