Headache

Question 1

Estrogen and migraines

Answer 1

Estrogen increases the likelihood and frequency of migraine headaches

Mechanistically, this is thought to be due to its influence on nitric oxide levels

For this reason, it is most common in 20-40 year old females.

Question 2

Migraine prodrome vs migraine aura

Answer 2

• Prodrome:
  
  • Nonspecific phenomena that occur hours to days prior to headache onset
  • May be psychological (euphoria, depression, irritability) or constitutional (increased urination, increased defecation, anorexia)
• Aura:
  
  • Transient frank neurologic dysfunction
  • Gradually develop over minutes and last 5-60 minutes
  • Classically occurs immediately before head pain, but may occur during headache or without headache in affected patients

Question 3

Some classical migraine auras

Answer 3

• Scintillating scotomas: zigzag luminous images, flashing lights with zigzag pattern, distortion of images
• Smells
• Tastes
• Nausea

Question 4

Features of the classical migraine headache

Answer 4

• Unilatreal
• Pulsating in quality
• Lasts 4 hours - several days
• Associated symptoms of nausea, photophobia, and phonophobia
• Desire to seek rest in a quiet, dark place

Question 5

Cortical spreading depression theory

Answer 5

• Important in both migraine and seizure spreading
• As disrupted cellular calcium homeostasis and chemical cascades propagate, trigeminal neurons signal dural vessels to release calcitonin gene-related peptide (CGRP), substance P, and neurokinin A
• These mediators lead to inflammation and dilation of blood vessels, resulting in pain signals which are sent to the brain

Question 6

If you think a patient’s headache is due to temporal arteritis, what do you do?

Answer 6

• Give empiric corticosteroids
• Send them to the ED
• Here they will get a screening ESR and CRP
• If elevated, they will get further workup including temporal artery biopsy

Question 7

Features of a tension headache

Answer 7

• Bilatreal
• Band-like tightness/pressure quality
• Sometimes precranial tenderness
• Not associated with nausea, vomiting
• May be associated with phonophobia or photophobia, but usually not both

Question 8

Studies that one might order for suspected secondary headache

Answer 8

• CT
• LP
• Biopsy

Question 9

Headache red flags

Answer 9

• Fever
• Focal deficit
• New-onset in age > 50
• Thunderclap headache (instantaneous onset worst headache of life)
• Progressive N/V that is worse in morning

Question 10

Analgesic rebound headache criteria for diagnosis

Answer 10

• Use of analgesics > 10 times per month
• Headaches occur when in withdrawal period after analgesic use

Question 11

Cluster headache

Answer 11

• Pathology: vascular
• Presentation: Asymptomatic for months, then experience a “cluster” of headaches 8-10 times per day
• Features: Unilateral eye pain, Horner’s syndrome, rhinorrhea, lacrimation, conjunctival injection
• Diagnosis: Clinical, but one-time brain MRI or CT is necessary to rule out other etiologies.
• Treatment:
  
  • Abortive: Oxygen (nasal cannula). If this fails, triptans.
  • Maintenance: Verapamil

Question 12

Migraine therapy

Answer 12

• Abortive:
  
  • 1st line: NSAIDs
  • 2nd line: Triptans, ergots (but be careful in CAD), OR midrin
  • NOT butalbital – no longer recommended
• Maintenance:
  
  • 1st line:
    
    • Beta blockers: Propranolol
    • Anticonvulsants: Topiramate, valproate, divalproex, gabapenti
  • 2nd line:
    
    • Combinations: Midrin
    • CCBs: Verapamil
    • Antidepressants: Amitryptiline, duloxetine, nortryptiline
  • 3rd line: Methysergide maleate, lithium carbonate, clonidine, captopril
  • 4th line: Botox injections q3 months

Question 13

Idiopathic intracranial hypertension aka pseudotumor cerebri

Answer 13

• Path: Increased ICP, for no discernable reason
• Presentation: Female patient with increased ICP and papilledema, but THEN imaging is negative for any etiology
• Often some form of visual disturbance is present, such as blurry vision when standing up quickly – untreated disease can lead to blindness
• Causes: OCPs
• Dx: Negative CT and/or MRI to rule out intracranial mass-occupying lesion. LP with opening pressure > 25 cm H₂O with relief after LP
• Tx:
  
  • 1st line: Acetazolomide and weight loss.
  • Refractory or bridging to acetazolomide: Repeated LPs
  • Truly chronic, refractory cases: VP shunt. Optic nerve fenestration (may help preserve vision)

Question 14

If sinusitis does not respond to anticongestants, consider. . .

