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Headaches

Tension Headache

  • RF: Due to stress or home life
  • Symptoms
    • Band-like tightening sensation across bilateral occipital areas
      • Gradual onset
      • Mild-moderate without pericranial muscle tenderness
      • Non-throbbing
    • Duration: >30mins (4-6hr usually); Constant
    • Location: Bilateral (frontal, occipital, and neck)
    • Absence of autonomic symptoms
    • Absence of nausea, photophobia, and phonophobia
  • Treatment
    • NSAIDs, acetaminophen or aspirin

Medication-Overuse Headache

  • Daily (>15 days per month) exposure to analgesic medications
  • Absence of autonomic symptoms

Trigeminal Autonomic Cephalalgias

  • General
    • Characterized by unilateral trigeminal pain associated with autonomic findings

Cluster Headache

  • RF: More common in men, may occur during sleep  Symptoms • Acute onset unilateral, retroorbital, or periorbital pain (15-180 mins) of severe pain o Occur in clusters of 6-12 weeks separated by periods of remission • Autonomic symptoms present o Eye redness, tearing, ipsilateral Horner’s, lacrimation, agitation, miosis, ptosis, corneal injection/nasal congestion • No visual changes • Follow circadian rhythm • Triggered by small amounts of alcohol or nicotine • Duration: 15-30mins; Episodic throughout the day • Location: Unilateral  Treatment • https://pubmed.ncbi.nlm.nih.gov/20679639/ • https://pubmed.ncbi.nlm.nih.gov/20816442/ • Acute: o Level A  100% O2 at 6-12L/min for 15 minutes  Sumatriptan 6mg SC  ± Zolmitriptan 5mg nasal spray o Level B  Sumatriptan 20mg NS  Zolmitriptan 5-10mg PO • Prophylactic: o Level A  Suboccipital steroid injections o Level C  Verapamil 360mg > lithium 900mg, or ergotamine, topiramate, melatonin 10mg daily

Paroxysmal Hemicrania

https://pubmed.ncbi.nlm.nih.gov/24523000/  Onset 30-40s, no gender predilection  Features • Severe, Throbbing, unpredictable • Last seconds to minutes (2-30 minutes) o Shorter and more frequent than cluster headaches • ≥5 attacks a day • Unilateral in trigeminal distribution • Ipsilateral Autonomic symptoms  Diagnosis: Improvement with indomethacin • Must get MRI to r/o intracranial process  Complications • Chronic Paroxysmal Hemicrania o Daily headache with pain-free periods • Hemicrania Continua o Daily headache without pain-free periods  Treatment • Indomethacin 75mg daily (diagnostic) o Complete response typical o Indomethacin responsive headache syndromes: chronic paroxysmal hemicrania and Hemicrania continua. How they were discovered and what we have learned since  https://pubmed.ncbi.nlm.nih.gov/20626997/ • Refractory o Neuromodulary procedures (greater occipital nerve blockade, blockage of sphenopalatine ganglion, neurostimulation of the posterior hypothalamus)

Primary Stabbing Headache

o Features  Stabbing head pain lasting a few seconds occurring in isolation or in series  No associated autonomic features  Extra-trigeminal in most patients, pain is fixed in ⅓ o Treatment  Indomethacin if recurrent

