Headaches Flashcards
e.g. Migraine, Tension Headache
Post-Traumatic Headache (PTH)
-> Definition + Etiology
PTH = a type of Secondary Headache
PTH =
Headache occurring in the days after a head injury or after regaining consciousness
Etiology:
PTH is a complication of..
- Traumatic Brain Injury (TBI)
- Whiplash injury (= Schleudertrauma)
- Craniotomy
Post-Concussive Syndrome
MODERATE or SEVERE Traumatic Brain Injury
Associated with:
1) Loss of consciousness for >30min
2) Glasgow Coma Scale (GCS) <13
3) Post-traumatic amnesia for > 24h
4) Altered Level of Consc. for > 24 h
5) Imaging positive for traumat. Head
injury -> e.g:
- Skull fracture,
- Intracranial Haemorrhage
- and/or Brain contusio
MILD Traumatic Brain Injury (mTBI)
Associated with NONE of the following
(= S&S of Moderate or Severe TBI):
a) Loss of consciousness for > 30min
b) Glasgow Coma Scale (GCS) <13
c) Post-traumatic amnesia for > 24h
d) Altered Level of Consc. for > 24 h
e) Imaging positive for traumat. Head
injury -> e.g:
- Skull fracture,
- Intracranial Haemorrhage
- and/or Brain contusio
Associated with MIND.1 of the following:
a) Transient confusion, disorientation, impaired consciousness
b) Memory loss for events immediately before / after injury
c) >2 of following Symptoms:
i. nausea
ii. vomiting
iii. visual disturbances
iv. dizziness and/or vertigo
v. gait and/or postural imbalance
vi. impaired memory and/or concentr.
Post-Traumatic Headache (PTH):
Diagnostic criteria & Types
PTH-Diagnosis is mostly based on Clinical criteria:
ACUTE PTH
- Onset of Headache within 7d after the head or neck trauma
- Remitting within 3 months after the onset
PERSISTENT PTH
(same as Acute =) Onset of Headache
within 7 d after head or neck trauma,
Persisting for > 3 months after onset
Secondary Headaches:
Venous Thrombosis
Symptoms, incl. Headache, depend on:
o Which Venous tract is involved?
-> Cortical veins vs. Venous sinuses
o How many vascular districts are affected?
-> limited vs. diffuse
o How fast does Thrombosis develop?
-> can collateral circuits be activated?
Secondary Headaches: Subarachnoid Hemorrhages (SAH)
SAH = dangerous bc autonomic symptoms (brady+tachyk, hypertension, vasospasms)
-> death within 15min
SAH & Headache as symptom:
o Thunderclub Headache in 97% of cases = very sudden / acute onset Headache
o Warning / Sentinel Headache
= Headache that rapidly disappears
-> occurs in case of:
i. Micro-bleeding
ii. Enlargement of the Aneurysm
iii. Intramural bleeding
iv. Vasospasm
v. Micro-embolic phenomena due to Intrasaccular clots
Secondary Headaches:
1. Vascular Intracranial / Cervical disorders
1) Hematomas:
-> Intracerebral, Subdural, Epidural
2) Subarachnoid Hemorrhages*
3) Venous Thrombosis*
4) Vascular Malformations in pre-clinical stage:
o Saccular Aneurysms
o AV-Malformations
Secondary Headaches: Vascular malformations in pre-clinical stage
o Saccular Aneurysm
o AV-Malformation
Secondary Headaches - Underlying disorders
= 9
- Vascular Intracranial / Cervical disorders*:
i. Hematomas
ii. Subarachnoid Hemorrhage
iii. Venous Thrombosis
iv. Vascular malformations in pre-clinical stage - Non-vascular intracranial disorders (= space occupying: Granulomata, Cysts)
- Trauma to Head / Neck
- Substance abuse / withdrawal
- Pathologies of other structures of the head (ears, eyes, teeth etc.)
- Infections: Meningitis, Encephalitis
- Disorders of Homeostasis:
Kidney, Liver, Respiratory insufficiency - Psychiatric disorders: Depression, Psychosis
- Brain Tumor:
Headache is an Onset symptom in 35%, but rarely occurs isolated
= more likely in pts who already have a Primary Headache history
Secondary Headaches Def
Headache that is a symptom of an underlying disease*
Other Primary Headache Diseases
Arnold-Chiari’s Malformation:
Cerebellar tonsils are positioned more downwards, can penetrate into the Foramen Magnum
-> with time can lead to compression of the
anteriorly located Brainstem -> e.g.
