Title: HEADACHE
1HEADACHE
2MIGRAINE
- Migraine is derived from the word hemicrania or
half-a-head - Episodic, lasting 4-72 h, associated with nausea
and/or vomiting, photophobia and phonophobia and
interferes with day-to-day functioning. - Headache has a throbbing or pulsatile quality and
is often unilateral (2/3rds of patients) although
may become generalised
3IHS diagnostic criteria for migraine without aura
- A. At least 5 attacks fulfilling B-D in the
absence of another alternative disorder (eg
metabolic, vascular, substance abuse) - Headache lasting 4-72 h (untreated or
unsuccessfully treated) - Headache with at least 2 of following-
unilateral, pulsating, moderate or severe
intensity (inhibits daily activities) or
aggravation by walking stairs or similar
activity) - During headache at least one of (i) nausea and/or
vomiting, or (ii) photophobia and phonophobia
4Migraine epidemiology
- Approximately 5 of men and 10-15 of women.
- First attack occurs in majority during
adolescence and early 20s. Uncommon to occur for
first time after age 40 years. Remission common
after menopause or in fifth and sixth decades. - 50-70 report a family history
5Migraine other symptoms
- Prodromal symptoms occur in 25-40 in the 24 h
prior to a headache and include mood changes eg
elation, food cravings, thirst and excessive
yawning. Presumably of hypothalamic origin. - Hypersensitivity of scalp, hypersensitivity to
smell - Auras blurring of vision or spots more common
than fortification spectra which are experienced
in 10-15. Paraesthesia is next commonest.
Dysphasia and hemiparesis less common. Auras
usually occur 1 hour prior to a migraine and last
less than 1 hour.
6IHS diagnostic criteria for migraine with aura
- At lease 2 attacks fulfilling B
- At least 3 of the following characteristics
- One or more fully reversible aura symptoms
indicating focal cerebral cortical and/or
brainstem dysfunction. - At least one aura symptom develops gradually over
more than 4 minutes, or 2 or more symptoms occur
in succession. - No aura symptom lasts more than 60 minutes. If
more than one aura symptom is present, accepted
duration is proportionally increased. - Headache follows aura with a free interval of
less than 60 minutes (but it may also begin
before or simultaneously with aura).
7Factors associated with an attack
- Increased incidence on weekends and holidays
- Menstrual pattern
- Reduced frequency in first trimester of pregnancy
- Stress (often as crisis is resolving)
- Fasting or missing a meal
- Certain foods eg chocolate, alcohol, cheese
- Extreme changes in weather
8Drug therapy
- Acute attacks analgesics, NSAIDS, dopamine
antagonists, ergotamines and triptans - Preventive therapy propranolol, tricyclic
antidepressants, pizotifen, methysergide,
valproate, natural therapies eg feverfew, high
dose riboflavin ? Newer AEDs gabapentin and
topiramate - ? Role of acupuncture etc
9Unusual migraine manifestations
- Migraine with prolonged aura aura lasts gt 60
minutes and lt 7 days with normal neuroimaging. - Migrainous infarction (prev called complicated
migraine) auras not fully reversible within 7
days and/or neuroimaging confirmation of
ischaemic infarction. - Status migrainosus attack lasts gt 72 h whether
treated or not. - Childhood periodic syndromes abdominal migraine
and cyclical vomiting, benign paroxysmal vertigo
of childhood, alternating hemiplegia of childhood
(typical age onset lt 18 months). - Familial hemiplegic migraine migraine with aura
including hemiparesis with at least one affected
first degree relative.
10Other headaches Normal headaches
- Excessive stimulation of scalp nerves eg wearing
tight goggles, diving into cold water - Ice-cream headache holding very cold ice-cream
in mouth or swallowing cold ice-cream.
Increased frequency in migraineurs - Hot dog headache eating cured meats ? Nitrites
- MSG
- Hangover secondary to acetaldehyde/acetate
- Fasting
- Exertion
11Tension headaches
- Two to three times more common in women
- Bilateral in 90
- Dull and pressure-like some patients experience
jabs of pain - 10 may also suffer from migraine
- In up to 50 of patients, the headache is daily
- If associated with regular analgesic usage
consider diagnosis of headache induced by chronic
substance use or exposure
12IHS diagnostic criteria for episodic tension-type
headache
- A. At least 10 previous headache episodes
fulfilling B-D. Less than 180 attacks/yr - Headache lasts 30 minutes to 7 days
- At least 2 of the following pressing or
tightening quality (no-pulsating), mild to
moderate intensity (may inhibit but does not
prohibit activities), bilateral, no aggravation
by walking stairs or similar routine activity - Both of the following (i) no nausea or vomiting
(may have anorexia) (ii) photophobia and
phonophobia are both absent (or one but not the
other is present). - Chronic tension headache has same features but
headache is present for at least 15 days a month
during at least 6 months.
