Headache Disorders

Adam Quick, MD

Department of Neurology

adam.quick@osumc.edu

Objectives

Be able to list the important questions to ask when taking a history from a patient with recurrent headaches.

List the most important things to check on neurologic examination in a patient with headaches.

Distinguish a dangerous headache (such as subarachnoid hemorrhage, meningitis, expanding mass lesion or temporal arteritis) from benign/primary headaches.

For each of the major primary headaches, describe the typical clinical features: frequency, onset, location, duration, character, premonitory symptoms, accompanying features, triggering or provocative features, ameliorating features, family history.

Describe briefly current theories of altered neuronal activity in the etiology of migraine and cluster headaches.

Describe the physiological and clinical manifestations of headaches

At the end of the module, you will learn to:

Headache

Headaches are an extremely common problem Most people will experience a headache of some sort during their

lifetime Primary headache disorders are headache syndrome that are not

caused by another medical problem – the headache syndrome IS the disorder itself

First purpose of history and examination is to distinguish benign recurrent or primary headaches from secondary headaches that suggest the possibility of a life-threatening event or condition

History Taking

Age of onset Frequency – single vs recurrent Onset, rate of progression Character of pain: pressure, stabbing,

throbbing, pounding Location of pain Severity of pain Duration

Symptoms Suggestive of Primary HA Disorder Stable pattern of headache over time…even if the

current headache is a little atypical Follows pattern of a defined primary headache Positive family history

Most common with migraine Headache improves with sleep Headache worsened during or just prior to menses in

women Normal physical and neurological examinations

Additional Headache history

Premonitory symptoms - auras Associated symptoms such as nausea, vomiting,

photophobia, phonophobia, tearing, ataxia, visual disturbances, numbness, other focal neurologic symptoms

Provocative and ameliorative symptoms And do you have several different types of headache

types? Important medications: oral contraceptives, analgesic

medications, anti-platelet agents

Headache Warning Signs First or worst headache of life Abrupt new headache symptoms or clear change in

headache pattern New onset headache after age 50 Headache that disrupts sleep or is present upon

awakening Headache brought on by exertion or coughing Headache with a significant positional component New headache following head trauma Signs/symptoms of systemic illness: fever, night

sweats, weight loss Neck stiffness Alterations in personality, behavior or consciousness Abnormal neurologic exam

Physical Examination

Vital signs: pulse, blood pressure, fever General systems examination: rash Pupils,visual fields and fundi (papilledema and retinal

hemorrhages) Localizing signs on neurologic exam Signs of meningeal irritation – meningismus or neck

stiffness Superficial temporal artery pulses

Diagnostic Testing

Labs that may be useful include :CBC, Erythrocyte sedimentation rate, Thyroid Stimulating hormone level and toxicology

Lumbar Puncture Neuroimaging

Lumbar Puncture Crucial in several clinical situations

First or worst headache of the patient’s life Headache associated with altered mental status or fever Progressively worsening headache Postural headache An atypical chronic and intractable headache

Generally in a patient presenting with headache it is reasonable to get imaging (CT) prior to LP

Indications for Neuroimaging Any unexplained objective abnormality

on neurological exam Rapidly increasing headache frequency History of being awakened by

headache New headache in patients with cancer

or immune deficiency H/O IV drug use Recent head trauma or history of falls

(especially in elderly) New-onset HA after age 50 HA precipitated by coughing, sexual

activity, exercise Fever, personality changes or altered

level of consciousness Head CT has about a 95% chance of

finding sub-arachnoid hemorrhage within the first 24 hours

Headache – Initial Impression

After taking the history and performing an exam, you should be able to categorize the headache as most likely a primary headache disorder such as migraine or tension headache vs. a secondary headache from a process such as meningitis or intracranial hemorrhage.

