Primary Headache Flashcards
chronic headaches
-new, severe, or acute is more likely related to intracranial disorder than chronic headaches
-may be primary or secondary to another disorder
primary headache syndromes
-migraine (with or without aura)
-tension type headache (episodic or chronic)
-cluster headache (episodic or chronic)
-no demonstrable structural abnormality
secondary causes of headaches
-intracranial lesions
-head injury
-cervical spondylosis
-dental disease
-ocular disease
-temporomandibular joint dysfunction
-sinusitis
-hypertension
-depression
-etc
-sleep disturbance, substance withdrawal
migraine
-pulsating or throbbing
-lateralized throbbing headache
-occurs episodically following its onset in adolescence or early adult life
-can be associated with anorexia, nausea, vomiting, photophobia, phonophobia, osmophobia, cognitive impairment, blurring of vision
-gradual buildup and last hours or longer
-focal disturbances of neurological function may precede or accompany
-scotoma- visual disturbances; field defects
-photopsia- unformed light flashes
-scintillating scotomas- some combination of field defects and luminous hallucinations
tension headache
-sense of tightness or pressure
-band like pain
neuritic caused headache
-sharp lancinating pain
migraine or cluster headache
-ocular or periorbital icepick-like pain
-lateralized headache
intracranial mass lesion
-dull or steady headache
-may be focal or generalized
ophthalmologic disorder
ocular or periocular pain
sinusitis
-tenderness of overlying skin and bone
trigeminal or glossopharyngeal neuralgia
-localized pain to one of the divisions of the trigeminal nerve or to the pharynx and external auditory meatus respectively
precipitating (triggering) factors
-recent sinusitis
-dental surgery
-head injury
-systemic viral infection
-SARS-CoV-2
-emotional stress
-fatigue
-foods containing nitrite or tyramine
-menstrual period
-alcohol
-temporomandibular joint dysfunction (chewing)
-cough
timing of headaches
-headaches are worse awakening in pts with intracranial mass or sleep apnea
-cluster headaches occur at the same time each day
-tension headaches are worse with stress / end of day
headaches that requires MRI or CT scan
-progressive headache disorder
-new onset in middle or later life
-disturb sleep
-related to exertion
-neurologic symptoms or a focal neurologic deficit
-rules out intracranial mass lesion
-CSF exam to exclude subarachnoid hemorrhage or meningeal infection
essentials of migraine diagnosis
-headache, usually pulsatile, lasting 4-72 hours
-usually unilateral pain
-nausea, vomiting, photophobia, and phonophobia
-aggravated with routine physical activity
-aura of transient neurologic symptoms may precede head pain
-commonly occurs with no aura
general consideration of migraines
-neuronal dysfunction in trigeminal system
-results in release of vasoactive neuropeptides such as calcitonin gene (peptide that leads to neurogenic inflammation, sensitization, and headache)
-aura is hypothesized to result from cortical spreading depression- wave of neuronal and glial depolarization that slowly moves across the cerebral cortex
-autosomal dominant inheritance sometimes- familial hemiplegic migraine
initial process
-life threatening?
-old or new? chronic? sudden?