13Headache induced by chronic substance use or
exposure
- Occurs after daily doses of substance for gt 3
months. Headache is chronic (15 days or more per
month) and headache disappears within 1 month
after withdrawal of substance. - Ergotamine induced headache preceded by daily
ergotamine ingestion (oral ? 2mg, rectal ? 1mg). - Analgesic abuse headache (gt 100 tablets a month
or aspirin or equivalent of other mild
analgesics). - Caffeine withdrawal headache patient consumes
caffeine daily and gt 15 g/month. Occurs witin 24
h of last caffeine and is relieved within 1 hour
by 100 mg caffeine.
14Cluster headache
- Severe, unilateral pain, orbitally,
supraorbitally and/or temporally, lasting 15-180
minutes, occurring from once every other day to 8
times a day. - Bouts may last weeks or months (or so-called
cluster periods) and then remit for months or
years (average 1/year) - 80-90 are episodic (as above), 10-20 are
chronic. 85 with episodic cluster headaches are
males vs FgtM for chronic
15IHS diagnostic criteria for episodic cluster
headache
- At least 5 attacks fulfilling B-D
- Severe unilateral orbital, supra-orbital and/or
temporal pain lasting 15-180 minutes untreated. - Headache associated with at least one of the
following signs conjunctival injection
lacrimation nasal congestion rhinorrhea
forehead and facial sweating miosis, ptosis,
eyelid oedema. - Frequency once every other day to 8 per day.
- Chronic refers to similar attacks but occurring
for gt 1 year without remission or with remission
lasting lt 14 days.
16Cluster headache (continued)
- Associated features Horners syndrome, nasal
blockage and rhinorrhoea, conjunctival injection - Alcohol and vasodilators may trigger pain during
an attack - Treatment acute 100 oxygen, ergotamines and
triptans preventive ergotamines, methysergide,
corticosteroids, verapamil, lithium
17Chronic paroxysmal hemicrania
- Attacks with same characteristics of pain and
associated symptoms and signs as cluster headache
but short lasting (2-45 minutes), more frequent
(attack frequency 5 a day or more for more than
half of the time), occur mostly in females and
there is absolute effectiveness of indomethacin
(150 mg or less). -
18Trigeminal neuralgia
- FM 21
- Most commonly after age 40 years
- Pain affecting gums, cheek or chin as single or
repeated stabs although in less than 5 forehead
(CNV division 1) may also be affected - Important characteristics are pain intensity,
brevity and tendency to recur in cycles - Pain never crosses to opposite side but may be
bilateral in 3-5. - Majority are idiopathic although compression of
trigeminal nerve by blood vessel in brainstem
most likely cause (gt85). Tumour or angioma can
be seen in up to 6 and lt5 of patients may have
MS. Hence, MRI is diagnostic test of choice.
19Other non-serious headaches
- Post-herpetic neuralgia
- Occipital neuralgia
- Cervicogenic headaches
- Analgesia rebound headaches
- TMJ dysfunction
- Sinusitis
- Low pressure headache post lumbar puncture
- BIH
20Serious causes of headache
- Raised ICP secondary to structural lesion eg
haemorrhage or tumour - Subarachnoid haemorrhage
- Meningo-encephalitis
- Temporal arteritis
- Cerebrovascular disease
21Case history 1
- 25 y.o.female
- Previously well. No past medical history.
- 1 day history of gradual onset generalised
headache, throbbing quality - Vomited x 1, photophobia, phonophobia
- ? Diagnosis
- ? Investigation
- ? Treatment
22Case history 2
- 80 year old female
- 3 week history of intermittent but daily
bifronto-temporal headache - Non-specific visual disturbances with episodic
blurring - Associated myalgias
- ? Diagnosis
- ? Investigations
23Case history 3
- 35 year old male
- Sudden onset of severe generalised headache
whilst lifting weights at gym - Resolved within 10 minutes of ceasing activity
but recurred at same level of activity if
repeated - ? Diagnosis
- ? Investigations
- ? Treatment
24Case history 4
- 15 year old female
- Non-specific generalised headache of gradual
onset with visual obscurations and diplopia on
lateral gaze - Past medical history acne treated with
vibramycin - Clinical examination papilloedema
- ? Diagnosis and investigations