#59 – Headaches


Classifications and Subtypes

  • 3rd Edition of the International Classification of Headache Disorders (ICHD-3)
    • Primary Headaches
    • Secondary Headaches
    • Neuropathies, Facial Pains, and Other Headaches
  • 90% of headaches fall into 3 primary headache categories



Trigeminal Autonomic Cephalgias

Approach to Evaluation

  • Malignancy of myeloid precursor cells
    • Multipotential hematopoietic stem cell –> common myeloid progenitor –> myeloblast

Signs and Symptoms

  • Environment
    • Turn off the lights
    • Speak quiet
    • Let the patient talk uninterrupted about what is going on
  • History
    • Age of onset
    • Past medical and family history
    • Medication history
    • Presence of absence of aura
    • Characteristics
      • Frequency
      • Intensity
      • Duration
      • Onset
      • Quality
      • Location
      • Radiation
    • Number of headaches per month
    • Associated symptoms
      • Fever, nausea, vomiting, visual disturbances, dizziness, syncope
    • Precipitating, exacerbating or relieving factors
      • Positional changes, exertional
      • Photophobia, phonophobia
      • Relationship to food or alcohol
    • Women
      • Contraception
      • Associated with menstrual cycle
  • Physical Examination
    • Review of vital signs
    • Auscultate for bruits (evaluation for AVM)
      • Neck, eyes, head
    • Palpate head, neck, and shoulder regions
    • Palpate neck and head arteries
    • Palpate neck muscles for spasms or tightness
    • Neurologic examination
      • Mental status
      • Cranial nerve evaluation
      • Fundoscopy
      • Motor and sensory examination
      • Cerebellar exam, including gait, Romberg

Concerning History and Physical Examination Findings

  • SNNOOP10 Red Flag List
    • Systemic symptoms
      • Fever
    • Neoplasm history
    • Neurologic deficits
      • Focal or general
    • Onset
      • Sudden or abrupt
    • Older age
      • Age > 50 years
    • Pattern change or recent new headache
    • Positional
    • Precipitation
      • Sneezing, coughing, exercise, exertional
    • Papilledema
    • Progressive headache and atypical presentations
    • Pregnancy or postpartum
    • Painful eye with autonomic features
    • Post-traumatic
    • Pathology of the immune system
    • Painkiller overuse
  • Presence of ANY of the SNNOOP10 require further investigation
  • Low-Risk Documentation Pearls
    • Age < 50 years
    • Features typical of primary headache
    • History of similar headache
    • No abnormal neurological findings
    • No concerning change in usual headache pattern
    • No high-risk comorbid conditions
    • No new or concerning findings on physical examination

Serious and/or Life-Threatening Headaches

  • “Thunderclap”
    • sudden onset, maximal intensity
  • Neck pain with Horner’s Syndrome and/or neurologic deficit
    • Cervical artery dissection
  • Fever, AMS, and/or nuchal rigidity
    • Meningitis, encephalitis
  • Neurologic deficit and/or papilledema
    • Increased intracranial pressure
      • Pseudotumor cerebri, mass effect lesion
  • Orbital or periorbital symptoms
    • Acute angle closure glaucoma, cavernous sinus thrombosis/fistula

Imaging Recommendations

  • Criteria for imaging in Headaches
    • Any of the SNNOOP10 findings
  • Emergency Setting
    • CT is generally the study of choice because:
      • Widely available
      • Most life-threatening conditions are seen on CT
      • Safer for unstable patients
    • MRI is an option if:
      • New headache with optic disc edema
      • Chronic headache with new features
      • Known or suspected cancer
      • Patient is pregnant
  • Outpatient Setting
    • American Academy of Neurology recommend imaging for:
      • Patients with unexplained abnormal finding on neurologic examination
      • Patients with atypical headache features or headaches that don’t fulfill strict definition of other primary headache disorder
    • Choosing Wisely Campaign – MRI is recommended over CT
    • Consult radiology for recommendations of type of study
      • Imaging vessels, facial structures, orbits

Indications for Lumbar Puncture

  • Suspicion of SAH with a negative CT
  • Suspicion of infectious or inflammatory pathology
  • Suspicion of pseudotumor cerebri

Tension-Type Headache


  • Most common headache subtype
  • 2nd most prevalent disorder in the world
  • Slightly more prevalent in women
  • Least distinct of the primary subtypes
  • Least studied


  • Episodic
    • Infrequent – < 1 episode per month
    • Frequent – 1-14 episodes per month
  • Chronic – 15 or more episodes per month


  • Peripheral activation or sensitization of the myofascial nociceptors leading to heightened sensitivity of the pain pathways in the central nervous system
    • Central factors
      • Increased pain sensitivity
      • Altered brainstem and limbic-controlled descending pain systems
    • Peripheral factors
      • Muscular abnormalities
        • Trigger points, postural, mobility

Clinical Features

  • History
    • Quality
      • Dull, pressure, fullness, band-like, weight on shoulders
    • Increased stress and mental tension
    • Pericranial muscular tenderness
      • Masseter, temporalis, sternocleidomastoid, trapezius

Diagnostic Criteria

  • Two of the following:
    • Bilateral location
    • Pressing/tightening, non-pulsatile quality
    • Mild/moderate intensity
    • Not aggravated by routine physical activity
  • Both of the following
    • No more than one of photophobia or phonophobia
    • No moderate/severe nausea or vomiting
  • Episodic
    • At least 10 episodes lasting 30 minutes to 7 days
  • Chronic
    • At least 15 episodes per month for at least 3 months lasting for hours to days


