Podcast
Questions and Answers
What is the primary cause of secondary headaches?
What is the primary cause of secondary headaches?
Which of the following is a common primary headache syndrome?
Which of the following is a common primary headache syndrome?
What type of headache is characterized by a sensation of tightness or pressure?
What type of headache is characterized by a sensation of tightness or pressure?
Which of the following is a precipitating factor for chronic headache?
Which of the following is a precipitating factor for chronic headache?
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What is the typical duration of a migraine headache?
What is the typical duration of a migraine headache?
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What is the pathophysiological mechanism underlying migraine headaches?
What is the pathophysiological mechanism underlying migraine headaches?
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What is the typical onset of migraine headaches?
What is the typical onset of migraine headaches?
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What is the purpose of preventive treatment for migraine headaches?
What is the purpose of preventive treatment for migraine headaches?
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Which of the following medications is often particularly helpful for migraine headaches?
Which of the following medications is often particularly helpful for migraine headaches?
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What is the contraindication for using ergotamine-containing preparations?
What is the contraindication for using ergotamine-containing preparations?
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Which of the following medications is supported for headache prophylaxis in tension headaches?
Which of the following medications is supported for headache prophylaxis in tension headaches?
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What is the typical duration of cluster headache episodes?
What is the typical duration of cluster headache episodes?
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What is the gold standard for diagnosing Giant Cell Arteritis?
What is the gold standard for diagnosing Giant Cell Arteritis?
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What is the highest positive predictive value (PPV) symptom for Giant Cell Arteritis?
What is the highest positive predictive value (PPV) symptom for Giant Cell Arteritis?
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What is the typical age range for patients affected by Giant Cell Arteritis?
What is the typical age range for patients affected by Giant Cell Arteritis?
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What is the recommended treatment for medication overuse headache?
What is the recommended treatment for medication overuse headache?
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Which of the following is a trigeminal autonomic cephalgia?
Which of the following is a trigeminal autonomic cephalgia?
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What is the recommended treatment for acute cluster headache?
What is the recommended treatment for acute cluster headache?
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When should imaging be performed for headache?
When should imaging be performed for headache?
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What is the typical characteristic of headache in intracranial mass lesions?
What is the typical characteristic of headache in intracranial mass lesions?
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Study Notes
Headache Overview
- Headache is one of the most common presentations in primary care, with more than 90% falling into either migraine or tension-type.
- Migraine headaches are the second most common disabling condition seen in adults, after back pain.
Primary Headache Syndromes
- Common primary headache syndromes include migraine, tension-type headache, and cluster headache.
- Secondary causes to consider include intracranial lesions, head injury, cervical spondylosis, dental or ocular disease, TMJ, sinusitis, hypertension, depression, and general medical disorders.
Headache Characteristics
- Quality of pain:
- Migraine: pulsating or throbbing
- Tension headache: sensation of tightness or pressure
- Nerve headache: sharp, lancinating pain
- Ocular or periorbital icepick-like pains: migraine or cluster headache
- Dull, steady headache: intracranial mass
- Ocular or periocular pain: ophthalmologic disorder
- Lateralized pain: migraine or cluster
- Tenderness of overlying skin and bone: sinus headache
- Precipitating factors:
- SARS-CoV-2 can precipitate chronic headache
- Migraine may be exacerbated by emotional stress, fatigue, foods containing nitrite or tyramine, or menstrual periods
- Alcohol may precipitate cluster headache
- Timing of pain:
- Headaches worse on awakening: intracranial mass or sleep apnea
- Onset at same time each day or night: cluster headache
- Worse with stress or end of the day: tension headache
- Associated symptoms:
