Red Flag Symptoms of a Headache
First or worst
Fundamental pattern change
Headache pattern change when (<5 yo,>50 yo)
Cancer, HIV, pregnancy
Abnl. physical exam
Neuro symptoms > one hour
Headache onset with Seizure/syncope; Exertion, sex, valsalva
Comfort Signs/Symptoms of a Headache
Family history of similar headaches
Normal physical exam
What % have migraine with significant intracranial pathology?
What % of headaches in PCPs are migraine?
What % of PCP patients have migraine?
How many women have migraines?
How many households have migraines?
What % of migraines have been not diagnosed?
0.18% have migraine with significant intracranial pathology
75% of headache in PCP – Migraine
33% of patients in PCP waiting rooms have Migraine
1 in 5 women has migraines
1 in 4 households has a migraine sufferer
50% have not been diagnosed
What are the characteristics of a primary headache?
What are the types?
No identifiable underlying pathology
No diagnostic tests
Defined by clinical symptomatology (Dx based on ruling out pathology)
Types: Migraine, Cluster, Tension-type
What are possible underlying etiologies of secondary headaches?
Which anatomical structures are sensitive to pain?
Proximal portions of the cerebral arteries
Dura at the base of the brain
CN V, VII, IX, X
Cervical Nerves: 1,2,3
What are the indications of neuroimaging in headache?
What is the difference between CT and MRI?
Recurrent migraine: Neither CT nor MRI warranted EXCEPT
Recent change in pattern
New onset seizures
Focal neurologic signs or symptoms
Nonmigraine: Unclear CT or MRI benefit
CT versus MRI
Some secondary headache causes may not be evident on CT
What non-CT/MRI diagnostics can also be used for a headache?
CBC, CMP, Thyroid, Sedimentation Rate/CRP, Cervical Spine X-Ray, Carotid/Transcranial Doppler
What is the diagnostic criteria in cluster headache?
Minimum of 5 attacks
Frequency of attacks 1 every other day to 8 per day
Description of headache (all of the below)
Unilateral orbital, supraorbital, and/or temporal location
Lasts 15 to 180 minutes (untreated)
Associated symptoms (one of the following)
Forehead and facial sweating
What is Horner's Syndrome?
Unilateral pain around one eye, drooping of the lid, tearing and congestion
What is the diagnostic criteria for migraine without aura?
Headache attack lasts 4 to 72 hours
Description of headache (two of the following)
Moderate or severe intensity – Inhibits prohibits daily activities
Aggravation by walking up stairs or similar routine physical activity
Associated symptoms (one of the following)
Photophobia and phonophobia
What is the diagnostic criteria for a tension-type headache?
Headache occurring on ~15 days per month on average for > 3 months
Last hours or may be continuous
Description (Two of the Following)
Mild or moderate intensity – Inhibit, does not prohibit activities
No aggravation by walking up stairs or similar routine physical activity
Associated Symptoms (No more than one of)
Mild nausea (Neither moderate or severe nausea nor vomiting)
What are the defining traits of tension-type headaches?
Stress as associated event
Tension headache as premonitory symptom
What is associated with sinus headache?
What are the characteristics?
Associated with nasal stuffiness and pressure before treatment
Weather as Trigger
What is the incidence of chronic daily headahce?
What are the risk factors for chronic daily headache (non readily modifiable vs readily modifiable)?
Not readily modifiable
Low socioeconomic status
Stressful life events
Snoring (sleep apnea, sleep disturbance)
What is the pathway of migraine pathophysiology?
What causes cortical neuronal hyperexcitability?
Enhanced excitatory NT release:
Elevated plasma glutamate
Identified genetic mutations in familial hemiplegic migraine (FHM)
Reduced intracortical inhibition
Low brain Mg2+
Altered brain energy metabolism
What is cortical spreading depression?
What is its velocity?
What does it underly?
Where does it occur?
Wave of intense cortical neuron activity: rCBF increased
Followed neuronal suppression: rCBF decreased, coincides with headache onset
Velocity 2-3 mm/min
Underlies visual aura
Occurs in clinically silent areas of the cortex – Migraine without aura
What are the mechanisms of brainstem dysfunction that cause migraine/headache?
Dysfunction in areas involved in central control of nociception – PAG
Role of brainstem as a generator to induce migraine
Activation and sensitization of TNC neurons – Decreased descending inhibition during migraine attack