HEADACHE

Southern Neurology
MIGRAINE
Migraine is derived from the word
hemicrania or half-a-head
Episodic, lasting 4-72 h, associated with
nausea and/or vomiting, photophobia and
phonophobia and interferes with day-to-day
functioning.
Headache has a throbbing or pulsatile
quality and is often unilateral (2/3rds of
patients) although may become generalised
IHS diagnostic criteria for migraine
without aura
A. At least 5 attacks fulfilling B-D in the absence of
another alternative disorder (eg metabolic,
vascular, substance abuse)
B. Headache lasting 4-72 h (untreated or
unsuccessfully treated)
C. Headache with at least 2 of following- unilateral,
pulsating, moderate or severe intensity (inhibits
daily activities) or aggravation by walking stairs
or similar activity)
D. During headache at least one of (i) nausea and/or
vomiting, or (ii) photophobia and phonophobia
Migraine epidemiology
Approximately 5% of men and 10-15% of
women.
First attack occurs in majority during
adolescence and early 20s. Uncommon to
occur for first time after age 40 years.
Remission common after menopause or in
fifth and sixth decades.
50-70% report a family history
Migraine other symptoms
Prodromal symptoms occur in 25-40% in the 24 h
prior to a headache and include mood changes eg
elation, food cravings, thirst and excessive
yawning. Presumably of hypothalamic origin.
Hypersensitivity of scalp, hypersensitivity to smell
Auras blurring of vision or spots more common
than fortification spectra which are experienced in
10-15%. Paraesthesia is next commonest.
Dysphasia and hemiparesis less common. Auras
usually occur 1 hour prior to a migraine and last
less than 1 hour.
IHS diagnostic criteria for migraine
with aura
A. At lease 2 attacks fulfilling B
B. At least 3 of the following characteristics:
One or more fully reversible aura symptoms indicating
focal cerebral cortical and/or brainstem dysfunction.
At least one aura symptom develops gradually over
more than 4 minutes, or 2 or more symptoms occur in
succession.
No aura symptom lasts more than 60 minutes. If more
than one aura symptom is present, accepted duration is
proportionally increased.
Headache follows aura with a free interval of less than
60 minutes (but it may also begin before or
simultaneously with aura).
Factors associated with an attack
Increased incidence on weekends and holidays
Menstrual pattern
Reduced frequency in first trimester of pregnancy
Stress (often as crisis is resolving)
Fasting or missing a meal
Certain foods eg chocolate, alcohol, cheese
Extreme changes in weather
Drug therapy
Acute attacks analgesics, NSAIDS,
dopamine antagonists, ergotamines and
triptans
Preventive therapy propranolol, tricyclic
antidepressants, pizotifen, methysergide,
valproate, natural therapies eg feverfew,
high dose riboflavin; ? Newer AEDs
gabapentin and topiramate
? Role of acupuncture etc
Unusual migraine manifestations
Migraine with prolonged aura aura lasts > 60 minutes and
< 7 days with normal neuroimaging.
Migrainous infarction (prev called complicated migraine)
auras not fully reversible within 7 days and/or
neuroimaging confirmation of ischaemic infarction.
Status migrainosus attack lasts > 72 h whether treated or
not.
Childhood periodic syndromes abdominal migraine and
cyclical vomiting, benign paroxysmal vertigo of childhood,
alternating hemiplegia of childhood (typical age onset < 18
months).
Familial hemiplegic migraine migraine with aura
including hemiparesis with at least one affected first degree
relative.
Other headaches Normal
headaches
Excessive stimulation of scalp nerves eg wearing
tight goggles, diving into cold water
Ice-cream headache holding very cold ice-cream
in mouth or swallowing cold ice-cream.
Increased frequency in migraineurs
Hot dog headache eating cured meats ? Nitrites
MSG
Hangover secondary to acetaldehyde/acetate
Fasting
Exertion
Tension headaches
Two to three times more common in women
Bilateral in 90%
Dull and pressure-like; some patients experience
jabs of pain
10% may also suffer from migraine
In up to 50% of patients, the headache is daily
If associated with regular analgesic usage consider
diagnosis of headache induced by chronic
substance use or exposure
IHS diagnostic criteria for episodic
tension-type headache
A. At least 10 previous headache episodes fulfilling B-D.
Less than 180 attacks/yr
B. Headache lasts 30 minutes to 7 days
C. At least 2 of the following: pressing or tightening quality
(no-pulsating), mild to moderate intensity (may inhibit
but does not prohibit activities), bilateral, no aggravation
by walking stairs or similar routine activity
D. Both of the following (i) no nausea or vomiting (may
have anorexia); (ii) photophobia and phonophobia are
both absent (or one but not the other is present).
Chronic tension headache has same features but
headache is present for at least 15 days a month during
at least 6 months.
Headache induced by chronic
substance use or exposure
Occurs after daily doses of substance for > 3
months. Headache is chronic (15 days or more per
month) and headache disappears within 1 month
after withdrawal of substance.
Ergotamine induced headache preceded by daily
ergotamine ingestion (oral 2mg, rectal 1mg).
Analgesic abuse headache (> 100 tablets a month
or aspirin or equivalent of other mild analgesics).
Caffeine withdrawal headache patient consumes
caffeine daily and > 15 g/month. Occurs witin 24 h
of last caffeine and is relieved within 1 hour by 100
mg caffeine.
Cluster headache
Severe, unilateral pain, orbitally, supraorbitally
and/or temporally, lasting 15-180 minutes,
occurring from once every other day to 8 times a
day.
Bouts may last weeks or months (or so-called
cluster periods) and then remit for months or years
(average 1/year)
80-90% are episodic (as above), 10-20% are
chronic. 85% with episodic cluster headaches are
males vs F>M for chronic
IHS diagnostic criteria for episodic
cluster headache
A. At least 5 attacks fulfilling B-D
B. Severe unilateral orbital, supra-orbital and/or temporal
pain lasting 15-180 minutes untreated.
C. Headache associated with at least one of the following
signs: conjunctival injection; lacrimation; nasal
congestion; rhinorrhea; forehead and facial sweating;
miosis, ptosis, eyelid oedema.
D. Frequency once every other day to 8 per day.

