section name header

Information ⬇

[Section Outline]

A benign, episodic syndrome of headache associated with other symptoms of neurologic dysfunction in varying admixtures. Second to tension-type as most common cause of headache; afflicts ∼15% of women and 6% of men annually. Diagnostic criteria are listed in Table 51-3 Simplified Diagnostic Criteria for Migraine. Onset usually in childhood, adolescence, or early adulthood; however, initial attack may occur at any age. Family history is often present. Women may have increased sensitivity to attacks during menstrual cycle. Classic triad: premonitory visual (scotoma or scintillations), sensory, or motor symptoms; unilateral throbbing headache; and nausea and vomiting. Most pts do not have visual aura or other premonitory symptoms. Photophobia and phonophobia are common. Vertigo may occur. Focal neurologic disturbances without headache or vomiting (migraine equivalents) may also occur. An attack lasting 4-72 h is typical, as is relief after sleep. Attacks may be triggered by glare, bright lights, sounds, hunger, stress, physical exertion, hormonal fluctuations, lack of sleep, alcohol, or other chemical stimulation.

TREATMENT

Migraine

  • Three approaches to migraine treatment: nonpharmacologic (such as the avoidance of pt-specific triggers; information for pts is available at www.americanmigrainefoundation.org); drug treatment of acute attacks (Tables 51-4 Treatment of Acute Migraine and 51-5 Clinical Stratification of Acute Specific Migraine Treatments); and prophylaxis (Table 51-6 Preventive Treatments in Migrainea ).
  • Drug treatment necessary for most migraine pts, but avoidance or management of environmental triggers alone is sufficient for some.
  • General principles of pharmacologic treatment:
    • Response rates vary from 50% to 70%.
    • Initial drug choice is empirical and individualized-influenced by age, coexisting illnesses, and side effect profile.
    • Efficacy of prophylactic treatment may take several months to assess with each drug.
    • When an acute attack requires additional medication 60 min after the first dose, then the initial drug dose should be increased for subsequent attacks or another class of drug tried.
  • Mild to moderate acute migraine attacks often respond to over-the-counter (OTC) NSAIDs when taken early.
  • Triptans are widely used and have many formulations.
  • There is likely less frequent headache recurrence when using ergots, but more frequent nausea.
  • For prophylaxis, tricyclic antidepressants are a good first choice for young people with difficulty falling asleep; verapamil is often a first choice for prophylaxis in the elderly.
  • Monoclonal antibodies to calcitonin gene-related peptide (CGRP) or its receptor have been reported to be effective and well-tolerated in chronic migraine and have recently been approved for this purpose.

Tension-Type Headache !!navigator!!

Common in all age groups. Pain is described as bilateral tight, bandlike discomfort. May persist for hours or days; usually builds slowly.

  • Pain can be managed generally with simple analgesics such as acetaminophen, aspirin, or NSAIDs.
  • Often related to stress; responds to behavioral approaches including relaxation.
  • Amitriptyline may be helpful for chronic tension-type headache prophylaxis.

Cluster Headache !!navigator!!

Rare form of primary headache; population frequency ∼0.1%. Characterized by episodes of recurrent, deep, unilateral, retroorbital searing pain. Unilateral lacrimation and nasal and conjunctival congestion may be present. Visual complaints, nausea, or vomiting is rare. Unlike migraine, pts with cluster tend to move about during attacks. A core feature is periodicity. Typically, daily bouts of one to two attacks of relatively short-duration unilateral pain for 8-10 weeks a year; usually followed by a pain-free interval that averages a little less than a year. Alcohol may provoke attacks.

  • Prophylaxis with verapamil (40-80 mg twice daily to start; effective doses may be as high as 960 mg/d), lithium (400-800 mg/d), or prednisone (1 mg/kg up to 60 mg/d for 7 days followed by a taper over 21 days).
  • High-flow oxygen (10-12 L/min for 15-20 min) or sumatriptan (6 mg SC or 20-mg nasal spray) is useful for the acute attack.
  • Deep-brain stimulation of the posterior hypothalamic gray matter is successful for refractory cases as is the less-invasive approaches of occipital nerve stimulation and sphenopalatine ganglion stimulation with an implanted battery-free stimulator.

Post-Traumatic Headache !!navigator!!

Common following motor vehicle accidents, other head trauma; severe injury or loss of consciousness often not present. Symptoms of headache, dizziness, vertigo, impaired memory, poor concentration, irritability; typically remits after several weeks to months. Neurologic examination and neuroimaging studies normal. Not a functional disorder; cause unknown and treatment usually not satisfactory.

Lumbar Puncture Headache !!navigator!!

Typical onset within 48 h after LP but may be delayed for up to 12 days; follows 10-30% of LPs. Positional: onset when pt sits or stands, relief by lying flat. Most cases remit spontaneously in ≤1 week. Oral or IV caffeine (500 mg IV over 2 h) successful in many; epidural blood patch effective immediately in refractory cases.

Indomethacin-Responsive Headaches !!navigator!!

A diverse set of disorders that respond often exquisitely to indomethacin (25 mg two to three times daily). Includes:

  • Paroxysmal hemicrania: Frequent unilateral, severe, short-lasting episodes of headache that are often retroorbital and associated with autonomic phenomena such as lacrimation and nasal congestion.
  • Hemicrania continua: Moderate and continuous unilateral pain associated with fluctuations of severe pain that may be associated with autonomic features.
  • Primary stabbing headache: Stabbing pain confined to the head or rarely the face lasting from 1 to many seconds or minutes.
  • Primary cough headache: Transient severe head pain with coughing, bending, lifting, sneezing, or stooping; lasts for several minutes. Usually benign, but posterior fossa mass lesion in some pts; therefore consider brain MRI.
  • Primary exertional headache: Features similar to cough headache and migraine, but precipitated by any form of exercise.

Outline ⬆

Section 3. Common Patient Presentations