Table of contents
.
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)).
- 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
- Severe unilateral pain in orbitotemporal region (lasts 15-180min, 1-8x/day)
- Chronic Paroxysmal hemicrania
- ~15min, 8-40x/day
- Responds to INDOMETHACIN!
- 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
Comments