Chronic refers to similar attacks but occurring for > 1

year without remission or with remission lasting < 14
days.
Cluster headache (continued)
Associated features Horners syndrome,
nasal blockage and rhinorrhoea,
conjunctival injection
Alcohol and vasodilators may trigger pain
during an attack
Treatment acute: 100% oxygen,
ergotamines and triptans; preventive:
ergotamines, methysergide, corticosteroids,
verapamil, lithium
Chronic paroxysmal hemicrania
Attacks with same characteristics of pain
and associated symptoms and signs as
cluster headache but short lasting (2-45
minutes), more frequent (attack frequency 5
a day or more for more than half of the
time), occur mostly in females and there is
absolute effectiveness of indomethacin (150
mg or less).

Trigeminal neuralgia
F:M = 2:1
Most commonly after age 40 years
Pain affecting gums, cheek or chin as single or repeated stabs
although in less than 5% forehead (CNV division 1) may also
be affected
Important characteristics are pain intensity, brevity and
tendency to recur in cycles
Pain never crosses to opposite side but may be bilateral in 3-
5%.
Majority are idiopathic although compression of trigeminal
nerve by blood vessel in brainstem most likely cause (>85%).
Tumour or angioma can be seen in up to 6% and <5% of
patients may have MS. Hence, MRI is diagnostic test of choice.
Other non-serious headaches
Post-herpetic neuralgia
Occipital neuralgia
Cervicogenic headaches
Analgesia rebound headaches
TMJ dysfunction
Sinusitis
Low pressure headache post lumbar puncture
BIH
Serious causes of headache
Raised ICP secondary to structural lesion eg
haemorrhage or tumour
Subarachnoid haemorrhage
Meningo-encephalitis
Temporal arteritis
Cerebrovascular disease
Case history 1
25 y.o.female
Previously well. No past medical history.
1 day history of gradual onset generalised
headache, throbbing quality
Vomited x 1, photophobia, phonophobia
? Diagnosis
? Investigation
? Treatment
Case history 2
80 year old female
3 week history of intermittent but daily
bifronto-temporal headache
Non-specific visual disturbances with
episodic blurring
Associated myalgias
? Diagnosis
? Investigations
Case history 3
35 year old male
Sudden onset of severe generalised headache
whilst lifting weights at gym
Resolved within 10 minutes of ceasing activity but
recurred at same level of activity if repeated
? Diagnosis
? Investigations
? Treatment
Case history 4
15 year old female
Non-specific generalised headache of
gradual onset with visual obscurations and
diplopia on lateral gaze
Past medical history acne treated with
vibramycin
Clinical examination papilloedema
? Diagnosis and investigations