-epidemiology
-ALWAYS consider serious causes of headaches
-history- OLDCARTS
-physical exam- you dont need a physical exam to diagnosis a primary (tension, migraine, cluster)
-working diagnosis
-reassure pt if no evidence of serious underlying causes & initiate treatment
3 main primary headaches
-tension (most common)
-migraine
-cluster (least common)
history of adult with headache
-age at onset
-presence or absence of aura and prodrome
-frequency, intensity, and duration of attack (# per month)
-time and mode of onset
-quality, site, and radiation of pain
-associated symptoms and abnormalities
-family history of migraine
-precipitating and relieving factors
-exacerbation or relief with change in position
-effect of activity on pain
-relationship with food/alcohol- chocolate, cheese, caffeine
-response to any previous treatment
-review of current medications
-any recent change in vision
-association with recent trauma
-any recent changes in sleep, exercise, weight, or diet
-state of general health
-change in work or lifestyle (disability)
-change in method of birth control (women)
-possible association with environmental factors
-effects of menstrual cycle and exogenous hormones
physical examination for adult with headache
-blood pressure
-pulse
-listen for bruit at neck, eyes, and head for clinical signs of arteriovenous malformation
-palpate the head, neck, and shoulder regions- tension -> tension headache
-check temporal and neck arteries- temporal arthritis- headaches forms due to inflammation of temporal artery -> urgent -> patient can go blind
-examine the spine and neck muscles
-Neurologic exam:
-mental status testing, cranial nerve exam, funduscopy (exam optic nerve/vein for papillae edema) and otoscopy, and symmetry on motor, reflex, cerebellar (coordination), and sensory tests
-gait exam -> getting up from seated positing without any support and walking on tiptoes and heels, tandem gait, and romberg test (stand with eyes closed to see if the pt sways)
classification of headache
-primary vs secondary
-acute vs chronic
-urgent / emergent vs nonurgent
primary headache
-associated features are the disorder itself
-often result in considerable disability and a decrease in the pts quality of life
-no underlying cause
-tension, cluster, migraine
-trigeminal autonomic cephalalgias
-benign cough headache
-benign exertional headache
-headache associated with sexual activity
-benign thunderclap headache
-idiopathic intracranial hypertension (pseudotumor cerebri) (IITCH)
secondary headaches causes
-caused by exogenous disorders
-can be mild secondary or life threatening
-ex. subarachnoid hemorrhage is causing a headache
-due to trauma, cranial/cervical vascular disorder, non-vascular intracranial disorder, substance/withdrawal, infection, disorder of homeostasis, disorder of cranium, neck, ears, eyes, nose, sinus, teeth, mouth, or other facial structure, psychiatric disorder
chronic headaches
-primary or secondary to another disorder
-frequency of 15 or more days a month for longer than 3 months in the absence of organic pathology
-common primaries -> migraine, tension, cluster
-common secondary causes -> intracranial lesions, head injury, cervical spondylosis, dental or ocular disease, temporomandibular joint dysfunction, sinusitis, hypertension, depression, etc.
-sleep disturbance, substance withdrawal
acute headaches
-rapid onset
-age > 40 years
-severe intensity
-thunderclap, trauma, exercise onset
-fever
-vision changes
-nuchal rigidity
-HIV infection
-current or past hx of hypertension
-neurologic findings (mental status changes, motor or sensory deficits)
chronic headache subtypes
-chronic migraine headache
-chronic tension type headache
-medication overuse headache (opioids 10, NSAIDS 15)
-hemicrania continua- one sided, persistent, responds to indomethacin (NSAID)
-new daily persistent headache
-chronic daily headache (CDH) is not a specific headache type but a syndrome that encompasses other primary headaches
examples of secondary headaches
-subarachnoid hemorrhage
-meningitis
-subdural hematoma
-temporal arteritis
-CNS tumor
-posttraumatic
-primary cough headache
-sinusitis
-toothache
-medication overuse
etiologies that require urgent investigation/treatment
-vascular causes
-infections
-intracranial masses
-preeclampsia (frontal)
-CO poisoning
-headache brought on by cough, exertion, or sexual activity
tension headache
-duration- 30mins to 7 days
-exacerbated by: emotional stress, fatigue, noise, or glare
-pain characteristics: pressing or tightening; band like tightness, mild to moderate severity, bilateral location, peri-cranial tenderness, poor concentration, NO aggravation by routine physical activity*
-associated symptoms: (all must be met)- no vomiting, no more than one of: nausea, photophobia, phonophobia, and no family hx
-management: oral analgesics (NSAIDS, acetaminophen), treat anxiety and depression, alternative therapies
-prophylaxis (prevention)- TCA’s (tricyclic antidepressants)
migraine types
-without aura- most common
-classic migraine (with aura)
-migraine in children
-basilar artery migraine
-ophthalmoplegic migraine- can cause temporary blindness - artery constricts cutting of blood
-chronic migraine
-atypical migraine
-status migrainosus
-hemiplegic migraine
migraine screen
-photophobia?
-incapacity? does it limit you?
-nausea?
-if yes, to 2-3 questions -> migraine
brief headache screen
-how often do you get severe headaches (without treatment it is difficult to function)
-how often do you get other (milder) headaches
-how often do you take headache relievers or pain pills (overuse?)
