9/29 Headache - Bhise Flashcards
(33 cards)
primary headache disorders
- migraine
- tension-type headache
- trigeminal autonomic cephalalgias
- others
represent 80-90% of headaches
migraine headaches
- unilateral but not side-locked
- pouding or throbing
- photophobia, phonophobia, osmophobia
- nausea w/wout vomiting
- typically 4-24 hours
- aura that begins 5-30 min before headache
aura
seen with classic migraines
begins 5-30 mins before
- last 15-30min
- scotomata (flashing lights, bars)
- sometimes somatosensory
- maybe independent (acephalgic migraine)
history, prov/pall, and complications with migraines
history
- v common to have family history
- history of motion sickness
- comorbid anxiety, depression
provocation/palliation
- worsen with activity
- better when sleeping off in dark, quiet room
complications
- opthalmoplegia
- homonymous hemianopsia
- hemianesthesia
- hemiplegia
- word-finding difficulty
headache triggers
low threshold for external stressors like:
- stress, weather, lack of sleep
- skipping meals
- dehydration
- certain foods
- hormonal changes (menses, birth control, preg)
- medication (ex. nitroglycerin)
neurobiology of migraines
cortical spreading depression
- behind zone of activation, there is a zone of depression (depol) which correlates with onset of headache
- headache usually starts while flow is diminished
- activates trigeminovascular neurons → pain!!!
*oligemia isnt severe enough to cause ischemia
**reactive vasodilation (vascular theory) is not supported
trigeminovascular system involvement in migraines
CN V
- mediates pain from cerebrovasculature and craniofacial region
- handles reflex control of cerebral blood flow
- activated by neurogenic inflammation
major peptide: CGRP (calcitonin gene-related peptide)
neurovascular theory
complex neurovasc/neurochem process activates trigeminal pain pathways
brainstem nuclei (locus ceruleus and dorsal raphe nucleus)
→ superior salivary nucleus
→ pterygopalatine ganglia
→ pia, dura, and blood vessels, and trigeminal nucleus
→ release of CGRP (potent vasodilator)
- stimulates MMP (matrix metalloproteinase) → release of polypeptide “soup” to blood vessels
- serotonin, bradykinin, substance P, neurokinin P&Y, prostaglandins
→→→ perivascular inflammation and pain!
prodrome: suggestive of hypothalmis and/or brainstem origin
headache phase: indicative of trigeminovascular system
treatment of migraine
abortive treatment
- NSAIDs
- anti-emetics
- triptans/ergots
- combo
preventive tx
- pharmaco
- non-pharmaco
lifestyle modification examples
- headache log
- keeping on the lookout for: hunger, dehydration, lack of sleep
- limiting/stopping NSAID use
- rebound headaches when you stop taking a med
- avoiding junk food, caff drinks
high severity migraines
status migrainosus
- migraine lasting over 72hr
- abortive tx: ketorolac, meoclopramide, IV fluid
- secondary option: sumatriptan, DHE, methylprednisolone, valproic acid, MgSO4
transformed migraines
- moved into chronic daily headache
- vulnerable to long term conseqs of headaches!
tension headaches
most common headache type
usually episodic, but can be chronic (chronic? F>M)
typically bilateral
pressing or tightening, squeezing
incr pericranial tenderness on palpation
minutes-days
lacks migraine features:
- pain doesn’t worsen with routine phys activity
- not assoc with nausea
- either photophobia or phonophobia
tension headache pathophysiology
pain mechanisms
- peripheral pain mechs in episodic TH
- central pain mechanisms (sensitization) in chronic TH
- prob sensitized at supraspinal level and spinal dorsal horn/trigeminal nucleus in CTTH
- mood disorders may aggravate central sensitization
- low vitD, elevated IL-1beta levels?
trigeminal autonomic cephalalgias
- cluster headaches
- hemicrania: episodic, chronic, continua
- SUNCT (short-lasting unilateral neuralgiform headache attachs with conjunctival injection and tearing)
- SUNA (short-lasting unilateral neuralgiform headache attacks with cranial autonomic sx)
trigeminal autonomic cephalalgias:
autonomic features
autonomic features ipsilateral to headache:
- conjuctival injection or lacrimation
- nasal congestion and/or rhinorrhea
- eyelid edema
- forehead and facial sweating
- forehead and facial flushing
- sensation of fullness in ear
- miosis and/or ptosis
- Horner syndrome
cluster headaches
- 1-8 attacks per day
- attacks in series for weeks-months, separated by remission periods for months-yrs
- max effect: orbitally, supraorbitally, temporally
- excruciating boring pain, unable to lie down, pacing
- sense of restlessness or agitation
20s-40s: men > women
- men peak in 30s
- women peak in 20s, 60s
diffs between cluster headaches and migraines
cluster headaches have…
- no prodrome
- no aura
- worse with smoking/alcohol
timing
- headaches lasting 15min-hours
- awake pt in middle of night
- recurrent
- periodic: same time of day, same time of year
cluster headaches
mechanism
theories: vascular dilation, autonomic system, circadian effects, histamine release, genetics, autonomic system
- activation in ipsilateral posterior hypothalmic gray matter
- ant cingulate gyrus, bilateral insula
- low testosterone
- pain mediated by trigeminal nerve → vasodilation and edema (histamine, CGRP, substance P, VIP)
- parasympathetic fibers activated (CN VII involved)
sleep association
- often begins in sleep → disturbed circ rhythms suspected
- associated with migraines and sleep apnea
- suprachiasmatic nucleus [sleep pathologies] → parasympathetic pathway
genetic association
- first degree relative → 14-39x incr risk
- inherited auto dom in 5% of cases (HCRTR2 gene)
treatment of cluster headaches
hemicrania
1. paroxysmal: severe, unilat pain (orbital, supraorbital, temporal) lasting 2-30min, several times daily
2. continua: nonstop for over 3 months
- incessant, sometimes severe, side-locked headache that ONLY RESPONDS TO INDOMETHACIN
3. SUNCT: moderate or severe unilat head pain (orbital, supraorbital, temporal, other trigeminal distribution) - 1-600 seconds
- single stabs, series of stabs, sawtooth pattern
- SUNA: attacks lasting 7 days - 1 year spearated by pain free periods lasting at least 1 month
- 2s-10min duration
- freq: daily or more
indomethacin responsive headaches
indicated for
- paroxysmal hemicrania
- cough-induced
- ice pick (stabbing)
- SUNCT
trigeminal autonomic cephalgias
summary table
lasting less than 30min → likely paroxysmal hemicrania
lasting more than 30min → likely cluster
primary headaches
summary table
new daily persistent headache
acute onset, chronic headache - daily and unremitting
bilateral tightening (non-pulsating), mild-moderate intensity
over 3 months
not aggravated by normal activity
distinguishing features from chronic tension-type headache:
- chronic from onset
- often occurs in patients without prior HA history
