Headaches

Question 1

Where are Pain sensitive structures within the cranial vault?

Answer 1

Venous sinuses (e.g sagittal sinus)
Anterior and middle meningeal arteries
Dura at the base of the skull
CN’s V, IX, and X
Proximal portions of the ICA and its branches near the circle of Willis
Brainstem periaqueductal gray matter and sensory nuclei of thalamus

Question 2

Where are Extracranial pain-sensitive structures?

Answer 2

Skull periosteum
Subcutaneous tissues, muscles, and arteries
Neck muscles
Second and third cervical nerves
Ears, eyes, teeth, sinuses, and oropharynx, nasal cavity

Question 3

How does cn v present in headaches?

Answer 3

V – sensation from intracranial structures in the anterior and middle cranial fossae (above tentorium). Lesions here can produce pain that radiates in the V nerve distribution. Especially the ophthalmic VI division.

Question 4

How does cn 9 and 10 present in headaches?

Answer 4

IX and X convey sensory information from part of the posterior fossa; pain originating in this area may also be referred to the ear or throat, as in glossopharyngeal neuralgia.

Question 5

How do the upper cervical (c2-c3)present in headaches?

Answer 5

The upper cervical (C2-C3) nerves transmit stimuli from infra-tentorial and cervical structures; therefore, pain from posterior fossa often projects to the second and third cervical dermatomes.

Question 6

What can Acute headache & Facial Pain indicate?

Answer 6

New onset headache or change in headache demand prompt evaluation.
Sudden onset “Worst headache I have ever experienced” – concern?
Associated with neck stiffness and fever – concern? Meningitis

Acute headaches may accompany more benign processes such as viral or other febrile illnesses.

Question 7

What can Subacute headache & Facial Pain indicate?

Answer 7

Headaches that persist or recur over weeks-months may also signify serious pathology. Esp + Progressive pain and older populations.
Trauma? Malaise? Fever? Neck stiffness? Neuro signs? Weight loss? Visual changes (giant cell arteritis), medications?

Question 8

What can Chronic Headache and Facial Pain indicate?

Answer 8

MC benign cause (e.g, migraine, TTH - tension type headaches)

Question 9

What are Signs that headache may be caused by >ICP, including hydrocephalus or tumour?

Answer 9

Headache present at wakening
Pain triggered by coughing, sneezing, or straining
Vomiting (may also indicate migraine)
Worse when lying down

Question 10

What Precipitating factors can provide a cause oh headaches?

Answer 10

Recent dental surgery
Sinusitis/allergy exacerbation
Viral infection
Emotional stress/tension
Food group consumption e.g nitrates, tyramine etc.
Alcohol (common cluster HA trigger)
Coughing/exertion

Question 11

What are some preceding factors of Migraines?

Answer 11

Aura

Question 12

Signs that headache is caused be serious intracranial disease including tumour, encephalitis, or meningitis?

Answer 12

Progressive worsening over days or weeks
Neck stiffness and vomiting (meningeal irritation)
Rash or fever
History of cancer or HIV

Question 13

Signs that headache may be caused by haemorrhage?

Answer 13

Headache following head injury
Abrupt onset

Question 14

What types of headaches are unilateral?

Answer 14

Common in Migraine and cluster headache as examples

Question 15

What types of headaches are bilateral?

Answer 15

Common to TTH

Question 16

What types of headaches are Ocular or retroorbital?

Answer 16

acute iritis, optic neuritis, but also common to migraine and cluster HA.

Question 17

What types of headaches cause Bandlike or occipital?

Answer 17

common with TTH. Occipital localisation can also occur with meningeal irritation and with Cx spine disorders.
Lancinating pain localised to V1 and V2 – trigeminal neuralgia

Question 18

What are associated headache symptoms?

Answer 18

Fever or chills – may indicate systemic infection or meningitis
Visual disturbances – suggest an ocular disorder, migraine, or intracranial lesion involving optic pathway.
Myalgias – often accompany tension headache, systemic viral infections, and GCA.
Ipsilateral rhinorrhoea and lacrimation – cluster headache
Recent weight loss – May accompany malignancy, GCA.
Nausea and vomiting – are common in migraine and post-traumatic headache. Can also be seen in intracranial mass lesions.
Photophobia – migraine possibly, meningitis, SAH

Question 19

What could Fever or chills indicate?

Answer 19

may indicate systemic infection or meningitis

Question 20

What could Visual disturbances indicate?

Answer 20

suggest an ocular disorder, migraine, or intracranial lesion involving optic pathway

Question 21

What could Myalgias indicate?

Answer 21

often accompany tension headache, systemic viral infections, and GCA.

Question 22

What could Ipsilateral rhinorrhoea and lacrimation indicate?