Life-Threatening Headache Conditions

Subarachnoid hemorrhage Intraparenchymal hemorrhage Meningitis/Encephalitis Expanding mass (tumor, abscess) Hypertensive crisis Temporal arteritis

•PRIMARY HEADACHE DISORDERSMIGRAINETENSION HEADACHECLUSTER HEADACHE

MIGRAINE

The word migraine is French in origin and comes from the Greek hemicrania

(as does the Old English term megrim)

hemicrania means “half the head"

Migraine Headache

Common disorder with peak prevalence in middle age 15-18% of females!!!! 6% of males 7% of children Onset usually in 2nd or 3rd decade, prevalence increases

to age 40 and then declines Males more commonly have onset prior to puberty and frequently

improve in their late teens and 20’s Females more commonly have onset during puberty and may

see a remission at menopause

Diagnostic Criteria for Migraine

Defined as at least 5 episodic attacks of HA lasting 4 to72 hr with two of the following symptoms:

Unilateral pain Pulsating or throbbing type of pain Pain of moderate-severe intensity Aggravation with movement, or activity

And one of the following: nausea and/or vomiting; photophobia or phonophobia

Migraine Aura Seen in about 30% of migraine patients Cortical spreading depression - a wave of oligemia

that passes across the cortex at the rate of 2-6 mm per minute preceded by initial short phase of hyperemia

Oligemia is a response to depressed neuronal activity and is still present with the headache begins

Visual: scintillating scotoma (loss of portion of the visual field), flashing lights, spots, colors, “fortification spectra”

Somatosensory: numbness, tingling Can occur before, during or after the headache

phase

Spreading cortical depression

Scintillating scotoma

More scintillating scotomata

Aura - Frequency in Migraineurs

Frequency of migraine types:

64% - only w/o aura

18% - only with aura

13% - both with and w/o aura

5% - Aura without headache Therefore only 31% of patients with headache have aura

Diagnostic Criteria for Migraine with auraAt least 2 attacks fulfilling criteria for migraine without aura plus: Fully reversible visual symptoms including positive features

(flickering lights or spots) and/or negative features (scotoma) Fully reversible sensory symptoms including positive features such

as “pins and needles” and/or negative features such as numbness Fully reversibe dysphasic speech And at least 2 of

Homonymous visual symptoms or unilateral sensory symptoms At least one aura symptom develops gradually over > 5 minutes and/or different

aura symptoms occur in succession over >5 minutes Each symptom lasts 5-60 minutes duration

Headache occurs during or within 60 minutes of aura Not attributable to another disorder

Interesting migraine variants

Hemiplegic migraine – “stroke-like” Basilar migraine (brainstem findings such as vertigo,

ataxia, dysarthria, diplopia, confusion or alteration in level of consciousness)- despite the name there is no evidence that there is any involvement of the basilar artery physiologically

Retinal migraine – blindness in one eye

Migraine Pathogenesis Exact pathogenesis is not known A current leading theory is that there is neuronal hyperexcitability of the

cerebral cortex (a decreased threshold for activation – perhaps via calcium channel function abnormalities).

Excessive cortical neuron firing may then trigger cortical spreading depression and activation of the trigeminovascular system- location of pain sensitive structures When activated can cause the release of substance –P,CGRP Local vasodilatation and plasma leakage Neurogenic inflammation

Experimental evidence also shows dysfunction of brainstem pain and vascular control centers: Locus ceruleus, raphe nuclei, periaqueductal gray.

The sensory component of trigeminal nerve (trigeminal nucleus caudalis) is in a persistent hyper-excitable state

Suprachiasmatic nucleus may play a role

Migraine Triggers- these may alter cortical excitability Fasting Alcohol consumption Oral contraceptives/HRT Caffeine or caffeine withdrawal Foods: chocolate, aged cheeses, MSG, nitrites,

dairy products Stress or release from stress Sleep – too little or too much Bright lights, loud noises

Acute Treatment of Migraine

Analgesics/NSAIDs Antiemetics for nausea/vomiting Midrin Ergots - potent vasoconstrictors Triptans - serotonin 5-HT 1B/1D receptor agonists Narcotics - try to avoid