Answer 14

. . . migraine as a mimic of sinusitis

It is actually VERY common. In fact, 80% of patients with “sinus headache” actually have migraines, NOT sinusitis.

Question 15

If you have strong clinical suspicion for SAH despite a negative CT, you should. . .

Answer 15

. . . do an LP to look for xanthochromia

You WILL have to differentiate between migraine and SAH on the test.

Question 16

Why is “new onset headache in a patient over age 50” a red flag sign for headaches?

Answer 16

Because this is the demographic of patients at risk for temporal arteritis

Question 17

Lab data that support a diagnosis of temporal arteritis in someone with a case of TA vs migraine

Answer 17

Elevated ESR, CRP, and thrombocytosis

Question 18

Platelets in temporal arteritis

Answer 18

Platelets may be elevated in temporal arteritis, AND this elevation correlates with the risk of vision loss

Question 19

If there is strong clinical suspicion for temporal arteritis, . . .

Answer 19

. . . you should treat with corticosteroids immediately – prior to even confirming the diagnosis with a biopsy

Question 20

“Headache that awakens the patient from sleep”

Answer 20

Concerning for brain tumor

Question 21

How are triptans optimally used to abort migraines?

Answer 21

At the first sign that a migraine is coming on, such as during an aura in the case of migraine with aura

They can still help once the migraine has begun, but are less effective than if used ASAP

Question 22

How much triptan can someone take for a prolonged migraine?

Answer 22

Can be used q4 hours PRN, but not more than three doses per 24 hours

Question 23

Triptan side effects and contraindications

Answer 23

• Side effects:
  
  • N/V
  • Tingling in fingers and toes
  • Hypertension/vasospasm
• Contraindications:
  
  • History of CAD
  • History of HTN
  • Migraines involving hemiplegia or blindness as an aura
    *

Question 24

If you have to choose between a triptan and an ergotamine on the exam for the treatment of migraines, . . .

Answer 24

. . . triptan is almost always going to be the right answer

Question 25

First and most important step in migraine prophylaxis

Answer 25

Keeping a **headache diary** To identify migraine triggers, and thus avoid them

Question 26

Midrin

Answer 26

* Abortive AND maintenance therapy for migraines * Three components: * **Acetominophen** * **Chloralphenazone** (muscle relaxant) * **Isometheptene mucate** (vasoconstrictor) * If used for abortive therapy: Take 2 tablets at aura or headache onset, then one tablet hourly for three hours if headache persists (up to 5 doses total) * If used as maintenance therapy: Take 1 tablet BID, then a 3rd or 4th pill for breakthrough headaches

Question 27

When is pharmacologic migraine prophylaxis indicated?

Answer 27

When there are ***at least* 3 attacks per month** OR when **acute therapy is not effective**

Question 28

When using anticonvulsants for migraine ppx, . . .

Answer 28

. . . **we use a much lower dose than antiepileptic dosing** Thus, serum level monitoring is not required and risk of induced seizures is very low

Question 29

With regards to migraine prophylaxis: For whom are beta blockeres first line, and for whom are anticonvulsants first line?

Answer 29

In someone who is **young and healthy**, beta blockers may produce hypotension and dizziness, and generally be more difficult to tolerate. Thus, **anticonvulsants** like topiramate are usually first-line in these patients. In someone who is **older and has some HTN**, beta blockers will be better tolerated and will have additional benefits for other aspects of the patient's health. So, **beta blockers** will be first line.

Question 30

Chronic daily headache

Answer 30

* Daily or near-daily headache lasting at least 4 hours per day and at least 15 days per month. * DDx changes substantially from standard headache ddx: * Transformed migraine * Medication overuse rebound headache * Chronic tension headaches * Heicrania continua * New daily persistent headache

Question 31

Transformed migraine

Answer 31

* Form of **chronic, daily headache** that develops gradually over time in a patient with a **history of episodic migraine** * As frequency of episodic migraine increases, the associated **photophobia, phonophobia,** and **N/V** **decreases**, until the patient has near daily headches that ***resemble tension-type headaches, without any migraine-associated features*** * These patients will still experience **concurrent attacks of non-transformed episodic migraine intermittently** * The process of migraine transformation usually takes place over a **3-6 month period**

Question 32

Chronic migraine

Answer 32

Heaache occuring more than 15 days per month for 3 or more months in a patient with history of migraine. Headaches **meet migraine criteria on at least 8 days per month** Transformed migraine may meet the criteria for chronic migraine. Requires exclusion of secondary causes.

