Headaches & Migraine

Question 1

Primary Headache

Answer 1

 Migraine
 Tension-Type
 Cluster Headache

Question 1

Secondary Headache

Answer 1

Meningitis

Fasting

Nose/Sinus

Non-vascular intracranial
disease including tumours

Others

Question 2

Pain sensitive structure

Answer 2

Cranial nerves carrying pain fibers (CN V, VII, IX, X)

Circle of Willis and first few cm of their medium-sized
branches

Meningeal (Dural) arteries

Large veins in brain and dura

Portion of dural near vessels

Question 3

Mechanism of Migraine

Answer 3

Neurally induced dilatation and
inflammation of intracranial and
extracranial vessels

Question 4

Mechanism of Tension-Type Headache

Answer 4

Unknown; may be increased
sensitivity of pain-mediating
systems in brain

Question 5

Mechanism of Cluster Headache

Answer 5

Neurally induced inflammation and
edema of internal carotid artery

Question 6

Mechanism of Intracranial Mass Lesion:
e,g, Brain Tumor,
Hydrocephalus

Answer 6

Displacement (traction) of pain-
sensitive vessels

Question 7

Mechanism Low Intracranial Pressure
State: e.g Post-Lumbar
puncture

Answer 7

Traction through brain sagging on
dural attachments; intracranial
vasodilatation

Question 8

Mechanism of Meningitis, Subarachnoid
Haemorrhage

Answer 8

Inflammation of vessels in
meninges and of perivascular dura

Question 9

Mechanism of Temporal Arteritis,
Intracranial Vasculitis

Answer 9

Infalmmation of scalp and
intracranial vessels

Question 10

Headache - Diagnosis

Answer 10

A good medical history taking and neurological examination.
 Presence of papilledema  increased ICP warrants
diagnostic imaging study to rule out mass lesion or benign
intracranial hypertension
 Nuchal rigidity  meningeal irritation is seen with meningitis
and subarachnoid or intraparenchymal hemorrhage
 Atypical features of primary headache and secondary
headache – investigations

Question 11

Headache – Investigations

Answer 11

Blood Test
 FBC, ESR, CRP, biochemistry profile, hormonal profile
Imaging
 SXR, C-spine X-ray, X-ray of sinuses / para-nasal sinuses,
CT head, base of skull or sinuses, MRI brain
Lumbar Puncture
 exclusion of SAH, diagnosis of CNS infection, confirmation
of raised ICP in BIH
Biopsy
 temporal artery, meningeal

Question 12

Criteria for Diagnosing Migraine Without Aura
(Common Migraine)

Answer 12

At least 5 attacks fulfilling the following criteria
 Each attack, untreated or unsuccessfully treated, lasts 4-72 hrs
The attack has at least 2 of the following characteristics:
 Unilateral location; pulsating quality; moderate or severe
intensity; pain aggravated by exertion or routine physical activity
During an attack at least 1 of the following symptoms should be
present:
 Nausea / vomiting; photophobia, phonophobia
No evidence from history or physical examination of any other
disease that might cause headaches

Question 13

Migraine Aura

Answer 13

 Visual
scintillating saw-toothed crescents of light that drift across the
visual field
glistening points of light (photopsias)
shimmering heat-wave-like obscurations
 Sensory
tingling and/or numbness
typically originating in the mouth and/or hand
sometimes spread through half body
 Others
monoparesis, hemiparesis, dysphasia, cognitive changes

Question 14

Common Triggers For Migraine

Answer 14

Hormonal
menstruation, ovulation, oral
contraceptives, hormonal
replacement
Dietary
alcohol, nitrite-laden meat,
monosodium glutamate,
aspartame, chocolate, aged
cheese, missing a meal
Psychological
stress, post-stress (weekend
or vacation), anxiety, worry,
depression

Physical-environmental
glare, flashing lights, visual
stimulation, fluorescent lighting,
odors, weather changes, high
altitude
Sleep-related
lack of sleep, excessive sleep
Drugs
nitroglycerine, histamine,
reserpine, hydralazine, ranitidine,
estrogen
Miscellaneous
head trauma, physical exertion,
fatigue

Question 15

Migraine - Treatment

Answer 15

Abortive & symptomatic - Relief of headache and associated
symptoms

 NSAID
 e.g. Naproxen, ibuprofen
 Mixed barbiturate analgesics
 e.g. aspirin, acetaminophen, codeine-containing compound
 Triptans
 sumatriptan , zolmitriptan (Zomig), eletriptan (Relpax)
 Anti-emetics
 e.g. promethazine , prochlorperazine, metoclopramide

Question 16

Migraine – When to Start Prophylaxis?

Answer 16

Two or more attacks each month with significant
disability that lasts 3 or more days
 Contraindication to or ineffectiveness of symptomatic
medications
 Use of abortive medications more than twice a week
 Migraine variants such as hemiplegic migraine or rare
headache attacks producing profound disruption or risk
of permanent neurological injury