Headaches Notes

NOTES NOTES HEADACHES GENERALLY, WHAT ARE THEY? PATHOLOGY & CAUSES ▪ Cranial pain, disturbs everyday life TYPES Primary ▪ Migraine, tension headache, cluster headache Secondary ▪ Headaches caused by other disorders CAUSES ▪ Genetic, environmental factors; stress SIGNS & SYMPTOMS ▪ Unilateral/bilateral, localized/diffuse head pain ▪ Nausea, vomiting, aura/autonomic symptoms DIAGNOSIS DIAGNOSTIC IMAGING CT scan/MRI ▪ Used to exclude other diseases ▫ Unusual neurological symptomatology; headache accompanied by ↑ body temperature, stiff neck; new headache in individual with HIV/cancer TREATMENT MEDICATIONS ▪ Prophylactic management ▫ Prevention of further attacks ▪ Symptomatic treatment ▫ Pain, symptom-management medications CLUSTER HEADACHE osms.it/cluster-headache PATHOLOGY & CAUSES ▪ One-sided headache in ophthalmic nerve distribution region with autonomic symptomatology ▪ Hypothalamus involvement ▫ Episodic occurrence of cluster attacks ▪ Posterior hypothalamic activation → secondary trigeminal stimulation → 616 OSMOSIS.ORG afferents travel to nucleus caudalis ▫ Projection to thalamus, sensory cortex → perception of pain ▫ Hyperactivation of parasympathetic pterygopalatine ganglion → autonomic symptoms ▪ Cavernous sinus walls inflammation → ↓ venous flow → injury of internal carotid artery sympathetic fibers

Chapter 79 Headaches TYPES Episodic ▪ Daily episodes over 6–12 weeks; “clusters” followed by remission period up to 12 months Chronic ▪ Episodes without substantial remission period CAUSES ▪ Unknown; possibly genetic RISK FACTORS ▪ More common in individuals who are biologically male ▪ Stressful periods, allergic rhinitis, sexual intercourse, tobacco, excessive alcohol use COMPLICATIONS ▪ Progresses episodic → chronic SIGNS & SYMPTOMS ▪ Headache ▫ One-sided sharp, stabbing, burning orbital/supraorbital/temporal head pain ▪ Autonomic ▫ Ipsilateral conjunctival hyperemia with lacrimation, nasal discharge, miosis, edema, drooping eyelid ▪ Episodes ▫ 1–8 per day; lasts five minutes to three hours ▪ Restlessness, agitation, suicidal ideation DIAGNOSIS DIAGNOSTIC IMAGING CT scan/MRI ▪ Exclude possible cranial lesions OTHER DIAGNOSTICS ▪ Requires each of following ▫ Five unilateral/orbital/supraorbital/ temporal attacks; 1–8 episodes daily, ≤ three hours ▫ Agitation/restlessness ▫ ≥ one autonomic symptom on same side as headache TREATMENT MEDICATIONS Acute management ▪ Supplemental oxygen/intranasal sumatriptan/zolmitriptan ▫ Initial treatment ▪ Intranasal lidocaine/oral ergotamine/IV dihydroergotamine ▫ If initial treatment not effective Prophylaxis ▪ Verapamil ▫ Episodic attacks > two months/chronic cluster headaches ▪ Glucocorticoids (e.g. prednisone); can be used together with verapamil ▪ Lithium ▫ If other medications contraindicated SURGERY ▪ Block greater occipital nerve ▪ Percutaneous radiofrequency ablation of pterygopalatine ganglion ▪ Gamma knife radiosurgery ▪ Stimulation of pterygopalatine ganglion ▪ Posterior hypothalamus deep brain stimulation OSMOSIS.ORG 617

