Headache Flashcards
Primary headache
migraine (episodic, chronic)
tension type
trigeminal autonomic cephalgia (TACs) - e.g. cluster headaches
Secondary headache
headache and neck trauma extra-cranial vascular disease tumour infection abnormal CSF pressure: hyper/hypotension drugs
Episodic migraine headache characteristics
2 of: unilateral location throbbing quality worse with exertion moderate to severe intensity
Episodic migraine associated symptoms
1 of:
- nausea/vomiting
- stimulus sensitivity (light, sound, normally pleasant smells)
Episodic migraine headache diagnosis
2 characteristics + 1 associated symptom
5 attacks with 1 year history + normal exam
–> migraine without aura
Migraine with aura - visual symptoms
scintillations peripheral field loss photopsia central scotoma zigzag areas surrounding an area of gradual visual loss highly specific, short-lived symptoms ~20% of patients
Migraine with aura - nonvisual symptoms
common: sensory, cognitive
rare: motor, basilar, retinal (blind in 1 eye)
Migraine with aura - clinical findings
Gradual onset of one or more reversible symptoms
Symptoms develop over > 4 minutes, or in succession
Duration
Triggers of migraines
menstrual periods alcohol/foods weather change oversleeping exposure to odours let down period of stress
Chronic migraine diagnosis
Headache >15 days/month
Average headache > 4 hours
Headaches meet criteria for migraine > 8 days/month
With/without medication overuse (> 10 days/month for over 3 months)
primary disorder of the brain
often occurs after repeated attacks of episodic migraine
disorder of cortical hyperexcitability and dysfunctional brainstem pain modulating centres
Migraine progression
often gradual, months-years
neither inexorable/irreversible
happens in ~3% of episodic migraine sufferers
Prevalence of chronic migraine
2% of population 5x higher in women 80% of cases seen in a headache specialty clinic are CM 2.5% of EM will progress to CM in a year 50% are overusing medications
Episodic tension-type headache
"mild migraine"/entry point to migraine Generalized, nonpulsating pressure mild-moderate intensity No aggrevation with activity No nausea/vomiting Photophobia/sonophobia absent (or only 1 present)
sinus headache
recurrent frontal headache
nasal stuffiness/obstruction
meets criteria for migraine (>95% of “sinus headache” are migraine)
Trigeminal autonomic cephalgias (TACs)
cluster headache ice-pick cough coital benign exertional chronic paroxysmal hemicrania
Cluster headache characteristics
Severe unilateral orbital pain
short duration, 2 weeks without an attack
Cluster headache associated autonomic symptoms
Unilateral Conjunctival injection tearing rhinorrhea/nasal congestion ptosis/miosis: rare
Migraine pathophysiology
brainstem/occipital cortex
Cortical spreading depression
- wave of intense cortical neuron activity followed by neuronal suppression
- velocity 2-3 mm/min
- probably underlines visual aura
- possibly occurs in clinically silent areas of cortex (migraines without aura)
Primary cause of migraine headache
Hyperexcitable cortex
Dysmodulated brain - activation in dorsal pons
Non-pharmacologic acute therapy of migraines
cold (decrease v/d)
pressure
rest - dark/quiet atmosphere
Migraine symptomatic acute therapy
simple analgesics NSAIDs combination analgesics Opioids Acetaminophen not really too effective
Specific agents for migraine symptoms
Ergotamine: first drug released, therapeutic gain is awful
Dihydroergotamine: much less vasoactive, important use in iv line in hospitals
Triptans
Triptans
Sumatriptan: highly effective and relatively safe; multiple modes of administration naratriptan zomitriptan rizatriptan almotriptan electriptan frovotriptan
Triptan MOA
Decreased transmission through trigeminovascular system
Vasoconstriction
Modulation at trigeminal nucleus caudalis