-has there been any recent change in your headaches
migraine disability assessment score (MIDAS) questionaire
-questionnaire regarding the past 3 months
-how many days did you miss work/school because headaches
-how many days was your productivity reduced by half or more bc of headaches
-how many days did you not do household work bc of headaches
-how many days was your productivity in household work reduced by half or more bc of headaches
-how many days did you miss family, social, or leisure activities bc of headaches
-how many days did you have a headache
-on a scale of 1-10 how painful were these headaches
-Grade 1- minimal or infrequent disability 0-5
-Grade 2- mild or infrequent diability 6-10
-Grade 3- moderate disability 11-20
-Grade 4- severe disability >20
POUND
-pulsatile quality of headache
-one-day duration (4-72 hours)
-unilateral location
-nausea or vomiting
-disabling intensity
-92% probability of migraine in pts with at least 4 POUND criteria
migraine without aura
-most common subtype of migraine
-higher average attack frequency
-usually more disabling than migraine with aura
-triggers: smell, taste
-often have strict menstrual relationship
-most prone to accelerate with frequent use of symptomatic medication, resulting in a new headache
-medication overuse headache
migraine without aura criteria* IHS diagnostic criteria
-at least 5 attacks fulfill B-D
-B. headache lasting 4-72 hours (treated or not)
-C. headache has >2 of the following:
-unilateral location (usually frontotemporal)
-moderate or severe pain intensity
-aggravation by or causing avoidance of routine activity (walking, climbing stairs)
-D. during headache > 1 of the following:
-nausea $/or vomiting
-photophobia/phonophobia
-E. not attributed to another disorder (primary)
migraine with aura
-classic migraine
-at least 3:
-1 or more fully reversible aura symptoms
-at least 1 aura symptom develops gradually over >4 mins or 2 or more symptoms occur in succession
-no single aura symptom lasts > 60 mins
-headache begins within 60 mins of aura onset
-H&P and diagnostic tests do not suggest any underlying organic disease
aura
-precede the migraine 5-60mins
-simmering spots or stars
-zigzag lines that gradually float across your field of vision
-loss of vision in one eye
-blurred vision
-blind spots (scotomas)
-objects in your surroundings that appear as if they are shimming in heat
-flashes of light
-feelings of numbness
-tingling
-dizziness (vertigo)
-difficulty with speech
-altered sense of smell or taste
-can mimic a stroke!
migraine in children
-attacks may last 1-72 hours
-commonly bilateral
-occipital (unilateral or bilateral) is rare and calls for diagnostic caution -> many cases are attributable to structural lesions
atypical migraines
-headaches are typical of migraine but at least one diagnostic criterion is missing
-uncommon
status migrainosus
-defined as a migraine attack lasting > 72 hours that has been refractory to treatment
-constant with no relief
-often associated with pernicious nausea, vomiting, dehydration, and despair
-oxygen, ergotamine (vasoconstrictor)
basilar migraine
-severe headache preceded by visual aura and brain stem signs of ataxia, vertigo, tinnitus, diplopia, nystagmus, dysarthria
-level of consciousness and cognition are affected
hemiplegic migraine
-familial syndrome with hemiplegia and alteration in level of consciousness varying from confusion to coma
ophthalmologic migraine
-associated with acute attacks of third cranial nerve palsy with dilated pupil and unilateral eye pain
chronic migraine
-migraine like or tension type like headache on greater than or equal to 15 days/month for >3 months that fulfill criteria B and C
-B. Occurring in a pt who has had at least 5 attacks fulfilling criteria for migraine without aura and/or criteria for migraine with aura
-C. on greater than of equal to 8 days/month for > 3 months
-criteria C and D for 1.1 Migraine without aura
-criteria B and C for 1.2 Migraine with aura
-believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
-D. not better accounted for by another diagnosis
criteria of migraine status migrainosus
-A. headache attack fulfilling criteria B and C
-B. in a pt with migraine without aura and/or migraine with aura, and typical of previous attacks except for its duration and severity
-C. both of the follow characteristics:
-unremitting for >72 hours
-pain and/or associated symptoms are debilitating