MIGRAINE osms.it/migraine PATHOLOGY & CAUSES ▪ Disease characterized by one-sided head pain ▪ Probable mechanism ▫ ↑ neuronal hyperexcitability → cortical spreading depression wave across cortex → release of proinflammatory cytokines, matrix metalloproteinases (MMP), nitric oxide (NO), glutamate, adenosine triphosphate (ATP), potassium ions from neurons/glial/ vascular cells → alters blood-brain barrier → activates perivascular trigeminal nociceptors ▫ Release of substance P, calcitonin gene-related peptide, neurokinin A → neurogenic inflammation with meningeal blood vessels dilatation, protein exudation → further nociceptor stimulation ▫ Projection of afferents to trigeminal nucleus-pars caudalis → fibers relay to thalamus, sensory cortex → perception of pain ▪ Trigeminal nociceptors innervate anterior head region, upper cervical dorsal roots innervate posterior head region → converge in trigeminal nucleus caudalis → characteristic pain distribution affecting anterior, posterior head region ▪ Aura likely caused by depression spreading to areas where perceived consciously ▪ Serotonin receptors possibly involved in migraine pathogenesis ▫ Directly acting on blood vessels/ affecting pain pathways ▪ If nociceptors stimulated too frequently → neuronal sensitization, cutaneous allodynia phenomenon (nociceptive response to nonnociceptive stimuli) 618 OSMOSIS.ORG TYPES Migraine with aura ▪ Typical aura migraine with/without headache ▪ Brainstem aura migraine ▪ Hemiplegic migraine ▫ Familial; types I, II, III ▫ Sporadic ▪ Ocular migraine Migraine without aura ▪ Menstrual migraine ▫ Develops ≤ two days before, continues ≤ three days after menstrual period ▪ Chronic migraine ▫ ≥ 15 headaches per month for ≥ three months ▫ Analgesics, nonsteroidal antiinflammatory drugs (NSAIDs) overuse biggest risk factor Probable migraine ▪ Attacks similar to migraine without one feature needed for migraine diagnosis CAUSES ▪ Inheritance ▫ ↑ neuronal excitability ▪ Familial hemiplegic migraine (FHM) ▫ Type I: CACNA1A gene mutation ▫ Type II: ATP1A2 gene mutation ▫ Type III: SCN1A gene mutation RISK FACTORS ▪ Individuals who are biologically female, age 30–39 ▪ Stress, hormone oscillations, irregular eating/sleeping, weather, light, alcohol, tobacco, odors ▪ Syndromes associated with migraine ▫ Recurrent gastrointestinal (GI) disturbance; benign paroxysmal vertigo, torticollis

Chapter 79 Headaches COMPLICATIONS ▪ Status migrainosus ▫ Migraine lasting ≥ 72 hours without spontaneous resolution ▪ Persistent aura without infarction ▫ ≥ one week ▪ Migrainous infarction ▫ Preceded by migraine attack with aura symptoms ≥ one hour; retinal migraine → permanent blindness ▪ Migraine aura-triggered seizure ▪ Rebound headache due to medication overuse SIGNS & SYMPTOMS ▪ One-sided, pulsatile headache worsened by physical activity, with maximum pain at supraorbital location; followed by nausea, vomiting, hypersensitivity to light and sounds ▫ May be accompanied by cutaneous allodynia phenomenon ▪ Prodromal symptoms (appear hours/days before attack) ▫ ↑ irritability to light, sound, smells; yawning, food cravings, mood changes, constipation/diarrhea ▪ Postdrome symptoms ▫ Lasting approx. one day after headache; sudden movements → short-lasting pain in previously affected regions; exhaustion/tiredness/euphoria Aura ▪ Negative features (areas of vision loss) ▫ Hemianopia/quadrantanopia, peripheral vision loss, spot-like scotomas, blurriness/blindness ▪ Positive features ▫ Scintillating scotoma: glimmering geometric shapes (e.g. zigzag line) appearing centrally with expansion to periphery; visual hallucinations ▫ Visual: most common ▫ Sensory: tingling sensations beginning from one hand → arm, face → shortlasting numbness ▫ Motor: facial/extremities weakness ▫ Language: progresses from mild speech impairment to aphasia ▪ Subtypes ▫ Brainstem aura: dizziness, double vision, tinnitus, speech difficulties, altered consciousness ▫ Hemiplegic: aura usually includes onesided motor weakness; vision, sensory defects, ↑ body temperature, seizures, coma ▫ Ocular: loss of vision/scotomas in one eye; headache DIAGNOSIS LAB RESULTS ▪ ↓ serum N-acetyl-aspartate levels OTHER DIAGNOSTICS Non-aura migraine ▪ Requires each of following ▫ ≥ five attacks: lasting 4–72 hours ▫ ≥ two of the following: one-sided, throbbing quality, moderately severe pain, worsening with physical activity ▫ ≥ one of following with headache: nausea/vomiting; light, sound sensitivity Migraine with aura ▪ Requires each of following ▫ Aura symptoms: visual, sensory, motor, speech ▫ ≥ two of following: ≥ one aura symptom lasting ≥ five minutes, followed by other aura symptomatology; auras lasting five minutes–one hour; one aura, one-sided; aura precedes headache that occurs within 60 minutes ▫ ≥ two attacks: with listed characteristics OSMOSIS.ORG 619