Migraine

o MC severe headache, 13% of adults annually, 90% of clinic visits o RF: More common in women, FH (+) o Symptoms  Nausea, vomiting, vision changes, scintillating scotoma, and photophobia  Duration: >2 hours but usually <24hr  Location: Unilateral  Neck pain (75%)  “Sinus” symptoms – tearing or nasal drainage (50%) o Diagnosis: ≥5 lifetime attacks lasting 4-72 hours without treatment  Must also have 2 of 4: • Unilateral location • Throbbing nature • Moderate to severe intensity • Worsening with routine physical activity  And must have 1 of 2: • Nausea ± vomiting • Photophobia + phonophobia  Chronic (≥15 days per month) or episodic (<15 days per month)  Subclassified: • Migraine without Aura o Often occipital • Migraine with Brainstem Aura (MBA; Basilar-type Migraine) o Must have ≥2:  Vertigo  Dysarthria  Tinnitus  Diplopia  Bilateral visual symptoms  Hypacusis  Ataxic gait ± speech  Impaired Consciousness o R/O:  Mimics posterior cerebral circulation dysfunction  TIA, Basilar Aneurysm, Temporal Lobe Epilepsy, and BPPV • MRI Brain and MR Angiography of the head and neck  EEG if AMS to r/o seizure o Treatment  Antiemetics  Non-vasoconstricting agents (NSAIDs) • If not responding, Triptans are Ok, otherwise, CI  Discontinue OCPs  CI: Triptans, BBs, Ergotamine  Prevention: Verapamil • Alt: Lamotrigine, amitriptyline, topiramate • Migraine with Typical Aura o Visual (flickering light, diagonal lines) o Sensory (numbness) o Aphasia • With aura o Occurs in 20-30% of patients with migraine, often precedes the pain o Involves positive and negative symptoms (paresthesia vs. Scotomata)  Resolution is gradual and complete o Treatment  https://www.acpjournals.org/doi/epdf/10.7326/AITC201704040 • https://pubmed.ncbi.nlm.nih.gov/28384749/  Acute: • Diphenhydramine 25mg IV prevents dystonic reaction • Mild-Moderate o Tylenol 1000mg + Reglan 5mg • Moderate-Severe o NSAIDs o ≥3 non-responsive to NSAIDs  Triptans (CI: Coronary, Cerebral, PVD, uncontrolled hypertension, Migraine w/brainstem aura or hemiplegic aura) • Primary o Level A  Oral Triptans, Ergotamine, or Metoclopramide > Acetaminophen 1000mg  Oral Sumatriptan (25-100mg PO)  Oral Rizatriptan (5-10mg PO)  Nasal Zolmitriptan (5mg NS)  Subcutaneous Sumatriptan (6mg SC) • 1st line if prominent nausea, moderate-severe pain o Butorphanol 1mg NS o Level B  IV prochlorperazine 10mg or metoclopramide for termination  IV prochlorpromazine o Other  Dihydroergotamine (1mg nasally or SC) • Secondary o Naproxen 250-1000mg o Ibuprofen 400-800mg o Aspirin 325-900mg o Diclofenac potassium (solution) 50mg • Recurrence • Rescue o Prochlorperazine Suppository  May cause akathisia  Prevention: • >4/month or >12hr duration • Often requires months of therapy, continue 6-12 months, then trial off medication • Episodic Migraine o Level A  Betablockers • Propranolol • Timolol • Metoprolol  Antiepileptics • Divalproex Sodium • Topiramate o Level B  Atenolol  Amitriptyline  Venlafaxine 150mg  NSAIDs • Chronic Migraine o Topiramate o Onabotulinum toxin A • Both o CGRPs  Used after 2-3 adequate but unsuccessful trials of oral preventive medication • Other o SNRIs  Duloxetine 60mg o CCBs  Verapamil 240-620mg daily  Flunarizine 5-10mg daily o Other  Cyproheptadine  Gabapentin (1800mg +)  Candesartan 16mg daily • Status Migrainosus o Migraine lasting 72 hours o Treatment  IV dihydroergotamine with antiemetics over 2-3 days • Thunderclap Headache o Definition: Severe attack of headache pain developing abruptly and reaching maximum intensity within 1 minute o Vascular  Subarachnoid Hemorrhage • MCC (25%) of thunderclap headache • Worst headache ever, Nuchal rigidity, Xanthochromia on CSF  Reversible Cerebral Vasoconstriction Syndrome (RCVS) • Reversible segmental and multifocal vasoconstriction of the cerebral arteries o 2nd MCC of thunderclap headaches • Rare condition that can be triggered with: o Medications (Amphetamines, SSRIs) o Immunosuppression o Postpartum • Features o Recurrent, after childbirth o Maximal at onset o With or without associated focal neurological deficits and seizures o Beading of the major intracranial arteries o Normal CSF • Treatment o Verapamil has been associated with reduction in neurologic adverse events  Aneurysmal Thrombosis or Expansion  Cerebral Hemorrhage  Cervical Arterial Dissection  Cerebral Venous Thrombosis  Hypertensive Crisis  Pituitary Apoplexy o Non-Vascular  Spontaneous Intracranial Hypotension/Hypovolemia  Colloid Cyst of the 3rd Ventricle  Meningitis  Sinusitis  Primary Cough, Sexual, or Exertional Headache • Benign Sexual Headache  Primary Thunderclap Headache (Idiopathic) • Trigeminal Neuralgia • Temporal Arteritis o Transient retina, choroid, or optic nerve ischemia o Sudden-onset dull throbbing temporal headache, muscle aches, jaw claudication, fever, and visual loss, elevated ESR o Diagnosis: Temporal Artery Biopsy after high dose steroids o Treatment  High dose corticosteroids if vision loss  Oral corticosteroids if no symptoms  ± low dose aspirin • Brain Tumors o Dull, gradual worsening associated with neurologic signs o Worse at night and wakes patient from sleep, aggravated by increased ICP o Nausea, vomiting, syncope, focal neuro deficits o Papilledema o Diagnosis: CT of the head • Pseudotumor Cerebri • Cerebral Abscess