- Nausea, sensitivity to light, sound, exertion, and desire to retreat to a dark, quiet room: migraine
- Anxiety, agitation, and even suicidality: cluster headache
Migraine
- Typically pulsatile, lasting 4-72 hours, and unilateral
- Nausea, vomiting, photophobia, and phonophobia are common accompaniments
- Pain is aggravated with routine physical activity
- Aura of transient neurologic symptoms may precede head pain
- Most often, head pain occurs with no aura
- Pathophysiology: probably relates to neuronal dysfunction in the trigeminal system, resulting in neurogenic inflammation, sensitization, and pain
- Typical onset in adolescence or early adulthood
Migraine Aura
- Visual disturbances may consist of:
- Field defects (scotoma)
- Luminous visual hallucinations (photopsia)
- Geometric patterns or zigzags of light
- Scintillating scotomas (combination of field defects and luminous hallucinations)
- Rarely, migrainous headaches occur without pain (migraine aura without headache)
Migraine Treatment
- Symptomatic therapy:
- Rest in a quiet, darkened room until symptoms subside
- Simple analgesics (aspirin, acetaminophen, ibuprofen) taken immediately often provide relief
- To prevent medication overuse, use of simple analgesics should be limited to 15 days or less per month
- Cafergot, eletriptan, and IV metoclopramide may be useful in some cases
- Preventive treatment:
- May be necessary if migraine occurs more frequently than 2-3 times a month or with significant disability
- Antiepileptics, CV medications, and antidepressants may be used
Tension Headache
- Most common type of primary headache disorder
- Patients frequently report pericranial tenderness, poor concentration, and a vise-like or tight pain
- Headaches may be exacerbated by emotional stress, fatigue, noise, or glare
- Usually generalized, may be most intense about the neck or back of the head
- Not associated with focal neurologic symptoms
- TCAs (amitriptyline) are supported for headache prophylaxis
Cluster Headache
- Affects predominantly middle-aged men
- Pathophysiology is unclear, may relate to activation of cells in the ipsilateral hypothalamus triggering the trigeminal autonomic vascular system
- Episodes of severe pain occur daily for several weeks
- Often accompanied by one or more of the following:
- Ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of the eye, and Horner syndrome (ptosis, pupillary meiosis, and facial anhidrosis or hypohidrosis)
- Restlessness and agitation during attacks
- Typically occur at night, awaken patient, and last 15 minutes-3 hours
Giant Cell Arteritis
- Affects patients over 50; incidence increases with each decade
- Previously called temporal arteritis because the temporal artery is frequently involved
- Polymyalgia rheumatica and giant cell arteritis frequently coexist
- Important differences: polymyalgia rheumatica is not a systemic vasculitis, does not cause blindness, and responds to low-dose prednisone
- Giant cell arteritis can cause blindness and large artery complications
- Classic symptoms: headache, scalp tenderness, visual symptoms, jaw claudication, or throat pain
- Jaw claudication has the highest PPV
- Fever can be as high as 40°C (104°F)
Giant Cell Arteritis: Emergency
- Early diagnosis and treatment required to prevent blindness
- Start prednisone 1 mg/kg/day immediately
- Biopsy is the gold standard
Intracranial Mass Lesions
- May cause headache due to displacement of vascular structures/other pain-sensitive tissues
- Headache may be worse upon lying down, awaken the patient at night, or peak in the morning after laying down overnight
- Other suggestive features: fever, night sweats, weight loss, immunocompromised, history of malignancy
- Signs of focal or diffuse cerebral dysfunction or of increased intracranial pressure also need evaluation
Medication Overuse
- Often responsible for chronic daily headaches
- Patients have chronic pain or severe headache unresponsive to medication (no effect after regular use for more than 3 months)
- Ergotamines, triptans, medications containing butalbital, and opioids cause medication overuse headache when taken on more than 10 days per month
- Acetaminophen, aspirin, NSAIDs may also cause headaches if taken on more than 15 days per month
When to Image
- Progressive headache disorder
- New onset headache in middle or later life
- Headaches that disturb sleep or are related to exertion
- Headaches associated with neurologic symptoms or a focal neurologic deficit
- Signs of meningeal irritation and impairment of consciousness also need further investigation
When to Refer
- Thunderclap onset
- Increasing headache unresponsive to simple measures
- History of trauma, hypertension, fever, visual changes
- Presence of neurologic signs or of scalp tenderness
When to Admit
- Suspected hemorrhage
- Structural intracranial lesion
- SNOOP10 “Danger Signs”
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Description
Learn about the different types of headaches, including migraine and tension-type, and their causes, including intracranial disorders and secondary causes.