- Bulbar part containing Breathing center
- Swallowing center
S&S:
- very frequent Headaches = bilateral & located posteriorly
- contraction of the Occipital Peri-cranial muscles
- if Brainstem compressed => impaired swallowing, breathing, reduced level of consciousness
Treatment: must be corrected surgically
Migraine Pathophysiology - Further contributions:
1) Interplay with Reticular Formation:
Locus Coerulus = major site of Catecholamine synthesis (wsl. reason for Autonomic symptoms in Migraine)
Raphe Nuclei → decreased Serotonin levels (→ Depression + Anxiety = common Migraine comorbidities)
2) Hypothalamic activation in the Prodromic Phase → explains associated Symptoms: Polyuria, Mood changes, Appetite changes
3) Activation of Temporal + Occipital Cortex
→ explains Photophobia
Medication Overuse Headache - Treatment
=> Withdrawal of overused medication
=> + Preventive medication
Advice itself is effective in > 50%, other possibility is Withdrawal programe (Hospital- / Home based)
Outcomes
in 80%: Resolution of Medication overuse
in 50%: Reduction of monthly Headache days to <50%
in 70%: Reversion to Episodic Migraine (<15 Monthly Migraine Days)
in 35%: Relapse of MOH
Medication Overuse Headache - Diagnosis
consider NEUROIMAGING
PSYCHOLOGICAL assessment, bc:
- Med. Overuse Headache has high comorbidity with Anxiety + Depression
- to determine the Overuse-pattern (addiction vs. “simple” overuse)
Medication Overuse Headache - Def
= Type of Headache that develops + gets worse with frequent use of Medications = most often Acute Headache Medications, against pain in Migraine- or TTH-pts
-> underlying Headache disorders transform from Episodic conditions to Chronic Daily Headache
-> 15 Headache days / month (i.e. Chronic)
General Pathophysiology of Headaches
The Brain parenchyma itself does not have pain receptors!
Instead, pain originates in Algogenic (pain producing) structures in the Head:
● Scalp skin + vessels
● Head + Neck muscles
● Venous sinuses
● Meningeal + large Cerebral Arteries
● Dura Mater at the cranial base
● Nerve fibers: CN V + IX + X
● Non-neurological structures in Head: teeth, oral mucosa, paranasal sinuses, eyes, ears**
Cluster Headache - Treatment
● Acute attacks:
o Oxygen administration (FiO2 of 100%)
o Sumatriptan (5-HT1 receptor blocker), via nasal spray or IV
● Prophylactic treatment:
o Short-term (for Episodic CH) – Prednisone, Verapamil (CCB)
o Long-term (episodic + chronic CH) – Verapamil, Lithium
(Verapamil -> ECG monitoring mandatory, bc risk for prolonged PR segment)
● Neurostimulation therapy (DBS)
o when medical therapy fails
o There are less invasive methods by stimulating the occipital nerve, sphenopalatine ganglion or the vagus nerve
Secondary Headaches
= Headache is a symptom of an underlying disease:
o Trauma to Head and / or Neck
o intracranial / cervical Vascular disorder: Hemorrhage, Venous Thrombosis
o Non-vascular intracranial disorder: cyst, granuloma (= space occupying)
o Substance Abuse or Withdrawal
o Infections: Meningitis, Encephalitis
o Disorder of Homeostasis = imbalance of ions or metabolites: Liver / Kidney / Respiratory Insufficiency
o Pathologies of structures of Head: eyes, ears, nose, sinuses, teeth, oral mucosa
o Psychiatric disorders: depression, psychosis
o Brain Tumors:
Headache = onset symptom in 30-40% of cases, but it rarely comes isolated;
more common in pts with history of Primary Headaches
Cranial Neuralgia
= Nerve Pain
-> Pain follows CN territories (eg. CN V) or Roots of C1 / C2
Neuropathy refers to nerve damage Neuralgia is a type of Nerve pain. Neuralgia can be a symptom of neuropathy
Types of Headache
Primary H.
Secondary H*
Painful Cranial Neuropathies (e.g. Cranial Neuralgias*), other Facial pains
Comorbidities & Epidemiology in Primary Headache Types
Bild
Characteristics of the different Types of Primary Headache
- Duration*
- Pain features (siehe Bild)
İ. intensity
ii. quality
iii. side
iv. location
v. Autonomic symptoms?
vi. Other accompanying symptoms
vii. Aggravated by physical activity? - Comorbidities*
- Epidemiology
- Treatment
- Other additional characteristics
Diagnosis Primary Headaches
- Diagnostic Algorithm: Primary vs. Secondary Headache (KK)
- HISTORY
i. Family History -> in Migraine usually parents are affected
ii. Medical History
o Past -> TTH: Hypertension, Mood disorders
o Recent: Stroke, Trauma, Intracranial surgery
iii. Natural History: was the Headache present/absent during important developmental periods?
(eg. females -> puberty, menopause)
- Pain features*
- General Medical examination
- Neurological examination
- İnstrumental examination
