Neurology Diagnostic Evaluation

Headache & Migraine

Alejandro Diaz, M.D. Headache

**Diaz’s lecture is verbatim from Adams Principles of Neurology. I

inserted his notes on each important topic and adopted some from Warning signs
Adams. I haven’t acquired the original powerpoint yet. This transcription NO YES
present
is outlined from previous years’ lectures. Sana makatulong for
Monday’s quiz. Good luck! ☺
Primary Secondary
General Considerations Headache Headache
1. Quality
- Most headaches are dull, aching & NOT sharply localized
(which are seen in disease of structures deep to the skin)
Investigations
- The most important information to be obtained is whether
the headache throbs, indicating a vascular sensitivity
2. Location Mechanisms of Cranial Pain or Headache
- More informative 1. Distention, traction & dilatation of intracranial & extracranial
- Lesions of paranasal sinuses, teeth, eyes, & upper cervical arteries
vertebrae induce a less sharply localized pain, but one that 2. Infection or blockage of paranasal sinuses
is still referred to a certain region, usually to the forehead, 3. Hypermetropia & astigmatism: headache of ocular origin
the maxilla or around the eyes 4. Spasm, inflammation, trauma to cervical & cranial nerves
- Posterior fossa lesions cause pain the occipitonuchal region 5. Meningeal irritation
- Supratentorial lesions induce frontotemporal pain which 6. Others: activation of brainstem structures
approximates the site of lesion
- But localization may also be deceiving. Pain in the frontal Note:
regions may be due to diverse lesions & mechanisms as  Headaches that accompany disease of ligaments, muscles &
glaucoma, sinusitis or thrombosis of the vertebral or basilar apophyseal joints in the upper part of the spine are referred to the
artery occiput & nape of the neck on the same side
3. Intensity
- Better index of severity is the degree to which it has MIGRAINE
incapacitated the px i.e., if activities of daily living are
disrupted by the headache Migraine Without Aura (Common Migraine)
4. Time course  Headache has ≥ 2 of the following:
- The ff are examples:  Unilateral
 Subarachnoid hemorrhage: abrupt attack with maximal  Throbbing
severity in a matter of minutes  Moderate-severe
 Migraine: brief sharp pain in the eyeball  Aggravated by movement
(ophthalmodynia) or cranium  One of the following:
 Classic migraine: early morning hours or daytime,  Nausea
reaches peak in a half hour or so, lasts for 4-24hrs  Photo & photophobia
unless treated  Similar pain in the past & no evidence of organic disease
5. Precipitation & relieving factors
- The ff are examples: Migraine With Aura (Classic Migraine)
 Migraine: in some women, attacks happen  Headache preceded by ≥ neurologic symptom
premenstrual  Visual
 Headache of cervical arthritis: intense after a period of - Scintillating scotoma
inactivity such as a night’s sleep - Fortification spectra
 Hypertensive headaches: induce by emotional stress & - Photopsia
excitement  Sensory
- Numbness
Note: - Paresthesia
 Headache early in the morning then px coughs, consider an early  Others
malignancy. You may want to request for CT or MRI even if - Weakness
neurological examination is normal. - Aphasia
 Migraine is more common in women than in men & peaks at
middle-aged adults Variants of Migraine
 Tension type of headache: most common variety of headache 1. Headache accompany the neurological abnormalities rather than
follow them
2. Vertebrobasilar migraine – typical migraine except that they
occupy the whole of both visual fields
 3. Ophthalmoplegic migraine – recurrent unilateral headaches Nasal Endoscopy
associated with EOM palsies; usual picture is transient third nerve  With moderate to severe “sinus” headache
palsy with ptosis  Trigeminovascular reflex: Activation of cranial parasympathetic
4. Hemiplegic migraine – episodes if unilateral paralysis that may nerves to sinuses
outlast the headache  Not merely vascular, brain problem
5. Status migrainosus – pain is unilateral, throbbing & disabling;
continuous migraine throughout the day Stress: most frequent migraine trigger
6. Complicated migraine – neurologic symptoms leaving a  Stress
permanent defect (i.e., homonymous visual defect)  Menstruation
7. Premenstrual migraine  Strong odors
 Changes in sleep
TENSION HEADACHE  Skipping meals
 Headache has ≥ 2 of the following:  Physical exertion (Endorphins: morphine-like substances)
 Bilateral
 Pressing, tightening (non-pulsating quality) Deep White Matter Lesion
 Mild or moderate intensity  MRI lesion: white matter lesion
 Not aggravated by movement  Micral infarcts
 Can cause decrease in cognitive
Pattern Recognition
 Migraine: Episodic Risk Factor Modification
 Tension type headache: continuous usually in the afternoon  Don’t skip meals
 Combination  Drink 8 or more glasses of water
 Cluster headache  Sleep
 Trigeminal neuralgia: brief, excruciating pain  Coffee: 200mg/day has an anti-headache property
 Intracranial lesions: gradual, becoming progressive, think space  Structured treatment plan
occupying lesion  Exercise

