Headaches Flashcards
Primary vs. Secondary Headaches
Primary:
- Genetic disposition, with secondary influences
- Migraine
- Tension
- Chronic daily headache
Secondary: caused by something else
- CNS lesion
- systemic disorders
- structural disorders of the head and neck
Headache Red Flags
- Worsening headache: in frequency or severity
- Severe, acute headache: Subarachnoid hemorrhage
- Headache upon awakening, or wakes patient up in sleep: might be related to increased intracranial pressure
- Ataxia or dizziness
- Alteration of consciousness
- Focal neurological findings
- Associated stiff neck: Meningismus, bleed in the brain
- Double vision
- Persistent headache after head injury
- Headaches in the very young: kids under 6 yo
Genetic abnormality for Familial Hemiplegic Migraine
- Chromosome 19: abnormality of voltage gated calcium channel
Migraine
Must have at least one of the following:
- Nausea +/- vomiting
- Photophobia or sonophobia
2 of the following:
- Throbbing
- Hemicranial (affects only 1 side of the head)
- Increased with movement
- One to 72 hour, intermittent headache
- At least moderately severe
Migraine with Aura
Aura: neurologic symptom, (usually visual In migraine)
- Aura can proceed the headache or come on simultaneously
- Aura last few minutes up to one hour
- Positive aura: e.g., shiny shimmery light
- Negative aura: lose a whole visual field
- Can be sensory, e.g., Paresthesias: buzzing around mouth or arm
Migraine pathogenesis
- Name the important neuronal circuit
- Basic defect is neuronal hyperexcitability
- Important circuit:
Cortex – trigeminal nerve (NC) - vascular - There may be Serotonin (5-HT) or Calcium channel irregularities
- There may also be prolonged VASOCONSTRICTION or formation of local thrombi due to vessel narrowing
Tension headaches
- Absent most of the characteristics of migraine
- Intermittent headaches lasting one hour to 5 days
- May be on a continuum with migraine
- Dull squeezing, band-like headaches
- No other explanation for headaches
Chronic daily headache
- Clinical definition: At least 15 headache days per month, for at least 3 months
- Often transformed migraine; about 10% are newly onset
- Analgesic rebound: “medicine overuse headache”; commonly due to OTCs: aspirin, Tylenol, ibuprofen)
- Not rare in adolescents
- Look for drug and alcohol
- Rule out psychological factors
Hidden reasons for chronic daily headache:
- Pseudotumor without papilledema: w/ increased intracranial pressure; Dx with spinal tap
- Sleep disorders: not enough sleep, delayed sleep phase, sleep apnea
Cluster headache
- Occur in clusters: headache same time everyday; severe, boring headache (can cause people to commit suicide)
- Autonomic symptoms: Ptosis, miosis, sweating (like Horner’s)
- 15 to 180 minutes
- Male predominance: 80-90%
- Usually early adulthood
- Need to move
Paroxysmal hemicrania
- 1 to 40 attacks per day (that’s a lot!)
- Female predominance
- last 2 to 45 minutes
- Autonomic symptoms
- Need to lay still in the dark
- Indomethacin: very good response; almost diagnostic
Short-lasting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT)
- Rare
- Male predominance
- Last 5 to 250 seconds
- 5 to 10 episodes per hour
- Autonomic symptoms
Hemicrania continua
- Continuous unilateral headache
- Autonomic symptoms
Acute Severe Headache: “Worst headache of my life”
Sub-arachnoid hemorrhage: very acute boom explosive headache; does not build up over time
- CT of head looking for SAH: sees SAH 90% of time
- LP looking for SAH: performed if can’t see SAH on CT
- Pain management
Could also be:
- Thunder clap headache: migraine variant
- Coital headache: headache during sex
- First migraine
Principles of Headache management
- Behavior/Lifestyle changes: avoid triggers
- Use OTC medications first: More effective if used early in headache onset; use proper dose
Secondary management:
- Triptans (abortive medication)
- Preventive medications (not curative): Requires 4-6 weeks to work (e.g., Cyproheptadine, Beta-Blockers, Tricyclic antidepressants, Ca channel blockers, Anti-convulsants)
Trigeminal Neuralgia (Tic Douloureux)
- Short headache not associated with autonomic features
- pain in the V1 or V2 distribution on the face
- Responds to anticonvulsants
