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Most common type of headache



Most common type of headache presenting to physician



7 causes of secondary headaches

1) Intracranial HTN (idiopathic or secondary)

2) Intracranial hypotension

3) SAH

4) GCA

5) CNS infection (meningitis/encephalitis)

6) Cranial neuralgias

7) Brain tumor


What are 11 historical red flags for a headache?

1) Onset after age 50

2) Worse on awakening** (may be secondary to increased ICP)

3) WHOML (thunderclap - sudden onset is worse than just hearing WHOML)

4) Change in typical headache pattern

5) History of Cancer

6) Fever

7) Visual loss (other than as part of an aura)

8) Diplopia

9) Change in personality

10) New onset seizures

11) History of HIV


What are 8 physical exam red flags for a headache?

1) Fever

2) Meningeal irritation

3) Papilledema

4) Enlarged blind spot

5) Loss of visual acuity

6) Tender temporal artery

7) Focal neuro findings

8) Alteration of arousal


Normal ICP



How does laying down increase ICP?

More blood in head.

Note: When sleeping, total minute ventilation decreases. The increases serum CO2 which lowers pH. This causes vessels in brain to dilate leading to higher ICP.

***If your ICP is already elevated at baseline, you'd get a HA when you wake up


Which cranial nerve is most susceptible to increases in ICP?

CN 6 (diplopia)


Signs of compressive lesion to CN3?

They affect parasympathetic fibers first - pupils will be dilated initially


IHS criteria for migraine

Must be recurrent

Not explained by secondary disorder

Must have 2 out of 4 of:
1) Unilateral
2) Pulsating
3) Moderate to severe intensity
4) Aggravated by routine physical activity

Must have 1 out of 2 of:
1) Nausea and/or vomiting
2) Photophobia AND phonophobia


Migraine aura

Most migraines DONT have aura, but if there is an aura there are usually several features they share

Develops over minutes

HA should begin within an hour

Older adults may get "acephalic" migraines

Typically visual - fortification spectra, scintillating scotoma, phosphenes, metamorphopsia

Can be non-visual - numbness from hand to mouth, aphasia, unilateral weakness, slurring of speech

Aura is thought to be from cortical spreading depression due to vasoconstriction


Abortive tx of migraines

OTC - aspirin, NSAIDs, Acetaminophen, excedrin (must take at high doses), naproxen (Aleve) has longer half-life than ibuprofen

1st line: Triptans - vasoconstrict abnormally dilated vessels. Can be PO, SQ, nasal. They work better when taken as soon as you feel HA starting. AVOID IN PTS WITH CAD, CVA, PREGNANCY, COMPLICATED MIGRAINES

2nd line: Antiemetics, corticosteroids

3rd line: opiates

Relying on pain meds for HA can cause rebound HAs - USE A TRIPTAN


Prophylactic tx of migraines

For 2 or more debilitating attacks per month

B-blockers (propranolol and nadilol)

TCAs (Amitryptiline - anticholinergic action)

Antiepileptics (Topiramate -side effect is weight loss, tingling, teratogen cleft lif/Valproate - side effect is teratogenic neural crest)

2nd line: Verapimil, ARBs, SSRIs

Avoid known triggers

BoTox for chronic migraines - more than 14 HAs per month can get 31 injections q3mo


Typical migraine characteristics - 8 factors

1) Onset - teenage to age 40 occuring anytime during day

2) Location - Half of face; frontal, usual in or about eye or cheek

3) Precipitating factor - fatigue, stress; hypoglycemia; diet (tyramine, alcohol); sunlight; hormonal change (menstruation)

4) Freq - 2-4 per month or sporadic; can be cyclic with menstruation

5) Sex distrib - 70 female/30 male

6) Duration of attack - head pain 4 hours, aura to postdrome 24-36hrs

7) Pain type and severity - begins as dull ache, progress to stabbing pain; intense

8) Associated sx - n/v; photophobia, visual obscuration


Migraine prevalence in children

even in boys and girls. Only in adults do you see the female predominance


Common migraine triggers

1) Chocolate, cheese, red wine, citrus, coffee, tea, tomatoes, potatoes, irregular meals

2) Excessive/insufficient sleep

3) Changes in hormone balance in women (menses, pill, menopause)

4) Stress or relaxation after a period of stress

5) Caffeine withdrawal

6) Physical activity

7) Smoking

8) Flashing lights or noise

9) Weather - high pressure conditions, hot dry winds, change of season, exposure to sun and glare

10) Sexual arousal

11) Smells - paint, fumes from car heaters or perfume


Evaluation of migraine

Complete H and P. If history is consistent with migraine then just go to treatment.

