Headache

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    Approach

    HeadacheApproachChart.png

     

    Criteria for Migraine Headaches

    • Headache lasting 4 to 72 hours
    • Headache with at least two of the following characteristics:
      • Is unilateral
      • Is pulsatile
      • Is of moderate or severe intensity
      • Is aggravated by routine physical activity
    • Headache accompanied by at least one of the following associated symptoms:
      • Nausea and/or vomiting
      • Photophobia and/or phonophobia
    • At least five headache attacks that fulfill these criteria
    • History and findings from physical and neurologic examinations not suggestive of any underlying organic disease
    • Management:
      • NSAIDs (1st line)
      • Triptans
        • Oral, Nasal, subligual (less effective), and SC exist. 
        • Subcutaneous sumatriptan available for refractory migraine without aura
      • Opioids and butalbital should be avoided (no evidence, and increased risk to transform into chronic migraines)

     

    • Loder E. Triptan therapy in migraine. N Engl J Med. 2010;363(1):63-70. PMID: 20592298

     

    Trigeminal Autonomic Cephalalgia

    • trigeminal nerve-mediated pain and ipsilateral autonomic features (lacrimation, ptosis, conjunctival injection, nasal congestion, rhinorrhea). 
    • Pain described as searing, sharp, penetrating.
    • They differ in duration and frequency of episodes.
    • Three types (but more exist);  (All distributed to V1 (opthalmic distrubition of V1 nerve)).
    1. Cluster headache
      • Severe unilateral pain in orbitotemporal region (lasts 15-180min, 1-8x/day)
        • Associated with ipsilateral autonomic features (tearing, rhynorrhea, motor restlessness).
        • Episodes Last 6-8weeks, followed by remission 2-6mo.
      • Risk Factors: male, tobacco use.
      • Flare:
        • Oxygen by face mask at 10L/min for 10 minutes. (75% efficacy)
        • Oral triptans do not work, can try subcutaneous or intra-nasal sumatriptan.  Zolmitriptan also can be effective.
      • Prevention:
        • Verapamil
        • Oral corticosteroids
    2. Chronic Paroxysmal hemicrania
      • ~15min, 8-40x/day
      • Responds to INDOMETHACIN!
    3. Short-lasting unilateral neuralgiform headache + conjunctival injection + tearing (SUNCT syndrome)
      • Dozens of hundreds of times daily, lasts seconds to minutes.
      • NO known therapy.
    • Trigeminal Neuralgia is different
      • Pain lasts 2-3s, recurs in jabs or stabs of pain.
      • Paroxysms with pain-free periods lasting seconds to hours.
      • Painful episodes occur with trigger zones (mouth and nostrils)
      • Different from above: involves V2 and V3 distribution, and no autonomic symptoms
      • Responds to carbamazepine.

    Subarachnoid Hemorrhage

    • Definitions:
      • "Thundercalp Headache", "Worst headache of life"
      • Defined as: Severe headache that reaches maximum intensity within 60s of onset. 
      • 25% of "Thunderclap Headache" is SAH --> Neurosurgical Emergency
    • Other Dx:
      • dural sinus
      • thrombosis
      • meningitis
      • migraine
    • Diagnosis:
      • 1st test: Non-Contrast Head CT
      • 2nd test: (if CT negative) --> Lumbar Puncture
        • Evaluate for erythrocytes or xanthochromia.
        • Xanthochromia describes a yellow discoloration of the CSF from breakdown of erythrocytes, which may not develop for at least 6 hours after the initial event.
      • Normal CSF has a very good negative predictive value (generally excludes)
      • 3rd Test: (If all normal) --> rule out other causes:
        • MRI Head
        • MRI Angiography: Cervicocephalic arterial dissection, internal carotid artery dissection (often Horners)
        • MRI Venography:  Deep venous thrombosis and cerebral venous sinus thrombosis. 
    • Treatment:
      • Neurosurgical referral
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