-D. not better accounted for by another ICHD-3 diagnosis
goal for acute migraine treatment
-rapid and consistent freedom from pain and associated symptoms, especially the most bothersome symptoms, without recurrence
-restored ability to function
-minimal need for repeat dosing or rescue medications
-optimal self care and reduced subsequent use of resources (ER, dx imaging, clinician and ambulatory infusion center visits)
-minimal or no adverse events
-cost considerations
management of migraines
-lifestyle modification and education
-identify migraine symptomatology that allow for intervention as early as possible
-proper nutrition, regular exercise, adequate hydration, proper sleep, stress management, and maintaining a migraine diary
-instruct in the proper use of their medications- duration, CI, AE
-mild to moderate attacks
-moderate to severe attacks
-rescue/abortive treatment
-non pharmacologic- relaxation, thermal biofeedback, acupuncture
-pharmacologic- triptans
-neuromodulation
-prophylactic management- if occurs more frequently than 2-3 times a month or debilitating -> associated with attacks
-frequency, intensity, variants, patient preference, lowest effective dose, adequate trial, long acting preparations
otc medication
-start medication immediately
-Tylenol, ibuprofen
-can prevent / abort
-earlier the better
-educate patient
symptomatic therapy
-simple analgesic (aspirin, acetaminophen, ibuprofen, naproxen)
-limit to 15 days or less per month, and combination analgesics should be limited to no more than 10 days per month
ergotamines
-cafergot- combination of ergotamine tartrate and caffeine
-1 or 2 tablets are taken at the onset of headache or warning symptoms, followed by 1 tablet every 30 minutes (if needed)
-up to 6 tablets per attacked (per 24 hours)*
-no more than 10 days per month*
-suppository, intravenously or subcutaneously or intramuscularly
-contraindications: pregnancy, cardiovascular disease or its risk factors, pts taking potent CYP 3A4 inhibitors
-constricts the blood vessels -> affects fetus, coronary artery disease
serotonin agonists
-triptans
-5-HT 1b/1d receptor agonists
-at least 7 different medications
sumatriptan
-subcutaneously by an auto injection
-may repeat once after 2 hours if needed
-nasal and oral preparations
-zolmitriptan is available in oral and nasal formulations (if pt is vomiting)
-side effects- nausea and vomiting
-contraindications- pregnancy, pts with hemiplegic or basilar migraines, hx of stroke or TIA, uncontrolled hypertension, pts with coronary or peripheral vascular disease and prinzmetal angina
-pts with controlled hypertension -> triptans commonly used safely although caution is advised
other medicinal treatments
-ubrogepant (ubrelvy)- Calcitonin gene–related peptide antagonists
-lasmiditan (reyvow)- lacks vasoconstrictive properties that other triptans have -> good for pts with cardiovascular risks
-rimegepant (nurtec OTD)- Calcitonin gene–related peptide antagonists
-prochlorperazine- sedative, rectally, IV, IM
-metoclopramide- antiemetic, IV
-chlorpromazine- sedative, antiemetic
prophylactic management
-if migraine headache occur more frequently than 2 or 3 times a month or significantly disability is associated with attacks
-avoidance of triggers and maintenance of homeostasis with regular sleep, meals, and hydration
-headache diary
antidepressants
-amitriptyline: more effective, weight gain, dizziness, constipation, improves insomnia
-can be addictive
-SSRIs
antihypertensive
-beta blockers (propranolol)
-ACE and ARBs (lisinopril, candesartan)
antiseizure meds
-topiramate
-valproate
-gabapentin
-cheaper options
choice of treatment
-individualized choice of medication will depend on comorbidities, cost, patient preference (route, frequency)
-trial and error of medications
-length of use
-tapering and withdrawing medication
-in chronic migraines -> acupuncture, botulinum toxin type A - reduces frequency
-neurostimulation techniques- single- pulse transcranial magnetic stimulation, vagus nerve stimulators, and implantable occipital nerve stimulation
treatment barriers
-medication overuse
-underuse
-incorrect medication use- unadvised switches, mixing with OTC meds, delayed use of therapy
goal of treatment for headache recap
-frequency and severity of attacks, presence and degree of temporary disability, profile of associated symptoms such as nausea and vomiting determine Rx
-pt hx, response to, tolerance for specific medication must be considered
