Lecture 13: Headaches Flashcards
What are headaches?
headache is the most common symptom is related to the central nervous system
most adults (75%) report one or more headaches per year
chronic headache (more than 15 days for > 3 months) affects 2% of the population
headache disorders are the 6th highest cause of disability worldwide
What parts surrounding the pain perceive pain to cause migraines?
the brain itself doesn’t perceive pain, but the meninges, blood vessels, muscles, lining of the skull, and the lining of sinuses all cause pain
What nerves cause sensations in the face, scalp, meninges, and cerebral blood vessels?
meninges and blood vessels above the cerebral tentorium are innervated by CN V (trigeminal nerve) - first division (i.e. V1)
meninges and blood vessels below the cerebellar tentorium are innervated by cervical nerves C1-C3
innervation of the posterior scalp is largely from the greater occipital nerve (C2-C3)
innervation of the forehead is largely CN V (trigeminal) - V1
What are some examples of secondary headaches?
intracranial hemorrhage: skull fracture, disrupts blood vessels and causes internal bleeding
subarachnoid hemorrhage (irritation or inflammation)
neoplasm
What are primary headache disorders?
no other recognizable cause for the headache
most common types include: tension-type headache, migraine (with and without aura), and cluster headache
What are tension-type headaches?
most common type of headache
may be related to muscle contraction
headache is typically milder and bilateral
lasts hours to days
may be episodic or chronic
What symptoms need to be present for a headache to be classified as chronic?
> 15 days per month for >3 months
What are the criteria for clinical diagnosing migraines?
A. at least five attacks, 1 fulfilling 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
D. during headache at least one of the following: nausea and vomiting, photophobia and phonophobia
E. not better accounted for by another ICHD-3 diagnosis
What is the definition of a migraine?
is a complex brain network disorder with dysfunction in sensory processing with superimposed genetic predisposition
What are premonitory symptoms of migraines?
mood changes
fatigue
cognitive changes
food craving
repetitive yawning
neck stiffness
fully reversible neurological changes of various severity
What are the severe symptoms of migraines?
severe, throbbing pain
nausea
photophobia
phonophobia
osmophobia
What are the postdrome symptoms of migraines?
fatigue
cognitive changes
neck stiffness
What is the definition of premonitory symptoms?
precede headache by up to 72 hours
changes in mood and activity, irritability, fatigue, food cravings, repetitive yawning, stiff neck, and phonophobia, photophobia
may continue into the headache and postdrome phase
presumed triggers including sleep deprivation, hunger, or bright light, may in fact represent premonitory symptoms of an already ongoing attack
What is the aura phase of migraines?
one-third of migraine patients
one or more transient, fully reversible neurological deficits that develop over 5 min or more and last between 5 an 60 min
What is visual aura?
most common in 90% of cases
may show positive –> fortification spectra
negative –> scotoma, or both
other deficits include sensory, motor, speech, brain stem, and retinal aura symptoms
What are familial hemiplegic migraine?
genetic channelopathy
hemiplegic aura may last up to 72 hours
neurons are more excitable
What is cortical spreading depression?
wave of depolarization followed by a period where nerves don’t function properly (decreased activity)
starts in visual cortex then moves along
What is the headache phase of migraines?
lasts between 4 and 72 hours
typically, pulsatile and unilateral: moderate to severe intensity, made worse with activity
accompanied by nausea, photophobia, or phonophobia
What is the physiology of migraines?
activation of pons, midbrain, and sensory network processing
throbbing pain is blood vessels in the brain pumping blood from the heart
What is the diagnostic criteria for migraines with aura?
attacks separated in time with pain-free periods
may occur with or without aura
may evolve to chronic migraine - so called “chronification”
What is the diagnostic criteria for chronic migraines?
preceded by episodic migraine
> 15 headache days per month for >3 months
often lose migraine features
most disabling with significant decreased work/school attendance
What are cluster headaches?
severe or very severe unilateral orbital, supraorbital and/or temporal pain
shorter lasting between 15 and 180 minutes (when untreated)
typically includes autonomic features: conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, ptosis, forehead and facial sweating/flushing, forehead and facial flushing, miosis, sense of restlessness or agitation
attacks occur between one every day up to eight per day
defined from severe to very severe
What are the three types of trigeminal autonomic cephalalgias?
SUNCT
Paroxysmal hemicranial
Cluster headache
the three types are defined by duration
How is Onabotulinum toxin A (botox) used to treat migraines?
used to treat chronic migraines
injected into peri-cranial nerves: CN V nerve ending through skull sutures may transport to brainstem
botox has effect inside the brain