TREATMENT MEDICATIONS Mild/moderate ▪ NSAIDs (e.g. aspirin, naproxen, diclofenac, ibuprofen) ▪ Paracetamol Moderate/severe ▪ Triptans ▫ Serotonin agonists; constrict blood vessels, alter pain pathways ▫ Sumatriptan, zolmitriptan, naratriptan, eletriptan ▫ Oral/nasal/subcutaneous administration ▫ Triptan, NSAID combination; more effective than individual medications (e.g. sumatriptan, naproxen) ▫ Ergots (ergotamine) ▪ IV triptans ▪ Dopamine antagonists ▫ IV metoclopramide; IV/IM chlorpromazine ▪ Ergots (e.g. dihydroergotamine) ▪ Dexamethasone ▫ Combined with symptomatic therapy → ↓ early headache recurrence rate ▪ Antihypertensives ▫ Beta blockers (propranolol/metoprolol/ timolol) ▫ Calcium channel blockers (verapamil/ nifedipine) ▫ Angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs); e.g. lisinopril/ candesartan respectively ▪ Antidepressants ▫ Tricyclic antidepressants (amitriptyline, nortriptyline, doxepin) ▫ Serotonin-norepinephrine reuptake inhibitors (SNRIs) (e.g. venlafaxine) ▪ Anticonvulsants ▫ Topiramate/valproate OTHER INTERVENTIONS ▪ Complementary, alternative medicine ▫ Herbs: butterbur (Petasites hybridus), feverfew (Tanacetum parthenium) ▫ Supplementation: riboflavin, coenzyme Q10, magnesium TENSION HEADACHE osms.it/tension-headache PATHOLOGY & CAUSES ▪ Bilateral, “tightening” headache (most common headache type) ▫ ↑ tenderness of pericranial myofascial structures → activation of vasculaturesurrounding nociceptors → episodic TH → prolonged nociceptor stimulation → pain pathway sensitization with hyperalgesia → chronic TH TYPES Episodic ▪ Rare (≤ one headache monthly) 620 OSMOSIS.ORG ▪ Common (≤ 14 headaches monthly) Chronic ▪ ≥ 15 headaches monthly CAUSES ▪ ↑ muscle tenderness ▪ Combination of genetic, environmental factors ▫ Episodic TH ▪ Multifactorial inheritance ▫ Chronic TH RISK FACTORS ▪ White individuals who are biologically

Chapter 79 Headaches female of Ashkenazi Jewish descent ▪ Age ≥ 40 ▪ Stress, anxiety, depression, poor posture COMPLICATIONS ▪ Rebound headache ▪ Progresses episodic → chronic SIGNS & SYMPTOMS ▪ Moderate, bilateral, non-pulsating head pain ▫ Band-like distribution, without worsening during physical activity, few minutes to one week ▪ Photophobia/phonophobia ▪ Stiffness/tenderness of head, neck, shoulder muscles DIAGNOSIS OTHER DIAGNOSTICS Requires each of following ▪ Absence of nausea, vomiting ▪ Light/sound hypersensitivity without other aura symptoms ▪ ≥ two of following ▫ Both sides of head affected ▫ Non-throbbing quality ▫ Moderate intensity ▫ No worsening during physical activity TREATMENT MEDICATIONS Immediate symptoms ▪ Analgesics ▫ NSAIDs ▫ Paracetamol ▪ Caffeine ▪ Butalbital ▫ If contraindication for NSAIDs/caffeinecombined analgesics Prophylactic management ▪ Antidepressants ▫ Tricyclic antidepressants (amitriptyline, nortriptyline/protriptyline) ▫ Mirtazapine/venlafaxine ▪ Anticonvulsants ▫ Topiramate/gabapentin PSYCHOTHERAPY ▪ Behavioral, cognitive-behavioral, biofeedback therapy OTHER INTERVENTIONS ▪ Acupuncture, heating/icing, resting for immediate symptoms OSMOSIS.ORG 621