Migraine Headache and Variants Flashcards
Why should a general dentist care
about headaches?
Because:
(2)
- The same nerve pathway (Trigeminal) is
involved and may show up as a toothache,
gingival pain or facial pain in your patient. - Being able to diagnose referred pain from
headaches will allow you to refer your patient
to the proper specialist AND AVOID
UNNECCESARY DENTAL TX (i.e. RCTs,
extractions, restorative)
Migraine pathways
Headaches occur Most
frequently on arising in
the morning therefore the
DDS must differentiate if
the head/facial pain is
from migraine, bruxism or
obstructive sleep apnea.
Dental Causes of Headache
(2)
Dr. Graff-Radford was the first dentist to become a board member
for the American Headache Society. He became world-renowned in
the headache community, and he helped to change the perception
of dentistry in the medical community as it relates TMD.
Steven was a trailblazer for dentists, expanding dental pain
management to treat the full spectrum of headaches, and
personally training many residents and dentists
Headaches can mimic acute dental disease
If located in the
(three) can mimic dental
disease and cause tooth pain
lower half of the face (V2-3)
Migraine, cluster headache, or paroxysmal hemicrania
Dental Pain vs Headache?
1. Acute dental pain may spread unilaterally but (unlike headache)
rarely crosses the midline of the face.
2. Dental pain clinical characteristics:
(3)
Intense, throbbing
Poorly localized
Generally provoked by stimulation of the offending tooth (i.e. pressure,
hot/cold)
Headache attributed to
temporomandibular disorder (TMD)
Diagnostic Criteria:
(3)
A.Any headache fulfilling criterion C
B. Clinical and/or imaging reveals evidence of TMD
C.Evidence of causation demonstrated by ≥2 of:
1.headache has developed in temporal relation to onset of TMD
2.either or both of:
a) headache has significantly worsened in parallel with progression of
TMD;
b) headache has significantly improved or resolved in parallel with
improvement in or resolution of TMD
3. headache produced or exacerbated by active jaw
movements, passive movements through range of motion of
jaw and/or provocative maneuvers such as pressure on TMJ
and surrounding muscles of mastication
4. headache, when unilateral, is ipsilateral to TMD
D. Not better accounted for by another ICHD-3 diagnosis
Primary
Headache
Disorders
(3)
- Migraine
- Tension-type
headache - Trigeminal-autonomic
cephalgias (TAC’s)
- Trigeminal-autonomic
cephalgias (TAC’s)
(4)
Cluster headache
Paroxysmal hemicrania
Hemicrania continua
SUNCT syndrome
- Orofacial pains resembling
presentations of primary headaches
(3)
5.1 Orofacial migraine:
5.1.1 Episodic orofacial migraine
5.1.2 Chronic orofacial migraine
5.1.1 Episodic orofacial migraine
Diagnostic criteria:
A. At least five
attacks fulfilling
criteria B–D
B. Facial and/or oral
pain, without head
pain, lasting
– hours
(untreated or
unsuccessfully
treated)
C. Pain has at least
two of the following
four
characteristics:
D. Pain is
accompanied by one
or both of the
following:
E. Not better
accounted for by
another ICOP or
ICHD-3 diagnosis
4–72
- unilateral location 2. pulsating quality 3. moderate or
severe intensity - aggravation by, or
causing avoidance
of, routine
physical activity
(e.g. walking or
climbing stairs) - nausea and/or
vomiting - photophobia (light
sensitivity)and
phonophobia (noise
sensitivity)
5.1.2 Chronic orofacial migraine
Diagnostic Criteria:
A. Facial and/or oral pain, without head pain, on 15
days/month for >3 months and fulfilling criteria B
and C below
B. Occurring in a patient who has had at least five
attacks fulfilling criteria B–D for 5.1 Episodic orofacial
migraine
C. On 8 days/month for >3 months, fulfilling either
of the following:
1. criteria C and D for 5.1.1 Episodic orofacial
migraine
2. believed by the patient to be orofacial migraine at
onset and relieved by a triptan or ergot derivative
D. Not better accounted for by another ICOP or
ICHD-3 diagnosis.
Comment: A Pain Diary must be kept to track headache frequency
Pain sensitive
intracranial
structures
Include:
the skin and blood
vessels of the scalp; the
head and neck muscles;
the venous sinuses; the
arteries of the meninges;
the larger cerebral
arteries; the pain-carrying
fibers of the fifth, ninth,
and tenth cranial nerves;
and parts of the dura
mater at the base of the
brain.
The brain itself is
insensitive to pain
Impact of
Migraines
American Migraine Foundation is
fundraising for research on
migraines
– million Americans are estimated
to have severe migraine
headaches.