International Classification (ICH) of Headache Disorders Triptans (Sumatriptan)

 Primary Headache  Long-acting: half-life of more than 6 hours
 Migraine  Be careful in heart conditions: may cause ischemia
 Tension type  Frova
 Cluster & other trigeminal autonomic cephalgias  Amerge
- episodic & chronic  Short-acting: half-life of less than 4 hours
- paroxysmal hemicrania  Imitrex
- SUNCT  Relpax
 Other primary headaches  Zomig
- stabbing  Maxalt
- cough  Axert
- sexual activity
- hypnic Migraine Prophylaxis
- thundercap  Proven, accepted
- hemicrania continua  β-blockers: Propanolol, Metoprolol – but this is usually given
 Secondary Headache in high doses to take effect; risk of hypotension
 Head & neck trauma  TCAs: Aminotriptylline
 Cranial or cerebrovascular  Pizotifen
 Non-vascular or cranial disorder  Valproate
 Substance or its withdrawal  Topiramate
 Infection  Flumerizine: Increase incidence of Parkinson’s
 Disease homeostasis  Methylsergide
 Disease of neck, eyes, ears, nose, sinuses, teeth, mouth  Widely used, little evidence
 Psychiatric  Verapamil
 Cranial neuralgias  SSRI
 Headache not classifiable elsewhere  SNRI
 Promising: Gabapentin
Simple Diagnostic Screening Tool
 3-item screener identified: Name, photophobia, disability When to use preventive
 Scoring positive on 2 of 3 positive items  Traditional approach
 Positive predictive value: 93.3%  Increasing frequency of migraine attacks
 Acute medication > 2 days per week
 Inadequate acute treatment response
 Co-morbid disease issues
 Patient preference
TCA (Tricyclic antidepressants) Transformed Migraine
 Possible side effects:  Analgesic abuse associated with withdrawal headaches
 Drowsiness  Can be treated with Botox
 Dry mouth
 Constipation Vascular Theory
 Weight gain  Headache is caused by extracranial vasodilatation
 Cardiac arrhythmia
 Avoid with: Neuronal Theory
 Suicide risk  Slowly-moving, K+-liberating depression of cortical activity
 Bipolar disorders  Hypoxia, mechanical trauma
 Epilepsy  Fortification spectrum – disturbance of vision during migraine
 Conduction block attacks with formatting of dazzling zigzag lines
 Dysrhythmia
Temporal Arteritis
Topiramide  Inflammatory disease of cranial arteries
 Possible side effects:  In elderly people >55 y/o
 Paresthesias  Threat of blindness
 Nausea  Explosive onset of headache; increasingly intense throbbing or
 Weight loss nonthrobbing headache often with superimposed, sharp stabbing
 Altered sense of taste pains
 Memory loss  Dull & boring pain
 Word-finding difficulty  Worst at night
 Avoid with:  Scalp tenderness
 History of kidney stones  Tx: prednisone
 Glaucoma
Brain Tumor
Botulinum Toxin Use for Headaches  30% of pxs with brain malignancy experience headache
 First described by Binder  Pain is usually nondescriptiv
 Botulinum toxin given for cosmetic reasons resulted in significant  Intermittent deep pain
headache improvement in migrainers  Moderate intensity
 Significant improvement in headache intensity & days in patients  Worsen with exertion or change in position; rest diminishes its
getting 23 units of botulinum toxin frequency
 Blocks exocytosis of acetylcholine  May be associated with nausea & vomiting
 Blocks release of pain chemicals (neurokinin, substance P,  As the tumor grows, pain becomes more frequent
cGRP)
 Pain relief faster than relaxation of muscle

Posttraumatic Nervous Instability

 Headache is a prominent feature comprising of giddiness,
fatigability, insomnia, nervousness, trembling, irritability, inability
to concentrate & tearfulness
 Requires supportive therapy in the form of reassurance

Whiplash Injuries
 Of the neck, may be unilateral or bilateral retroauricular or
occipital pain due probably to stretching or tearing of ligaments &
muscles at the occipitonuchal junction

Posttraumatic Dysautonomic Cephalalgia

 Syndrome comprising of severe, episodic, throbbing, unilateral
headaches accompanied by ipsilateral mydriasis & excessive
sweating of the face thus stimulating migraine or cluster
headache

