HEADACHE

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HEADACHE

• Southern Neurology

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MIGRAINE

• 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

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IHS 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

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Migraine 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

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Migraine 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.

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IHS 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).

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Factors 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

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Drug 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

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Unusual 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.

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Other 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

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Tension 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

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IHS 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.

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Headache 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.

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Cluster 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

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IHS 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.

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Cluster 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

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Chronic 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).

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Trigeminal 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.

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Other non-serious headaches

• Post-herpetic neuralgia
• Occipital neuralgia
• Cervicogenic headaches
• Analgesia rebound headaches
• TMJ dysfunction
• Sinusitis
• Low pressure headache post lumbar puncture
• BIH

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Serious causes of headache

• Raised ICP secondary to structural lesion eg
  haemorrhage or tumour
• Subarachnoid haemorrhage
• Meningo-encephalitis
• Temporal arteritis
• Cerebrovascular disease

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Case 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

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Case 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

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Case 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

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Case 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