Term
| What are the 10 major types of head-aches? |
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Definition
1) Primary
- Migraine
- Tension-type
- Cluster
- Miscellaneous
2) Secondary
- Post-traumatic
- Vascular disorder
- Non-vascular intracranial (neoplasm, meningitis)
- Withdrawal
- Systemic infection or metabolic disorder
- Cranial or Extra-cerebral lesion |
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Term
| What are the "nasty nine" red flags for secondary headache disorders which necessitate getting an MRI or LP? |
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Definition
1) First/worst headache
2) Abrupt onset
3) Progression or fundamental change in pattern
4) New headache if <5 or >50
5) New headache with cancer, immunosuppresion or pregnancy
6) With syncope (loss of consciousness) or seizure
7) Triggered by exertion/sex
8) neurological symptoms >1h
9) Abnormal general or neurological exam |
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Term
| What is the threshold for considering a headache disorder as being chronic vs. episodic? |
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Definition
| >15 times per month for >6 months |
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Term
A patient presents with a headache that is mild/moderate in intensity. She claims that she has had it for 4 days.
It is bilateral and non-pulsatile, and remains unchanged with exercise.
It is most commonly triggered when the patient is under stress, but there is no vomiting, nausea or phonophobia.
What kind of headache is this? |
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Definition
Sounds like Episodic Tension-Type headache (if it lasts for >15 days a month, it may be chronic).
Remember, for TT headaches
1) 30min- 7 days (either <15 days per month or >15 for chronic)
2) At least 2
- Pressing/tightening
- Mild/moderate severity
- Bilateral
- No aggravation with physical exercise
3) No vomiting, and no more than one of nausea, photophobia, phonophobia.
These are usually not serious and are often just self-medicated with aspirin |
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Term
A patient presents with a headache that has been recurring over several weeks (usually between 2-4 per day).
The pain is intense perioorbital pain on the left side and lasts minutes-hours.
There is evidence of lacrimation and nasal congestion on the left side as well.
What kind of headache is this? |
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Definition
Episodic Cluster Headache (rare)
- Usually associated with nasal or ocular autonomic features
- Can vary from one every other day to 8 per day |
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Term
| A patient complains of a "sinus headache." What is most likely going on? |
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Definition
90% of reported sinus headaches actually meet criterion for migraine (25% of which have aura)
Without aura
- at least 5 attacks lasting 4-72 hours (untreated)
- at least 2 of (unilateral, pulsating, moderate or severe intensity, aggravation by activity)
- at least 1 of (nausea, photophobia and phonophobia)
with Aura
- at least 2 attacks with 3 of the following features
- one or more fully reversible aura
- at least one aura symptoms that develops gradually over >4 minutes
- no aura lasts >60 min
- attack follows aura with a free interval of <60 minutes |
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Term
| What are the diagnostic criteria for Migraine Headaches without Aura? |
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Definition
1) at least 5 attacks lasting 4-72 hours (untreated)
2) at least 2 of (unilateral, pulsating, moderate or severe intensity, aggravation by activity)
3) at least 1 of (nausea, photophobia and phonophobia) |
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Term
| What are the diagnostic characteristics for Migraine headaches with aura? |
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Definition
1) at least 2 attacks with 3 of the following features:
- one or more fully reversible aura symptoms
- at least one aura symptoms that develops gradually over >4 minutes
- no aura lasts >60 min
- attack follows aura with a free interval of <60 minutes |
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Term
A patient presents with a headache that is moderate/severe intensity with throbbing pain.
She claims that it gets worse with exercise and that she has had 5 such attacks in the past, all of which have been unilateral and accompanied by some nausea.
.
What kind of headache is this? |
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Definition
Migraine without aura.
Criteria
1) at least 5 attacks lasting 4-72 hours (untreated)
2) at least 2 of (unilateral, pulsating, moderate or severe intensity, aggravation by activity)
3) at least 1 of (nausea, photophobia and phonophobia) |
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Term
| What is the "Headache Pattern Recognition" Screen? |
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Definition
1) How often do you experience it (days per month)?
2) How often do you experience headache of any severity (days per month)?
3) Has there been any change in these headaches over the past 6 months?