Answer 22

Cluster headache

Question 23

What could Recent weight loss indicate?

Answer 23

May accompany malignancy, GCA.

Question 24

What could Nausea and vomiting indicate?

Answer 24

are common in migraine and post-traumatic headache. Can also be seen in intracranial mass lesions.

Question 25

What could photophobia indicate?

Answer 25

migraine possibly, meningitis, SAH

Question 26

What are Relieving and exacerbating factors?

Answer 26

E.g darkness & sleep – migraine relief, leaning forward – sinus pain

Question 27

What do you check in a physical examination for headaches?

Answer 27

Temperature
Pulse
BP
Respiration
Observation
Neck ROM – include meningeal irritation tests
Cranial nerve examination
Sensory & motor examination

Question 28

What are primary headaches?

Answer 28

Migraine headache
Tension-Type Headache
Trigeminal autonomic cephalalgias including cluster headaches
Other primary headache disorders

Question 29

What are secondary headaches?

Answer 29

List is extensive, headache as a result of other underlying cause.
E.g. Cervicogenic headache

Question 30

What are tension type headaches?

Answer 30

Tension-type headache is very common, with a lifetime prevalence in the general population ranging between 30% and 78% in different studies, and it has a very high socio-economic impact.
Although this type of headache was previously considered to be primarily psychogenic, a number of studies strongly suggest a neurobiological basis, at least for the more severe subtypes of tension-type headache.
Episodic - infrequent (most of population)and frequent (Considerable disability and QoL)
Chronic (<QoL, disability)

The exact mechanisms of Tension-type headache are not known. Peripheral pain mechanisms are most likely to play a role in Infrequent episodic tension type headache and Frequent episodic tension-type headache, whereas central pain mechanisms play a more important role in chronic tension-type headache.
Increased pericranial tenderness recorded by manual palpation is the most significant abnormal finding in patients with tension-type headache. The tenderness is typically present between headaches, is further increased during actual headache and increases with the intensity and frequency of headaches. Pericranial tenderness is easily recorded by manual palpation by small rotating movements and a firm pressure on the frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius and trapezius muscles. Local tenderness scores of 0-3 for each muscle can be summed to yield a total tenderness score for each individual

Question 31

What are Infrequent episodic tension-type headaches?

Answer 31

with/without pericranial tenderness
Infrequent episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, but photophobia or phonophobia may be present.
Diagnostic criteria:
At least 10 episodes of headache occurring on <1day per month on average (<12 days per year) and fulfilling criteria B-D
Lasting from 30 minutes to 7 days
At least two of the following four characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following:
1. no nausea or vomiting 2. no more than one of photophobia or phonophobia
E. Not better accounted for by another ICHD-3 diagnosis.
With Pericranial tenderness (WPT)- meeting above criteria with pericranial tenderness

Question 32

What are Frequent episodic tension-type headache (With and without Pericranial tenderness)?

Answer 32

Description:Frequent episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, but photophobia or phonophobia may be present.
Diagnostic criteria:
A. At least 10 episodes of headache occurring on 1-14 days per month on average for >3 months(>12 and <180 days per year) and fulfilling criteria B-D
B. Lasting from 30 minutes to 7 days
C. At least two of the following four characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia
E. Not better accounted for by another ICHD-3 diagnosis
With Pericranial tenderness (WPT)- meeting above criteria with pericranial tenderness

Question 33

What are Chronic tension-type headaches?

Answer 33

A disorder evolving from frequent episodic tension-type headache, with daily or very frequent episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting hours to days, or unremitting. The pain does not worsen with routine physical activity, but may be associated with mild nausea, photophobia or phonophobia.
Diagnostic criteria:
A. Headache occurring on 15 days per month on average for >3 months (180 days per year), fulfilling criteria B-D
B. Lasting hours to days, or unremitting
C. At least two of the following four characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following:
1. no more than one of photophobia, phonophobia or mild nausea
2. neither moderate or severe nausea nor vomiting
E. Not better accounted for by another ICHD-3 diagnosis.
With Pericranial tenderness (WPT)- meeting above criteria with pericranial tenderness

Question 34

What is the diagnostic difficulty?

Answer 34

The diagnostic difficulty most often encountered among the primary headache disorders is to discriminate between tension-type headache and mild migraine without aura. This is more so because patients with frequent headaches often suffer from both disorders

Question 35

What is Migraine Without Aura (Common Migraine)?

Answer 35

Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.
Diagnostic criteria:
A. At least five attacks fulfilling criteria B–D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has at least two of the following four characteristics:
unilateral location
pulsating quality
moderate or severe pain intensity
aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
D. During headache at least one of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia
E. Not better accounted for by another ICHD-3 diagnosis.