If atypical then use caution (male migraine under age 50, neuro exam abnormal) then can do workup that may include the following

1) Routine blood tests

2) Sed rate

3) LP

4) Imaging


Routine blood tests in setting of headache

Vasculitis, toxic exposures, metabolic diseases, severe HTN, infectious processes can all be associated with HA

CBC, HIV testing, vasculitis screen, thyroid function, serum protein electrophoresis can be ordered


Sed rate in setting of headache

In HA patients older than 60, temporal arteritis should be considered. It affects medium and large vessels of the upper body esp temporal vessels.

Can be coupled with pain/stiffness of neck, shoulders, back, and sometimes pelvic girdle. HA is one sided at temporal region

Major complication is vision loss


LP in setting of HA

Consider in patients with new onset HA with fever, stiff neck, or AMS

If ddx includes SAH or pseudotumor cerebri, an LP should also be considered

If LP is done to workup a HA then the patient should have a scan performed before the LP (unless bacterial meningitis is a serious possibility) - in cases where meningitis is suspected to LP immediately unless there's papilliedema


Imaging in setting of HA


CT may be adequate to detect a space-occupying lesion, shift in midline structures, brain herniation, or presence of SAH


Postspinal HA

25% of patients get HA after LP

Better when laying down and worse when sitting/standing up.

Can be associated with nausea and vomiting

Improve with bedrest and fluids

If don't improve, an epidural blood patch can be done


Postcoital cephalgia

Both before or after orgasm

Equal in men and women

Sudden, pulsatile HA often entire head

Usually benign (2% SAH)

Simple NSAID before sex is enough


Pseudotumor cerebri

Increased ICP without evidence of CNS malignancy

HA often associated with visual disturbances

Usually a woman who is obese with menstrual irregularities

All have papilledema

Diplopia maybe from CN VI palsy (otherwise normal neuro exam and MRI)

LP shows high opening pressure only

Not entirely benign bc of risk of vision loss

Standard tx = acetozolamide

Consider VPS or optic nerve sheath fenestration in severe or refractory cases


Acute glaucoma

Sudden orbital or eye pain in face of nausea and vomiting

Pain can begin after the use of anticholinergic drugs

High IOP is the hallmark of acute angle-closure glaucoma


Carotid dissection

Orbital or neck pain associated with neuro findings suggestive of carotid disease.

Horner syndrome (when sympathetic innervation to eye disrupted) on ipsilateral dissected carotid side

Trauma to neck or vigorous movements to neck will often trigger the dissection


Brain tumor

HAs from brain tumor are like typical tension or migraine headaches.

Quite frequent and can occur on a daily basis, often awakening the patient from sleep

Neuro exam can be normal but can reveal focal deficits as well as papilledema. HA is presenting feature in 40% of brain tumor patients



3 main etiologies

1) leakage of AVM
2) Leakage of ruptured aneurysm
3) Trauma

Debilitating HA that's WHOML.

Sudden onset with nausea, vomit, stiff neck

Can look like a migraine

Associated with blood in subarachnoid space which is usually seen on MRI or CT

An LP will confirm (blood or xanthochromic staining)

50% do not survive

Most common etiology is rupture of berry aneurysms off arterial circle of willis

Hunt-Hess grading system for prognosis based on severity of HA, level of consciousness, focal signs


4 drugs used in abortive therapies for migraines

1) Triptans
2) Ergotamine derivatives
3) Dihydroergotamine
4) Midrin



They work at 5HT-1D serotonin receptors as agonists

80% effective in treatment of individual attack

They can be given again as early as 4hrs if there's another HA

No more than 3x in 24hrs

Side effects are nausea, vomiting, numbness/tingling of fingers and toes

Contra is history of CAD, HTN

If patient has hemiplegia or blindness as an aura in a migraine attack then do not use