4) How often do you take prescription/over the counter meds? |
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Term
| What is the basic pathophysioogy of tension headache? |
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Definition
1) Pericranial myofascial tightness and tenderness
2) Elements of peripheral and central neuronal sensitization |
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Term
| What is the basic pathophysioogy of cluster headache? |
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Definition
- Activation of inferior posterior hypothalamus on fMRI
- Pain comes from both autonomic and trigeminal vascular circuits |
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Term
| What is the basic pathophysioogy of migraine headache? |
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Definition
1) genetically or traumatically "sensitized" CNS (hyperexcitability)
2) Dorsral-medial midbrain and dorsal-lateral pons by PET and fMRI (regions of dorsal raphe nuclei, periaqueductal gray and locus ceruleus)
3) Perhaps substantia nigra and red nucleus as well
- Could reflect "enhanced" sensitivity to enviornment rather then being defective.
- Risk factors include strong sensory stimuli, dietary stimulants and disruptions in chronobiological patterns |
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Term
| What is the neurological basis for "aura" in migraines? |
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Definition
1) PAINLESS wave of electrical excitation/depolarization, followed by period of "spreading cortical depression" across occipital cortex (3-6mm per minute)
- leads to activation of trigeminal system.
2) Secondary vascular effect with wave of hyperemia followed by zone of oligemia
- CGRP (vasodilator)
- Substance P (leakage of BBB)
- Neurokinin A (inflammation) |
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Term
| Where is the pain of migraine headaches thought to arise from? |
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Definition
Activation of trigeminal vascular system
1) Nerve terminal (opthalmic branch) release vasoactive chemicals such as Calcitonin gene related peptide (CGRP), substance P and neurokinin A leading to vasodilation and neruogenic sterile inflammation
2) Events are transmitted by CN V back to spinal trigeminal nucleus, integrating with signals from extracranial structures served by CN V.
3) Input from upper cervical roots is also integrated, and connections between spinal trigeminal nucleus and superior salivatory nucleus are also established ("Sinus" and "Tension" presentations of migraines). |
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Term
| What are some migraine headaches experienced as "sinus" or "tension" type headaches? |
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Definition
1) Tension
-Input from upper cervical roots is integrated with input from CN V coming from trigeminal-vascular interface where vasodilation and inflammation takes place
2) Sinus
- connections between spinal trigeminal nucleus and superior salivatory nucleus are also established |
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Term
| What types of headaches are the most concerning clinically? |
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Definition
Secondary headaches (they suggest a serious underlying cause).
Post-traumatic
- Vascular disorder
- Non-vascular intracranial (neoplasm, meningitis)
- Withdrawal
- Systemic infection or metabolic disorder
- Cranial or Extra-cerebral lesion |
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Term
1) What percentage of Americans suffer from Migraine headaches?
2) What percentage of those that present to the physician suffer from Migraines? |
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Definition
1) 13% (18% women and 6% men) get migraines.
- 25-30% of women ages 40-50 get it!
2) 94% present with either migraine (76%) or migrainous (18%) |
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Term
| Where does pain during headaches arise from? |
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Definition
Dura, Periosteum and Vessels (Trigeminovascular path)
- Vessels and dura are the victims of V1 nerve ending stimulation.
- Superior salivatory gland is also activated by the spinal trigeminal nucleus.
- Sinus pressure from V2. |
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Term
| What are the major differences between Cluster Headaches and Migraines in terms of clinical manifestations and treatment? |
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Definition
If it lasts < 3 hours, involves restlessness/pacing and autonomic features, THINK CLUSTER
If it lasts 4-72 hours, the patient is lying down still, think migraine (94% of the time you will be right!)
1) Cluster will present with pacing/restlessness and potent autonomic features (Ptosis, Miosis, Lacrimation) for 15-180 minutes.
- Treat with acetominophen or acetylsaliylic acid
2) Migraines last 4-72 hours (longer)
- often unilateral, pulsating, moderate/severely intense and are aggravated by activity.
- Have Nausea/vomiting and/or phonophobia/photophobia |
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Term
| What is the chronological course of a migraine headache with aura? |
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Definition
1) Prodrome
- mood, fatigue, muscle pain and food cravings
2) Aura
- reversible <1h
- Vocal/vision/speech
3) Early Headache
- Dull with nasal congestion (V2 of trigeminal)
4) Migraine
5) Post-migraine |
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Term
| How is it that blind people can with suffer migraines with photophobic symptoms? |
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Definition
Retinitis Pigmentosa spares the melanopsin neuronal path, which preserves diurnal circadian rhythms.
This pathway converges with input from the spinal trigeminal ganglion in the thalamus. |
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Term
| What is the basic 4-neuron pathway of pain generation in the context of migraine? |
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Definition
1) Trigeminal nerve
2) Spinal Trigeminal Nucleus (Pons)
3) Thalamus (VPM)
4) Cortex |
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