Question 33

Chronic tension-type headache

Answer 33

* Occurs in patients with a history of episodic tension headaches that increase in frequency and meets criteria for chronic headache * Pain is **bilateral** in the **temporal regions** or **hatband distribution**, *not* associated with N/V, phonophobia, photophobia * Quality of pain is described as pressing or tightening, and is non-pulsatile * May also be associated pain and tenderness in the occipital area as well as the posterior strap muscles of the neck * May also have an **occasional breakthrough migraine** headache, **but not at the same frequency as breakthrough headaches in transformed migraine** * Treatment of choice is **amitriptyline**

Question 34

Hemicrania Continua

Answer 34

* **Truly *constant* unilateral headache** at *baseline* with **superimposed episodes** of severe, sharp, stabbing pain occuring on the same side * Considered **one of the trigeminal autonomic cephalalgias**, along with tension headaches and SUNCT headaches * Superimposed episodes occur almost daily and last 30 minutes to 3 days, often accompanied by **ipsilatreal autonomic symptoms** (**ptosis, conjunctival injection, lacrimation, nasal congestion, rhinorrhea**) and **foreign body sensation** in the affected eye. **Migraine features** (N/V, photophobia, phonophobia) may also be present * **Absolute response to _indomethacin_ treatment is a DEFINING feature**

Question 35

Hemicrania continua is frequently misdiagnosed as. . .

Answer 35

. . . **migraine** or **cluster headache** Since the episodic exacerbations **share migraine-like features and autonomic symptoms** The key differentiating features are: 1. **baseline headache**, which is not present in migraine or trigeminal autonomic cephalalgias 2. **coexistence** of migraine and TAC features during exacerbations 3. **Excellent responsiveness to indomethacin therapy**

Question 36

What is the treatment for hemicrania continua?

Answer 36

Indomethacin

Question 37

New Daily Persistent Headache

Answer 37

* Abrupt onset of a **daily headache** over a **period of \< 3 days** * Patients have no prior history of a pre-existing headache syndrome * The patient **recalling the date or circumstance** during which the headache started is a pathognomonic feature * Headache is bilateral, may be aching or throbbing, and may be associated with tension-type features or migraine-type features. Thus, the **abrupt onset rather than headache features** should be used in making the diagnosis * Dx: **Diagnosis of exclusion** after ruling out more concerning causes of acute onset headache

Question 38

Occipital neuralgia

Answer 38

* Headache in which the **greater occipital nerves** are irritated or inflamed * Causes pain in the distribution of the occipital nerve * May be unilateral or bilateral * Pain is **neuropathic** in nature (shooting, burning, electrical sensation) and is accompanied by **overlying allodynia** * **Sometimes occurs secondary to a tension headache,** as the surrounding muscle tension in the neck and scalp can irritate the nerve * **Dx AND Tx: Occipital nerve block with steroid and local anesthetic**. Can also be treated more conservatively with **physical therapy** and **neuropathic analgesics** (tricyclics, low-dose antiepileptics, gabapentinoids) * Tx for refractory cases: **Pulse radiofrequency occipital nerve stimulation**

Question 39

Therapy of medication overuse headache

Answer 39

Requires gradual weaning of the overused agent along with management of withdrawal symptoms AND the original headache syndrome A minority of patients require admission to the hospital for weaning therapy

Question 40

Short-lasting unilateral neuralgiform headache attacks

Answer 40

* Unilateral, moderate-severe headaches that occur in the trigeminal distribution * **Often *mistaken* for trigeminal neuralgia** * Pain is stabbing and lasts from 1 second to 10 minutes * Two forms differentiated by their associated autonomic symptoms, both of which may be episodic or chronic * Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (**SUNCT**). Autonomic Sx: both conjunctival injection and lacrimation * Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symtoms (**SUNA**). Autonomic Sx: at least one of facial sweating, facial flushing, ptosis, pupillary miosis, eyelid edema, nasal congestion, rhinorrhea, ear fullness, conjunctival injection, lacrimation (but NOT both conjunctival injection and lacrimation -- since that is SUNCT) * Treatment: * Abortive: **IV lidocaine** * Maintenance: **Topiramate, lamotrigine, or gabapentin**. If refractory, occipital nerve block

Question 41

Flavors of hemicrania

Answer 41

* **Episodic paroxysmal hemicrania** * Recurrent attacks separated by at least one pain-free month * 2-30 minute long attacks * **Chronic paroxysmal hemicrania** * Recurrent attacks without period of remission of 1 month or greater * 2-30 minute long attacks * **Hemicrania continua** * Intractable pain and autonomic symptoms consistent with hemicranias, lasting for \> 3 months without cessation

