HA Overview

Question 1

ICHD-3 classification of primary HA

Answer 1

• Migraine
• TTH
• Cluster HA
• Trigeminal Autonomic Cephalalgias (TAC)

Question 2

ICHD-3 classification of secondary HA

Answer 2

• Trauma or injury to head/neck
• Cranial or cervical vascular disorder
• Non-vascular intracranial disorder
• Infection
• Homeostasis disorder
• HA/facial pain attributed to disorder of facial/cervical structures
• Psychiatric disorder

Question 3

Name the two main nerves implicated in the pathology of headaches

How are they implicated?

Answer 3

• Greater occipital nerve
• Trigeminal nerve (5th cranial nerve, from trigeminal ganglion, connects to brainstem, supplies face and head)

These pain-sensing nerves can be set off by stress, muscle tension, enlarged blood vessels, and other triggers.

Once activated, the nerves send messages to the brain, causing headache

Question 4

Headache pathophysiology

Answer 4

• Vasodilation of intracranial extracerebral blood vessels, activation of trigeminal nerves that release vasoactive neuropeptides to promote neurogenic inflammation
• Central pain transmission may activate other brainstem nuclei: associated symptoms (N/V, photo/phonophobia)

Question 5

Describe general pathophysiology, assign TTH/migraine to likely pathophysiology

Answer 5

• Myofascial mechanism - tenderness, inflammation (Peripheral sensitization) - TTH
• Vascular mechanism - incr blood flow in cerebral arteries (Peripheral sensitization) - migraine
• Central mechanism - dysfunction in descending pain modulation (central sensitization) - progress to chronic TTH
• Genetic predisposition (gene polymorphism)

Question 6

Red flags for secondary headache (SNNOOP10)

Answer 6

• Systemic symptoms
• Neoplasm
• Neurologic deficit (e.g., stroke) - can include vascular or nonvascular intracranial disorders (always look at symmetry)
• Onset of HA is sudden/abrupt
• Older age (>50y)
• Pattern change/recent onset
• Positional HA
• Precipitated by sneezing, coughing, exercise, valsalva maneuver (intracranial pressure)
• Papilledema (optic disc swelling due to incr intracranial pressure)
• Progressive HA w atypical presentation
• Pregnancy or puerperium (6 weeks after childbirth)
• Painful eye w autonomic features - more common in cluster HA
• Post traumatic onset of HA
• Pathology of immune system - immunocompromised
• Painkiller overuse / new drug at onset of HA - MOH

Question 7

Describe cluster headache
- Presentation
- Severity
- Aggravation
- Other symptoms
- Duration
- Frequency

Answer 7

• Unilateral (usually around eyes)
• Severe pain
• Restlessness, agitation
• Cranial autonomic symptoms in same side as headache (red, watery, swollen eye, nasal congestion, runny nose, sweating, eyelid edema or drooping, constricted pupils)
• 15-180min
• Frequent during clusters
• Affect men > women

Question 8

Describe TTH
- Presentation
- Severity
- Aggravation
- Other symptoms
- Duration
- Frequency

Answer 8

• Bilateral
• Pressing/tightening/band like, non-pulsatile
• Mild-mod pain
• Not aggravated by routine activities of daily living
• 30min - 7 days
• Infrequent to daily
• Affect women > men

Question 9

Describe migraine
- Presentation
- Severity
- Aggravation
- Other symptoms
- Duration
- Frequency

Answer 9

• Unilateral
• Pulsating/throbbing
• Mod-severe
• Aggravated by or causes avoidance of routine activities of daily living
• N/V, photophobia, photophobia, aura, allodynia
• 4h-72h
• Recurrent with variable frequency
• Affect women 2-3x > men

Question 10

mild-mod-severe scale

Answer 10

Mild: 1-3
Mod: 4-6
Severe: 7-10