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 auraA. 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 auraA. At lease 2 attacks fulfilling BB. 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 headacheA. At least 10 previous headache episodes fulfilling B-D.

Less than 180 attacks/yrB. Headache lasts 30 minutes to 7 daysC. 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 headacheA. At least 5 attacks fulfilling B-DB. 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 – Horner’s 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