Lecture 13: Headaches

Question 1

What are headaches?

Answer 1

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

Question 2

What parts surrounding the pain perceive pain to cause migraines?

Answer 2

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

Question 3

What nerves cause sensations in the face, scalp, meninges, and cerebral blood vessels?

Answer 3

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

Question 4

What are some examples of secondary headaches?

Answer 4

intracranial hemorrhage: skull fracture, disrupts blood vessels and causes internal bleeding

subarachnoid hemorrhage (irritation or inflammation)

neoplasm

Question 5

What are primary headache disorders?

Answer 5

no other recognizable cause for the headache

most common types include: tension-type headache, migraine (with and without aura), and cluster headache

Question 6

What are tension-type headaches?

Answer 6

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

Question 7

What symptoms need to be present for a headache to be classified as chronic?

Answer 7

> 15 days per month for >3 months

Question 8

What are the criteria for clinical diagnosing migraines?

Answer 8

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

Question 9

What is the definition of a migraine?

Answer 9

is a complex brain network disorder with dysfunction in sensory processing with superimposed genetic predisposition

Question 10

What are premonitory symptoms of migraines?

Answer 10

mood changes
fatigue
cognitive changes
food craving
repetitive yawning
neck stiffness

fully reversible neurological changes of various severity

Question 11

What are the severe symptoms of migraines?

Answer 11

severe, throbbing pain
nausea
photophobia
phonophobia
osmophobia

Question 12

What are the postdrome symptoms of migraines?

Answer 12

fatigue
cognitive changes
neck stiffness

Question 13

What is the definition of premonitory symptoms?

Answer 13

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

Question 14

What is the aura phase of migraines?

Answer 14

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

Question 15

What is visual aura?

Answer 15

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

Question 16

What are familial hemiplegic migraine?

Answer 16

genetic channelopathy

hemiplegic aura may last up to 72 hours

neurons are more excitable

Question 17

What is cortical spreading depression?

Answer 17

wave of depolarization followed by a period where nerves don’t function properly (decreased activity)

starts in visual cortex then moves along

Question 18

What is the headache phase of migraines?

Answer 18

lasts between 4 and 72 hours

typically, pulsatile and unilateral: moderate to severe intensity, made worse with activity

accompanied by nausea, photophobia, or phonophobia

Question 19

What is the physiology of migraines?

Answer 19

activation of pons, midbrain, and sensory network processing

throbbing pain is blood vessels in the brain pumping blood from the heart

Question 20

What is the diagnostic criteria for migraines with aura?

Answer 20

attacks separated in time with pain-free periods

may occur with or without aura

may evolve to chronic migraine - so called “chronification”

Question 21

What is the diagnostic criteria for chronic migraines?

Answer 21

preceded by episodic migraine

> 15 headache days per month for >3 months

often lose migraine features

most disabling with significant decreased work/school attendance

Question 22

What are cluster headaches?

Answer 22

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

Question 23

What are the three types of trigeminal autonomic cephalalgias?

Answer 23

SUNCT

Paroxysmal hemicranial

Cluster headache

the three types are defined by duration

Question 24

How is Onabotulinum toxin A (botox) used to treat migraines?

Answer 24

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

Question 25

How are CGRP humanized monoclonal antibodies used to treat migraines?

Answer 25

CGRP antibodies/gepants block CGRP responses in the dura mater

CGRP gepants may have central effects

CGRP antibodies/gepants block activities in the trigeminal ganglion

CGRP antibodies/gepants inhibit pain transmission in peripheral nerves

Question 26

How does the loss of vision affect migraines?

Answer 26

people who have become completely blind lost all migraine symptoms

people who are partially blind still have migraines

green light removed migraine symptoms

red, yellow, and blue light increased migraine symptoms

Question 27

What is the chronification of migraines?

Answer 27

increases from one a month to one every day

physical changes, parts that perceive pain grow, pain is perceived differently

very disabling and associated with structural brain changes