Chronic Subdural Hematoma

 Headache progresses or changes in intensity with a change in
position
 Deep-seated, steady, unilateral or generalized accompanied by
drowsiness, confusion, stupor & hemiparesis
-Additional Notes- IV. Headache of Nasal Vasomotor Reaction
 Pain in the nose/sinuses
Major Categories of Headache  Reaction to stress or environment changes
 Pain-sensitive:
I. Vascular Headache of Migraine Type  Nasofrontal area
A. Classic migraine  Mid-meatus
 Unilateral, sensory or motor prodrome 10-20min prior to  Lateral nasal wall & septum
headache  Treatment: nasal spray
 Aura: scotoma & visual hallucinations
 Nausea & vomiting V. Headache of Delusional, Conversion or Hypochondriac States
 Malaise
 Photophobia VI. Nonmigranous Vascular Headache
 Irritability  Systemic
 More common in women  Miscellaneous
 (+) family history in 2/3 of patients  Non-recurrent vasodilating head pains
 Onset: abrupt, throbbing  Hypoxic states
 Worsens in pregnancy  Carbon monoxide poisoning
 Less common than common migraine  Chemical ingestion
B. Common migraine  Caffeine withdrawal
 Without prodrome, less often unilateral  Oral contraceptives (mild brain edema)
 Longer course  Hang-over
 More common in women  Post-concussion states
 Most common of all migraine headaches  Post-convulsive states
 Onset: gradual, throbbing  Sodium-nitrate containing foods
 Sporadic with mood changes  Tyramine (cheese, etc.)
C. Cluster headache
 Boring sharp pain, unilateral VII. Traction Headache
 Associated with flushing, sweating, rhinorrhea, lacrimation  Primary or metastatic tumors
 Prodrome less often  Hematoma
 More common in men  Abscesses
 Awakens patient from sleep  Postlumbar puncture headache: loss of spinal fluids 
 Most excruciating intracranial hypotension
 1-5 attacks per days  Pseudotumor cerebri
 No aura  Overt cranial inflammation
 Onset: sudden, usually occurs in late evening or early
morning VIII. Headache due to overt cranial inflammation
D. Hemiplegic & ophthalmoplegic migraine
 Sensory/motor phenomena that persist during and after the IX. Headache due to disease of:
headache A. Ocular origin
E. Lower-half headache B. Aural nature
 Atypical facial neuralgia C. Nasal & sinus
 Sphenopalatine ganglion neuralgia (Sluder) D. Dental
 Vidian neuralgia (Vail) E. Other cranial or beck structures
 Tx: vasodilators F. Cranial neuritides

II. Muscle Contraction Headache X. Cranial neuralgia

 Sustained contraction of skeletal muscles related to chronic A. Trigeminal neuralgia
anxiety and fatigue  Most excruciating pain known to man
 Flat-band type of headache  Ophthalmic—least affected
 Can be triggered tars  Maxillary
 Most common of all the headache  Mandibular
 It is not muscle contraction headache if: Primary Secondary
 Unilateral Sudden onset Chronic pain
 Relieved by simple analgesics Sharp & lancilating Longer episodes
 With element of progression Initiated at trigger zones Trigger zones uncommon
 With clear-cut relief of symptoms Unilateral Less severe attacks
Course unknown
III. Combined Headache: vascular/migraine + muscle contraction  Treatment for trigeminal neuralgia:
 Phenytoin
 Clonazepam
 Alcohol injection
 Rhizotomy
  Baclofen
 Valproic acid
 Carbamazepine
B. Glossopharyngeal neuralgia
 Stabbing pain with trigger zone in the tonsillar area
 Salivation is common
 TMJ dysfunction  malocclusion
 Costen’s syndrome
 Deep pain
 Muscle spasm
 Upon physical examination:
 N mouth opening: 4cm
 Clicking sound at joint
 Pain of swallowing, yawning
 Note bite of patient
 Treatment:
 Soft liquid diet
 Heat
 NSAIDs
 Muscle relaxants
Carotidemia
 Pain on palpation of carotid arteries
 Superficial temporal artery: temporal arteritis
 Can lead to transient blindness, ischemic optic neuritis
 Treatment: steroids
Otalgia
 Pain in the ear
 Primary otalgia:
 Involvement of the ear itself or any structure of the ear
 Otitis externa
 Acute otitis media
 Secondary/referred otalgia:
 Structures other than the ear are involved (pharynx, larynx,
oral cavity, tonsillitis, laryngitis)
 Due to nerve supply of the ears

Treatment for Migraine:

 NSAID—inhibits prostaglandin synthesis
 Metoclopramide—allow easy absorption of drug (because of
gastric stasis in migraine), for nausea and vomiting
 Topiramate & Imipramine
 Ergot derivatives (ergotamine & dihydroergotamine) + caffeine =
Caffergot (potentiates absorption)
 Triptans—serotonin agonist

Migraine – affects the trigeminovascular system

The Present is the Point just passed.

Transcribed by Denise Zaballero ☺