Migraine will affect –% of women
over a lifetime.
Annual lost productivity in the U.S.
due to migraine costs over $ 1
billion per year.
36
30
Severe type of headache that affects
approximately –% of the world
population or 1 Billion
Gender Prevalence:
Episodes may occur at any time of the
10
2-3:1 W, M
day or night
Onset of migraine occurs in the first — life decades,
then the frequency decreases. — gender
distribution is equal.
four
Childhood
Introduction
Clinical Characteristics
Scalp tenderness occurs in – of the
patients during or after the headache
A — factor or familial history
is present in most migraineurs
More than –% of migraineurs have
less than two attacks per month.
2/3
genetic
50
Pathophysiology
Migraines & trigeminal autonomic cephalgias cause activation of the
— system causing release of inflammatory chemical
mediators in the brain known as —.
The — receptor (5-HT) gets activated. — acts as a
neurotransmitter in the CNS & is a potent —. It is found in
the brain, platelets & intestine.
— is believed to play a MAJOR role in
migraine pathogenesis
Trigeminovascular
neuropeptides
serotonin
vasoconstrictor
Calcitonin gene related peptide (CGRP)
Introduction
A small group of migraineurs transform into CHRONIC
daily headache which is now classified as …
(Previous classification was Medication
Overuse or Rebound Headache since use
of analgesics and migraine abortive
medications >2days/week can trigger
daily headaches in some individuals)
— is effective for treatment
of daily persistent migraines.
daily
persistent migraine- Headaches occur ≥ 15 times per
Month
Onabotulinum A
Family History
Familial tendency:
–% of migraineurs have a parent
with the disorder and up to –% have
at least one first-degree relative with
migraine
chromosome – is linked to migraines
– headaches rarely occur within
the same family
—% of tension-type headaches
sufferers have family members with
similar headaches
50-60, 80
19
cluster
40
Comorbidity of Migraine
Migraine is Comorbid with:
(4)
- stroke
- epilepsy
- depression
- anxiety disorders
In patients with migraine, anxiety disorders & major
depression, the onset of — generally precedes
the onset of migraine, whereas the onset of major
— usually follows the onset of migraine
anxiety
depression
skipped
Psychiatric Comorbidity of
Migraine
Odds Ratio
Major depression –
Manic episode –
Anxiety disorder –
Panic disorder –
4.5
6.0
3.2
6.6
International Headache Society
(IHS) Classification of Migraine
(4)
- Migraine with aura (Classic Migraine)
- Migraine without aura (Common Migraine)
Many patients have both forms
Aura can precede, accompany, or follow the actual
headache attack.
Aura prevalence is: Male-female ratio of 1:2
3. EPISODIC MIGRAINE < 15 migraine days/month
4. CHRONIC MIGRAINE >15 migraine days/month
1.1 Migraine without aura
Diagnostic Criteria
(A-E)
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hr (untreated or unsuccessfully
treated)
C. Headache has 2 of the following characteristics:
D. During headache 1 of the following:
E. Not better accounted for by another ICHD-3 diagnosis
C. Headache has 2 of the following characteristics:
(4)
- unilateral location
- pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (i.e., walking, climbing
stairs)
- aggravation by or causing avoidance of routine physical activity (i.e., walking, climbing
D. During headache 1 of the following:
(2)
- nausea and/or vomiting
- photophobia and phonophobia
Migraine Attack
Phases
(4)
- Prodrome - occurs hours
to days before the
headache. - Aura - immediately
precedes or
accompanies the
headache. - Headache
- Headache Resolution-
may take days
Prodrome
(3)
Change in mood or behavior (i.e. depressed,
hyperactive, euphoric, talkative, drowsy,
restless, or irritable).
Neurological (i.e. sensitivity to light & noise,
difficulty concentrating, yawning,&
hypersomnia).
General (i.e. stiff neck, food cravings, cold
feeling, anorexia, sluggish & thirsty)
Aura
Approximately –% of migraine attacks
are “with aura”.
Many patients have both forms
The aura consists of gradually
spreading neurological symptoms that
usually precede the headache by –
minutes
Most common symptoms are (2)
30
5-60
visual
disturbances such as flashing lights
(scotoma) or a zigzag pattern
(fortification spectra)
Sensory Auras
motor symptoms (i.e. weakness or atonia) - –%
prevalence
hyperkinetic movement disorders (i.e. chorea)
speech abnormalities (i.e. aphasia- absence of language
or dysarthria- poorly articulated speech) –%
prevalence
18
17-20
