Migraine Flashcards
Migraine Etiology and Epidemiology
-Common disabling primary disorder and the second leading cause of disability.
-Strong genetic Component affecting mostly women (Age: 30-39)
Classification of Migraines
-Migraine without aura (common migraine)
-Migraine with aura (classic migraine)
-less than 15 episodes per month
-Chronic Migraine
-More than 15 episodes per month
Possible migraine factors
Sleep disturbances and aspartame
-stress is the highest trigger
Migraine Pathophysiology
-The Vascular Theory of Migraine is no longer considered but suggested that the headaches were caused by dilation of blood vessels and the aura from vasoconstriction.
-Cortical Spreading Depression is the one we accept at the moment.
Cortical Spreading Depression (CSD)
- Fast wave of neuronal and glial depolarization across the brain
- Frontal excitation in cortex.
- Massive increase in intracellular sodium and calcium and extracellular glutamate and potassium
- Causes inflammation in meninges and/or directly stimulates the trigeminal nerve.
Migraine Aura
-Caused by the Cortical Spreading Depression (CSC)
-Last less than an hour
Positive Symptoms:
-stimulates vision, hearing, feeling or movement.
Negative Symptoms:
-loss of vision, hearing, feeling or movement.
What are the components of the Trigeminocervical Complex (TCC)
-Trigeminal Nerve (Cranial Nerve V)
- stimulation results in release of vasoactive neuropeptides such as substance P, calcitonin gene-related peptide (CGRP), and neurokinin A which promotes inflammation.
-Trigeminal Ganglion
Trigeminal nucleus caudalis
Neurovascular pain in Trigeminal area
Trigeminovascular system
- calcitonin gene related peptide (CGRP) released in brainstem causing inflammation, vasodilation, and pain
Migraine Clinical Features (POUND)
-Pulsating Pain (throbbing)
-One-day duration (4-72 hours)
-Unilateral (one-sided)
-Nausea and vomiting
-Disabling intensity
Four phases of a typical migraine attack
-Prodrome (days to hours before the aura)
-the aura
-the headache
-the postdrome
Migraine Diagnosis without aura
-At least 5 attacks lasting 4-72 hours
-headache has at least two:
-Unilateral position
-Pulsating quality
-Modarate or severe pain intensity
-Aggravation by or causing
avoidance of routine physical
activity
-During headache at least one:
-Nausea and/or vomiting
-Photophobia and Phonophobia
Diagnosis of Migraine with Aura
-At least two migraine attacks fulfilling criteria B and C
-One or more of the following symptoms:
-Visual
-Sensor
-Speech and/or language
-Motor
-Brainstem
-Retinal
-At least Three of the following:
-At least one aura symptoms spreads
gradually over 5 minutes
-Two or more aura symptoms occur
In succession
-At least one positive aura symptoms
-At least one asura symptom
unilateral
Migraine in Children
-Attacks from 2-72 hours
-At least three of the following:
-Aura
-Throbbing headache
-Unilateral location
-Nausea & vomiting
-Abdominal pain
-Family History
-Relief during sleep
Cluster Headache
-Caused by Trigeminal Automatic Cephalgia (TACs)
-Unilateral headache (The pain would be in the same side of the head)
Cluster Headache Epidemiology
-Prevalence less than 1%
-Most common in men
-Risk factors: Family history, tobacco use, and head trauma
Cluster Headaches Pathophysiology
-Hypothalamic activation-> Alterations in circadian rhythm; changes in cortisol, testosterone, prolactin, melatonin, etc.
-Activation of trigeminovascular neurons-> release of vasoactive neuropeptides; neurogenic inflammation.
-Genetic Predisposition
Cluster Headache Clinical Features (ROUND)
-Restlesness or agitation
-Orbital or supraorbital location
-Unilateral and very severe pain
-Nasal or ocular symptoms
-Duration shorter
Cluster headaches Triggers
-Watching television
-Alcohol
-Hot Weather
-Stress
-Use of nitroglycerin
-Sexual Activity
-Glare
Cluster Headache Diagnosis
-At least five attacks
-Temporal pain lasting 15-180 minutes
-At least one of the following:
-Conjunctival injection/Lacrimation
-Nadal congestion/Rhinorrhea
-Eyelid Oedema
-Forehaed and facial sweating
-Miosis/ptosis
-A sense of restlessness or agitation
Tension Type Headache (TTH) Epidemiology
-Lifetime prevalence of 30% to 78% in general population
-Slightly higher prevalence in female
TTH Pathophysiology
-Pathogenesis: Peripheral activation or sensitization of myofascial nociceptors.
-Central Factors: Heightened sensitivity of pain pathways in CNS
-Peripheral Factors: Muscular factors important in episodic TTH
-Genetic Component
Clinical Features (PIVOT)
-Physical Activity does not aggravate symptoms
-Intensity is mild to moderate
-Variable duration (30min to 7days)
-Occipitofrontal and bilateral
-Tightening or pressing pain (not pulsatile)
Diagnosis of Infrequent TTH
-At least 10 episodes of headaches occurring on less than a day/month on average (less than 12 days/year)
-Lasting 30 minutes to 7 days
Diagnosis of Frequent TTH
-At least 10 episodes of headaches occurring 1-14 days/month on average for more than 3 months.
-Lasting 30 minutes to 7 days
Diagnosis of Chronic TTH
-Headaches occurring on more than 15 days/month on average for more than 3 months
-Lasting hours to days, or unremitting.
Chronic Daily Headache (CDH)
-Refers either to the frequency of headaches or to the duration of the disease.
CDH Epidemiology
-Prevalence 4%
-Women more affected
-Majority of patients have:
-Chronic TTH
-Chronic Migraine
-Medication Overuse headache
Medication Overuse Headache (MOH)
-When a primary headache develops or markedly worsens during medication overuse.
Hemicrania Continua
Responds absolutely to therapeutic doses of indomethacin.
New Daily Persistent Headache (NDPH)
Characterized by headache that begins rather abruptly and is daily and unremitting from onset or witching 24 hours.
Tempomandibular joint pain (the only secondary headache discussed)
-Common in adults and children
-Usually caused by:
-Imbalance in joint movement by
poor bite
-Bruxism (teeth grinding)
-Inflammation of the joint
-Trauma
-Degenerative Changes
Tempomandibular joint pain Clinical Presentation
-Facial Muscle pain
-Headache
-Neck ache
-Earache
