Headaches

Question 1

what are the major 3 types of primary headaches?

Answer 1

1. migraine
2. tension headache
3. trigeminal autonomic cephalalgias

entirely diagnosed by history

Question 2

what are the clinically features of migraines? (7)

Answer 2

1. unilateral but not side-locked (could occur on either side)
2. pounding/throbbing
3. photophobia, phonophobia, osmophobia
4. nausea w/wo vomiting
5. typically 4-24 hours
6. classic migraines preceded by auras lasting 15-30mins (scotomata = flashing lights)
7. worsened by activity

Question 3

acephalgic migraine

Answer 3

independent aura without a migraine following

scotomata (flashing lights), sometimes somatosensory

Question 4

classic vs common migraine

Answer 4

classic = preceded by aura

common = NOT preceded by aura (more common)

Question 5

what are migraines caused by?

Answer 5

electrochemical processes triggering the trigeminal system

“neurovascular theory”: neuronal hyperexcitability causes release of CGRP (calcitonin gene-related peptide), a potent vasodilator

CGRP —> MMP (matrix metalloproteinase) —> inflammatory mediators (serotonin, bradykinin, substance P, neurokinin P/Y, prostaglandins) —> pain

Question 6

what are 3 dietary supplements that may be beneficial for patients with frequent migraines?

Answer 6

1. vitamin B2
2. magnesium
3. coenzyme Q10

Question 7

what defines status migrainosus

Answer 7

migraine lasting >72 hours

initial options: ketorolac, metoclopramide, IV fluids
secondary options: sumatriptan, DHE, methylprednisolone, valproic acid, MgSO4

Question 8

what are transformed migraines

Answer 8

migraines that transform into chronic daily headache

Question 9

what is the most common type of headache, and how do they present? (4)

Answer 9

tension headache

1. typically bilateral
2. pressing/tightening in band-like squeezing sensation
3. lasting 30 mins to days
4. pericranial tenderness to palpation

Question 10

how do trigeminal autonomic cephalalgias present?

Answer 10

type of primary headache which trigger pronounced autonomic features - dilated/constricted pupils, ptosis, lacrimation, facial sweating (Horner’s syndrome - occurs ipsilateral to headache)

Question 11

SUNCT vs SUNA

Answer 11

SUNCT = short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing

SUNA = short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms

both moderate/severe unilateral head pains lasting for short durations and occurring as single stabs in series or sawtooth pattern

Question 12

how do cluster headaches present?

Answer 12

1-8 attacks per day, occurring in series lasting for weeks of months, separated by remission periods (months or years)

excruciating drilling pain supraorbitally/temporally, restlessness

last 15mins-hours (usually shorter), classically awake patients in the middle of the night, higher risk in 1st degree relatives

may be treated acutely with high-flow O2, prevented with verapamil

Question 13

what does fMRI show in patients with cluster headaches?

Answer 13

activation of ipsilateral posterior hypothalamic grey matter —> triggers activation of trigeminal nerve/ release of inflammatory mediators

Question 14

what is the inherited form of cluster headaches?

Answer 14

autosomal dominant mutation in hypocretin receptor 2 gene (HCRTR2)

Question 15

hemicrania continua

Answer 15

non-stop headache >3 months, sometimes with severe side-locked headache that will only respond to indomethacin

Question 16

paroxysmal hemicrania

Answer 16

severe, strictly unilateral head pain which is orbital, supraorbital, or temporal lasting 2-30 mins and occurring several/many times a day

Question 17

rank/differentiate cluster, paroxysmal hemicrania, and SUNCT headaches by the following features:
a. daily attack frequency
b. duration of attack
c. pain quality
d. pain intensity

Answer 17

a. cluster (1-8) < paroxysmal hemicrania (1-40) «< SUNCT (3-200)

b. SUNCT (5-250s) «< paroxysmal hemicrania (2-30mins) < cluster (15-180mins)

c. cluster = sharp/throb, paroxysmal hemicrania = sharp/throb, SUNCT = stab/burn

d. all very severe

Question 18

which of the following types of primary headaches is most likely to present bilaterally?
a. cluster
b. migraine
c. paroxysmal hemicrania
d. SUNCT
e. tension

Answer 18

e. tension: gradual, constant, bilateral, dull, aching, squeezing

Question 19

patients with which of the following types of primary headaches often can be treated with indomethacin?
a. cluster
b. migraine
c. paroxysmal hemicrania
d. SUNCT
e. tension

Answer 19

c. paroxysmal hemicrania

indomethacin = NSAID

Question 20

patients with which of the following types of primary headaches are very restless and may be treated with high-flow O2?
a. cluster
b. migraine
c. paroxysmal hemicrania
d. SUNCT
e. tension

Answer 20

a. cluster - extremely intense pain

Question 21

what is the most effective intervention for headaches caused by idiopathic intracranial HTN?

Answer 21

aka pseudotumor cerebri

losing weight to help decrease the elevated intracranial pressure

Question 22

how do headaches associated with Chiari I malformations present?

Answer 22

Chiari I = downward displacement of cerebellar tonsils into upper cervical canal —> compression of nearby structures:

—> occipital/upper cervical headache with Valsalva maneuvers (bending over, laughing, coughing, sneezing - increase intracranial pressure)
—> neck/shoulder pain
—> down-beating nystagmus, other visual symptoms
—> ataxia (cerebellar)
—> diminished gag reflex
—> tinnitus, vertigo, fluctuating hearing loss

Question 23

how does temporal arteritis present, and what is a serious possible consequence?

Answer 23

inflammatory arteritis of temporal artery, presents in older patients with headache + jaw claudication (pain with chewing), loss of temporal artery pulse (artery is thick and rigid)

may cause irreversible monocular visual loss