Question 42

Treatment for all hemicranias

Answer 42

**Indomethacin** is always the answer **Indomethacin trial** is both **diagnostic and therapeutic**

Question 43

Main differentiating features between SUNCT/SUNA and hemicrania

Answer 43

* Attacks in hemicrania are long *on average* (2-30 minutes in hemicrania vs 1 second - 10 minutes in SUNCT/SUNA) * Hemicrania is more likely in females, while SUNCT/SUNA is more likely in males * Hemicrania responds well to indomethacin trial

Question 44

Headache mimics

Answer 44

* Sinusitis * Temporomandibular joint disorder * Cervicogenic headache (often w/ myofascial trigger points and reduced cervical ROM) * Trigeminal neuralgia (really a focal seizure, treat w/ carbamazepine)

Question 45

Trigeminal neuralgia

Answer 45

* **Shooting, shock-like pain** occuring in one or all branches of the trigeminal nerve * Pain is paroxysmal and recurrent, and may be triggered by activities such as **brushing hair or teeth, chewing**. Lasts on the order of seconds to minutes. Facial spasms may also be present. * Can be idiopathic, secondary to mass or vascular lesion, or secondary to demyelination (as in MS) * **Classic TN:** Neurovascular compression of trigeminal root by an aneurysm (usually of the superior cerebellar artery) * **Secondary TN:** Caused by another process (demyelination, tumor at cerebellopontine angle, AV malformation) * **Idiopathic TN:** No causative lesions identified * Diagnosis: **Clinical diagnosis. MRI** w/ and w/o contrast is indicated to determine whether TN is primary or secondary (or CTA if MRI is contraindicated). Normal MRI suggests idiopathic TN. * Treat w/ **carbamazepine**. If refractory, other anticonvulsants or gabapentinoids may be tried. **Microvascular decompression surgery** may be indicated in refractory cases of classical TN (w/ aneurysm/arterial loop)

Question 46

Classical trigeminal neuralgia diagram

Answer 46

Classically caused by a "loop" of the SCA compressing CNV

Question 47

Can trigeminal neuralgia be caused by MS?

Answer 47

YES

Question 48

Hemiplegic migraine

Answer 48

An uncommon subtype of migraine with aura that is distinguished by mo**tor weakness as the manifestation of the migraine aura** in at least some migraine episodes. May be sporadic or familial. Familial forms caused by a mutation in **CACNA1A**

Question 49

Migraine with brainstem aura

Answer 49

* Episodes of migraine preceded at least some of the time by brainstem aura (but can also be preceded by typical aura) * Criteria: * **≥****2 fully reversible brainstem symptoms** (dysarthria, vertigo, tinnitus, diplopia, ataxia, hearing loss, impaired consciousness) * No motor or retinal symptoms

Question 50

Many patients with migraine report having ___ as children

Answer 50

Many patients with migraine report having **motion sickness** as children

Question 51

Post-dromal phase of migraine

Answer 51

Fairly common among patients with migraine **Symptoms of difficulty concentrating, specific food cravings, and fatigue** following the end of a migraine headache

Question 52

Women with migraine are more likely to experience a migraine headache around the time of. . .

Answer 52

. . . **their menses** Due to the effects of estrogen withdrawal

Question 53

Treatment of migraine in children

Answer 53

* _Abortive_: * **NSAIDs** and **acetominophen** are first-line agents * **Sumatriptan** nasal spray is available for kids over age 12 * _Preventative_: * **Propranolol** and **amitriptyline** are first-line agents * For propranolol, you should monitor blood pressure when starting the medication * For amitriptyline, you should monitor QTc. Prolonged QT at baseline is a contraindication. * **Topiramate** is an option for kids over age 12 * For kids who cannot swallow pills, **cyproheptadine** oral solution can be perscribed (it is an antihistamine with anticholinergic and calcium channel blocking properties as well) * **Riboflavin (B2)** is considered effective for migraine prevention

Question 54

Coenzyme Q and riboflavin in migraine

Answer 54

Studies of the mechanism of migraine headaches suggest that migraineurs are in a state of **mitochondrial energy depletion**, and that suplementation with compounds that can be used by mitochondria to derive more energy, such as **CoQ and riboflavin (B2)**, have mechanistic and clinical benefit.

Question 55

What percentage of migraine headaches are unilateral?

Answer 55

**60%** So, **40% are bilateral!** If something has all the features of a migraine, but is bilateral (or starts unilateral and then generalizes), **do not be fooled into thinking it isn't a migraine.**