Headache

Approach

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