Triptans

Sumatriptan (Imitrex) - po, sq, pr, intranasal Zolmitriptan - (Zomig) Naratriptan – (Amerge) Rizatriptan - (Maxalt) Frovatriptan – (Frova) Almotriptan – (Axert)

Migraine Prophylactic Treatment

Beta-blockers: propanolol, metoprolol, nadolol, timolol TCA - amitriptyline, nortriptyline Calcium channel blockers: verapamil Anticonvulsants: topiramate, valproate Herbals: feverfew, butterbur

TENSION HEADACHEAdam Quick MD

Tension Headache

Thought to be the most common type of primary headache Lifetime prevalence of 30-78%

Persistent non-pulsating band like pain Clinical Presentation

Lasts 30 minutes to 7 days 2 of the following

Bilateral location Pressing/tightening (non-pulsating) quality Mild or moderate intensity Not aggravated by routine activity

Both of No nausea or vomiting No more than one of photophobia or phonophobia

Exact pathophysiology is unknown

Treatment of Tension Headache

NSAIDs Midrin TCA Non-pharmacological treatment

Relaxation, exercise, stress management, good sleep hygiene

CLUSTER HEADACHEAdam Quick MD

Cluster Headache Much less common than migraine or tension headache Male to female ratio of 5:1 High prevalence between ages of 20-40 Occurs in clusters lasting weeks or months Striking periodicity Pathogenesis

Less clearly understood than migraine headache Involves hypothalamus which controls circadian rhythms Functional hypothalamic dysfunction has been confirmed by abnormal

metabolism based on magnetic resonance spectroscopy and positron emission tomography

Excessive discharge of cholinergic activity is prominent Central disinhibition of nociceptive and autonomic pathways Increase blood flow through the orbit

Abnormal metabolism on PET scan

Clinical Manifestations of Cluster Headache Sudden, severe attacks of unilateral periorbital pain

Almost always stays on the same side Lasting from 15 minutes to 180 minutes Conjunctival injection, lacrimation, ptosis and nasal congestion Attacks occurs in clusters

One headache every other day to >5 in one day 2 weeks to 3 months 1-2 times/year

Commonly awakens person from sleep Clusters of headache may last several weeks and remit for months or years One of the worst pains known to humans

Patients will roam around, bang their heads on walls, extremely aggitated

Some consider suicide

Treatment Acute Therapies

High flow Oxygen Ergotamine Sumatriptan

Preventative Treatments Verapamil Prednisone Lithium Topamax Methysergide maleate Cyproheptadine Valproic sodium

Medication-Induced Headache Very common problem in patients with frequent

headaches People with recurrent headaches who take analgesics

such as aspirin, acetaminophen, non-steroidal anti-inflammatory medications or narcotics such as codeine may transform their headaches into a chronic daily headache through a poorly understood mechanism.

The goal is to manage frequent headaches effectively before this happens.

Goal should be to limit acute treatment to 2 days per week or less

Patients must be weaned off the culprit medication to see improvement Often done in conjunction with administration of a headache

preventative agent such as topiramate

Summary When taking a headache history and performing a physical exam, be certain

to focus on clinical features that can help you distinguish a primary headache disorder from a more threatening secondary headache

Migraine headache Very common primary headache that affects women more than men and typically

produces unilateral or bilateral throbbing pain of moderate to severe intensity with associate nausea/vomiting, light and sound sensitivity, worsened by activity.

Migraine aura affects a subset of patients with migraine and often produces visual phenomenon or other neurological symptoms

Tension headache is another common primary headache characterized by a aching, band-like pain

Cluster headache is one of a group of primary headache disorders known as the Trigeminal Autonomic Cephalgias One of the worse pains known to humans Seems to be associated with circadian rhythms and weather changes

Headache Quiz

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Adam.quick@osumc.edu

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