-coexisting conditions (heart disease, pregnancy, uncontrolled hypertension) may limit treatment choices
-formal plan of care empowers patients to manage their condition with potential to reduce the number of office and emergency visits
management recap
-early intervention
-stratified treatment
-dose and route- oral, injection, nasal, suppository
-medication overuse
-rescue treatment- connotes an ineffective outcome from abortive treatment and a need for effective symptom relief with goal of averting an unscheduled visit to a physician office or hospital emergency dept
cluster headache
-clinical dx
-pathophysiology- hypothalamic cell activation/triggering the trigeminal autonomic vascular system
-typically, men > women
-usually beings at age 20-40
-alcohol may trigger attack- stress, glare, or ingestion
-frequency- episodic:
-between 1 every other day to 8/day
-for 1-3 months; followed by remission for months to years
-some patients have cluster headache without remission
IHS criteria: cluster headache
-duration 15-180 minutes (3 hours untreated)
-severe UNILATERAL orbital, supraorbital/periorbital or temporal pain
-associated symptoms: (at least one; ipsilateral to pain)
-conjunctival injection (swelling of blood vessels in eye), lacrimation
-nasal congestion, rhinorrhea
-forehead and facial swelling
-miosis (pupil constriction) and ptosis (drooping)
-eyelid edema
cluster headache management
-acute treatment:
-Sc or intranasal triptans (sumatriptan- imitrex)*
-100% O2*
-ergotamine or a combination
-intranasal lidocaine? - can numb the area of the trigeminal nerve
-NSAIDS
-prevention: verapamil, methysergide, lithium, valproate, combination
primary cough headache
-A. at least 2 headache episode fulfilling criteria B-D
-B. brought on by an occurring only in association with cough, straining and/or other valsalva maneuvre (pressure, ex. going to bathroom)
-C. sudden onset (immediate)
-D. lasting between 1s and 2h
-E. not better accounted for by another ICHD-3 dx
-peaks immediately
-usually from short lasting efforts
primary exercise headache
-A. at least 2 headache episodes fulfilling criteria B and C
-B. brought on by and occurring only during or after strenuous physical exercise
-C. lasting <48 hours
-D. not better accounted for by another ICHD- dx
-usually from sustained physical exercise
-hot weather, high altitude
-usually pulsating
-indomethacin usually effective
primary headache associated with sexual activity
-A. at least 2 episodes of pain in the head and/or neck fulfilling criteria B-D
-B. brought on by and occurring only during sexual activity
-C. either or both of the following:
-increasing in intensity with increasing sexual excitement
-abrupt explosive intensity just before or with orgasm
-D. lasting from 1 min to 24h with severe intensity and/or up to 72 h with mild intensity
-E. not better accounted for by another ICHD-3 dx
-first onset -> mandatory to exclude subarachnoid hemorrhage, intra- and extracranial arterial dissection and reversible cerebral vasoconstriction syndrome (RCVS)
-multiple explosive headaches during sexual activity -> RCVS until proven otherwise by angiographic study
primary thunderclap headaches
-A. severe head pain fulfilling criteria B and C
-B. abrupt onset, reaching max intensity in < 1 min
-C. lasting greater than or equal to 5 mins
-D. not better accounted for by another ICHD-3 dx
-mandatory to exclude subarachnoid hemorrhage etc.
-this is a dx of last resort -> all organic causes have been ruled out
-CT first to check for increased ICP (also eye exam to check for papillae edema)-> lumbar puncture
-if you do a lumbar puncture with increase ICP it can cause herniation of the brain
-thunderclap is not primary -> prof stated on 9/13/23
idiopathic intracranial hypertension (IITCH)
-IIH
-pseudotumor cerebri
-disorder associated with obesity, female gender, occasionally pregnancy
-generalized headache
-generally present on awakening, worse with recumbency (migraine gets better when you lie down)
-improves as the day goes on
-often associated with papilledema but can also occur without visual problems
-MRI< including an MR venogram
-lumbar punction- if safe to do so
-treatment:
-acetazolamide-> 1st choice -> then topiramate - decreases fluid
-CSF removal
-shunting- chronic
scotoma
-visual disturbances; field defects
photopsia
unformed light flashes
scintillating scotomas
some combination of field defects and luminous hallucinations