  • Acute/Abortive
    • NSAID Analgesia
      1. Ibuprofen, acetaminophen, aspirin
      1. Can be combined with caffeine
    • Triptans can be used if NSAIDs fail
  • Preventative
    • Antidepressants
      • Tricyclic antidepressants
        • Amitriptyline has the best evidence
          • Start 10mg and increased 10mg every 2-3 weeks until:
            • Improvement of headaches
            • Max dose of 125mg/day
      • Mirtazapine and venlafazine has some limited data
    • Anticonvulsants
      • Topiramate and gabapentin can also be helpful
    • Trigger point injections
    • Botulinum toxin injections
    • Behavioral treatments
      • Cognitive-behavioral therapy
      • Relaxation techniques
      • Biofeedback
    • Acupuncture and physical therapy has limited evidence of success



  • Affects up to 12% of the population
  • More frequent in women
  • Most common age range is 30-40 years
Up-to-Date. 2020


  • Cortical spreading depression
    • Self-propagating wave of neuronal and glial depolarization that spreads across the cerebral cortex
    • This then causes:
      • Aura
      • Activation of the trigeminovascular system
        • Causes inflammatory changes in the pain-sensitive meninges
        • Increase pain sensitization
      • Alters blood-brain barrier permeability

Clinical Features

  • Cascade of four events over a course of hours to days:
    • Prodrome
      • 24-48 before headache
      • Yawning, euphoria, depression, irritability, food cravings
    • Aura
      • 25% of patient experience focal neurologic symptom
        • Visual
          • Positive
            • Lines, shapes, objects
          • Negative
            • Scintillating scotomas, vision loss
        • Sensory
          • Positive
            • Burning, paresthesias
          • Negative
            • numbness
        • Auditory
          • Positive
            • Tinnitus, noises
          • Negative
            • Hearing loss
    • Headache
      • Unilateral
      • Throbbing, pulsatile quality
      • Nausea or vomiting common
      • Photophobia and phonophobia common
    • Prodrome
      • Feeling of exhaustion, elation, euphoria
Scintillating Scotoma

Precipitating Factors or Triggers

Common Migraine Triggers

Diagnostic Criteria

  • Without an Aura
    • ≥ 5 attacks with the following:
      • Lasting 4-72 hours
      • Headache as 2 of the following:
      • Unilateral
      • Pulsating quality
      • Moderate/severe
      • Aggravation by exertion
    • ≥ 1 of the following:
      • Nausea or vomiting
      • Photophobia or phonophobia
  • With an Aura
    • ≥ 2 attacks with the following:
      • ≥ 1 of the following reversible aura symptoms:
        • Visual
        • Sensory
        • Speech
        • Motor
        • Brainstem
        • Retinal
    • ≥ 2 of the following:
      • Aura spreads and/or 2 or more occur in succession
      • Each aura lasts 5-60 min
      • At least 1 aura is unilateral
      • Aura is accompanied or followed by headache within 60 min


  • Acute/Abortive Therapy
    • Without nausea or vomiting
      • NSAIDs
    • With nausea or vomiting
      • Triptans
        • Sumatriptan
          1. SQ 6mg
          1. IN 20mg
      • Antiemetics
        • Metoclopramide 10mg
        • Prochlorperazine 10mg
      • Dihydroergotamine 1mg IM/SQ
        • Generally combined with metoclopromide
      • Dexamethasone 10mg IM
        • More for prevention of migraine recurrence
  • Preventative Therapy
    • Think about compelling indications and concomitant diseases
    • Antihypertensives
      • Beta Blockers
        1. Metoprolol, propranolol
      • Calcium Channel Blockers
        1. Verapamil, flunarizine
      • ACE/ARB
        1. Lisinopril, candesartan
    • Antidepressants
      • Amitriptyline, venlafaxine
    • Anticonvulsants
      • Topiramate, valproate, gabapentin
    • Calcitonin Gene-Related Peptide (CGRP) Antagonist
      • Erenumab, fremanezumab, galcanezumab
    • Acupuncture, nerve stimulation



  • <1% of headaches
  • Men > women


  • Complex and incompletely understood
    • Most widely accepted theory
      • Hypothalamic activation with secondary activation of the trigeminal-autonomic reflex

Clinical Features

  • Unilateral attacks of severe orbital, supraorbital, or temporal pain
    • Autonomic phenomena
      • Ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, nasal congestion
        • Only occur during the episode
        • Ipsilateral to the pain site
    • Circadian periodicity
      • Occur daily for several weeks and then remit for up to a year

Diagnostic Criteria

  • At least five attacks characterized by severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes with at least one of the following:
    • Conjunctival injections and/or lacrimation
    • Nasal congestion and/or rhinorrhea
    • Eyelid edema
    • Forehead and facial sweating
    • Miosis and/or ptosis
    • Sense of restlessness or agitation
  • Classification
    • Episodic
      • Occur in circardian periodicity in clusters
        • At least two cluster periods lasting 7 days to one year separated by a pain-free remission of at least 3 months
    • Chronic
      • Attacks occur without a remission period or remission lasting less than 3 months
  • Imaging
    • Initial event warrants an MRI to rule-out intracranial pathology that also can cause autonomic dysfunction


  • Acute/Abortive Therapy
    • 100% oxygen via non-rebreather
    • SQ sumatriptan 6mg
    • IN lidocaine 4-10% 1mL
    • Ergot-derivitives
    • Octreotide 100mcg SQ
  • Preventative Therapy
    • Verapamil 240mg daily
      • Bridge with prednisone 60-100mg daily for 5 days, with a 10mg/day taper
    • Galcanezumab can be used for chronic
    • Lithium has limited data
    • Topiramate can be used as add-on therapy

Up-to-Date. 2020

Up-to-Date. 2020

The Cottage Physician (1893)


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