Less than 5 attacks meeting the above criteria categorised as probable Migraine without Aura

Question 36

What is Migraine with Aura (Classic)?

Answer 36

Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms.
Diagnostic criteria:
A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms:
1. visual 2. sensory 3. speech and/or language 4. motor 5. brainstem 6. retinal
C. At least two of the following four characteristics:
At least one aura symptom spreads gradually over 5 minutes, and/or two or more symptoms occur in succession
Each individual aura symptom lasts 5-60 minutes1
At least one aura symptom is unilateral
The aura is accompanied, or followed within 60 minutes, by headache

The aura is the complex of neurological symptoms that occurs usually before the headache, but it may begin after the pain phase has commenced, or continue into the headache phase.
Visual aura most common type of aura > 90% of patients aura.
Next in frequency are sensory disturbances, in the form of pins and needles moving slowly from the point of origin and affecting a greater or smaller part of one side of the body, face and/or tongue.
Less frequent are speech disturbances, usually aphasic but often hard to categorize.
When the aura includes motor weakness, the disorder should be coded as Hemiplegic migraine or one of its subforms.

Premonitory symptoms may begin hours or a day or two before the other symptoms of a migraine attack (with or without aura). They include various combinations of fatigue, difficulty in concentrating, neck stiff- ness, sensitivity to light and/or sound, nausea, blurred vision, yawning and pallor.

In some cases migraine with aura may present without head pain. This increases diagnostic difficulty distinguishing from a more concerning neurovascular event.
Migraine with brainstem aura exists also.
1. Dysarthria 2. Vertigo 3. Tinnitus 4. Hypacusis 5. Diplopia 6. Ataxia 7. Decreased level of consciousness
When aura occurs for the first time after age 40, when symptoms are exclusively negative (e.g. Hemianopia) or when aura is prolonged or very short, other causes, particularly transient ischaemic attacks, should be ruled out.

Before or simultaneously with the onset of aura symptoms, regional cerebral blood flow is decreased in the cortex corresponding to the clinically affected area and often over a wider area. Blood flow reduction usually starts posteriorly and spreads anteriorly, and is usually above the ischaemic threshold. After 1 to several hours, gradual transition into hyperaemia occurs in the same region. Cortical spreading depression of Lea˜o is the likely underlying mechanism.

Question 37

What are the mechanisms of headaches?

Answer 37

Although the disease was previously regarded as primarily vascular, the importance of sensitization of pain pathways, and the possibility that attacks may originate in the central nervous system, have gained increasing attention over recent decades.
Cortical Spreading Depression (https://www.ncbi.nlm.nih.gov/pubmed/23196498)
Cortical spreading depression (CSD) is a slowly propagated wave of depolarization of neurons and glial cells, followed by a subsequent sustained suppression of spontaneous neuronal activity. Functional imaging studies of migraine patients have shown dramatic changes in blood flow and brain activity whose characteristics are similar to those of CSD, implicated in migraine visual aura. Although the trigeminal nerve innervates the meninges and participates in the genesis of migraine headaches, triggering mechanisms remain controversial and poorly understood. It is demonstrated by animal models that CSD activates trigeminovascular afferents and evokes a series of cortical meningeal and brainstem events consistent with the development of headache.
The messenger molecules nitric oxide (NO), 5-hydroxytryptamine (5-HT) and calcitonin gene-related peptide (CGRP) are involved.

Question 38

What are Trigeminal autonomic cephalalgias (TAC’s)?

Answer 38

The trigeminal autonomic cephalalgias (TACs) share the clinical features of headache, which is usually lateralized, and often prominent cranial parasympathetic autonomic features, which are again lateralized and ipsilateral to the headache.

Question 39

What are cluster headaches?

Answer 39

Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15–180 minutes and occurring from once every other day to eight times a day. The pain is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema, and/or with restlessness or agitation.
Diagnostic criteria:
A. At least five attacks fulfilling criteria B–D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated)
C. Either or both of the following:
1. at least one of the following symptoms or signs, ipsilateral to the headache:
a) Conjunctival injection and/or lacrimation
b) Nasal congestion and/or rhinorrhoea
c) Eyelid oedema
d) Forehead and facial sweating
e) Forehead and facial flushing
f) Sensation of fullness in the ear
g) Miosis and/or ptosis
2. a sense of restlessness or agitation
D. Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is active.
E. Not better accounted for by another ICHD-3 diagnosis.

Acute attacks involve activation in the region of the posterior hypothalamic grey matter.
Cluster headache may be autosomal dominant in about 5% of cases.
Some patients have been described who have both Cluster headache and Trigeminal neuralgia sometimes referred to as cluster-tic syndrome.