PRIMARY HEADACHES

TRIGEMINAL AUTONOMIC CEPHALALGIAS

Cluster headache, paroxysmal hemicrania, SUNCT.

Short lasting attacks associated with cranial autonomic symptoms.

Severe pain- more than once a day Patients with TACs should undergo pituitary

imaging and pituitary function tests.

CLUSTER HEADACHE

Pain- deep, non-fluctuating and explosive Core feature- periodicity Daily bouts of 1-2 attacks; short duration

U/L pain for 8-10 weeks a year; pain free interval averages1year.

Patients move about during attacks- pacing, rocking or rubbing the head for relief.

Associated with ipsilateral symptoms of cranial parasympathetic autonomic activation.

Photophobia/ phonophobia if present tend to be U/L.

Treatment of CH

CH attacks peak rapidly and thus treatment with quick onset is required. 100 % oxygen inhalation. Sumatriptan 6 mg s/c or 20 mg nasal spray

Preventive managementShort term- prednisolone/ verapamilLong term- verapamil/ lithium/ topiramate/ gabapentin.

PAROXYSMAL HEMICRANIA

U/L, very severe pain Short lasting attacks (2- 45 mins) Very frequent attacks (>5/ day) Marked autonomic features I/L to the pain Rapid course (< 72 hrs) Excellent response to Indomethacin. Male: Female ratio- 1:1 Pain tends to be retroorbital Treatment of choice- Indomethacin

SUNCT/ SUNA

Severe, U/L orbital/ temporal pain Stabbing/ throbbing in quality. 3 basic patterns:

single stabs- short livedgroups of stabslonger attacks ( saw tooth phenomenon)

DiagnosisCutaneous triggerability of attacksLack of refractory period b/w attacksLack of response to Indomethacin

Secondary/ symptomatic SUNCT seen in posterior fossa/ pituitary

lesionsevaluate with pituitary function tests

and a brain MRI with pituitary views

TreatmentAbortive- I/V Lidocaine Preventive- Lamotrigine (200- 400 mg/

day)Other drugs- Topiramate/

Gabapentin

OTHER PRIMARY HEADACHES

1. HEMICRANIA CONTINUA

moderate and continuousU/L asso with fluctuations of severe

paincomplete resolution with

Indomethacinexacerbation may be asso with

autonomic featureswomen affected twice as often as

men

2. PRIMARY STABBING HEADACHE

stabbing pain confined to headsingle/ series of stabsabsence of asso cranial autonomic featuresabsence of cutaneous triggering of attackspatterns of regular recurrence at irregular intervals described as “ ice-pick pain” or “jab and jolts”

3. PRIMARY COUGH HEADACHEgeneralized headachesudden onset; lasts for several minutesprecipitated by coughingtypically older patients

4. PRIMARY EXERTIONAL HEADACHEfeatures ~ to both cough headache and migraineprecipitated by any form of exerciseB/L, throbbing headache

5. PRIMARY SEX HEADACHEprecipitated by sexual excitementdull B/L- suddenly becomes intensereported more often in men

6. PRIMARY THUNDERCLAP HEADACHEsudden onset of severe headacheabsence of any known provocationshould be vigorously investigated with neuroimaging (CT/ MRI with MR angiography) and CSF exmntn.

7. HYPNIC HEADACHEtypically begins a few hours after sleep onsetlast for 15-30 mins.moderately severe and generalizedmost patients are femaleonset usually after age 60photophobia/ nausea usually absentmajor secondary consideration- poorly controlled HTN.

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