Secondary Idiopathic Intracranial Hypertension IIH Pseudotumor Cerebri

Normal cerebrospinal fluid (CSF) pressure ranges from 70 to 200 mm of H2O. Elevated intracranial hypertension may be idiopathic or due to secondary causes. Secondary causes for increased intracranial pressure are listed in Table 5.1. Once secondary causes of raised intracranial pressure are excluded, the diagnosis of idiopathic intracranial hypertension (pseudotumor cerebri, IIH) can be made on the basis of headache, papilledema, and other symptoms consistent with raised intracranial pressure....

Hemicrania Continua HC

Hemicrania Continua (HC) is a continuous, side-locked, low level headache with periodic exacerbations that are associated with autonomic features. By definition this headache is indomethacin responsive. Because HC has qualifying autonomic characteristics, it is likely to be moved into the category of TACs in the next iteration of the ICHD. The ICHD-2 criteria for HC are quite specific, but there are detailed descriptions of patients with this syndrome suggesting that clinical presentations can...

Chronic Tension Type Headache CTTH

This type of headache often evolves from ETTH. As in ETTH, it is characterized by bilateral or holocephalic pressure-like pain, of mild to moderate severity. Migrainous features are absent. It may be intermittent (with most episodes lasting at least 4 h), or continuous, occurring at least 15 days month for 3 months. Chronic tension-type headache has been associated with a poor life-style in adolescents smoking, obesity, and a sedentary life have been recently demonstrated independent risk...

Headache Attributed to Stroke and Transient Ischemic Attacks

Headache may be reported in 10-30 of patients presenting with an acute ischemic stroke and less commonly in transient ischemic attacks (TIAs). Distinguishing the focal neurologic deficit of a TIA from a migraine aura can be challenging. Deficits associated with a TIA are sudden in onset versus those related to a migraine aura, which tend to develop over 15-20 min. Headaches can also occur in association with strokes related to large vessel atherothrombotic disease, cardioembolism, and to a...

How to Set Up Preventive Treatment Active Tips

Look at each patient individually to determine an appropriate preventive regimen. Set realistic expectations. Emphasize a healthy lifestyle with aerobic exercise daily, good sleep hygiene, and limiting caffeine intake the equivalent of two 8 oz cups of coffee a day or less. Use the most efficacious drugs. All drugs have potential adverse reactions. Most side effects are minor, but some are life threatening causing anaphylaxis or Stevens-Johnson syndrome. Worsening of headache may occur with the...

Serotonin 5HT Antagonists

Cyproheptadine is safe and effective in the pediatric population and may be used in adults as well for migraine prevention. It can be safely used during pregnancy, but is not safe during lactation. Dosing is up to 4-8 mg tid. Adverse effects include drowsiness, dry mouth, constipation, and weight gain. Methysergide was an effective FDA-approved preventive agent no longer available in the USA. This drug required a 1-month drug holiday every 6 months in the hopes of preventing fibrotic...

Diagnosis of Migraine and Tension Type Headaches

Tepper Abstract Headache diagnosis in the office is predicated on deciding if the patient's headache is primary or secondary. Aiding diagnosis is the use of the International Classification of Headache Disorders, second edition (ICHD-2), as well as abbreviated screeners. While migraine is the most common primary headache seen in the office, tensiontype headache is more common in the community. The authors discuss the diagnostic findings typically seen with...

Epidemiology of Primary Headaches

Primary headaches are very common, and the headache usually encountered in the office is migraine. Outside the doctor's office, tension-type headache (TTH) is by far the most common diagnosis in the general population. But in clinical practice, when a patient complains of episodic headache, the diagnosis is usually migraine. Migraine occurs in about 12 of the US population, 18 of females, 6 of males, numbers established in three large population-based studies from 1989 to 2007. Thus, unless...

Impact Based Diagnosis of Migraine

Impact is the third criterion of ID Migraine. Migraine is the most common recurring, episodic primary headache which causes disability and has impact. The impact of migraine is why the aphorism is for a stable pattern of at least 6 months of episodic, disabling migraine. Tension-type headache rarely has any impact at all. Two screeners of disability or impact in episodic primary headache can indirectly suggest migraine. These are the Migraine Disability Assessment Scale (MIDAS) and the Headache...

Diagnosis of Tension Type Headache

Tension-type headache was described by the late Dr. Fred Sheftell as the featureless headache. The diagnosis of TTH is made predicated on the fact that it is not migraine. Thus, the ICHD-2 criteria for episodic TTH (ETTH) are summarized in Table 1.9. Really, the criteria for ETTH are that it is not migraine not unilateral, not throbbing, not severe, not worse with activity, no nausea, and generally no photophobia and no phonophobia. ETTH almost never causes any lasting impact. Patients rarely...

Diagnosis of Probable Migraine

Probable migraine (PM) is the term used by the ICHD-2 for migraine missing one criterion. This could be that a patient has bilateral, non-throbbing, moderate headache, worse with activity, with photophobia but no phonophobia, thus missing one of the D criteria. Table 1.10 Migraine without Aura (ETTH)_ A. At least 5 (10) attacks lasting 4-72 h with B. At least two of the following four 3. Moderate to severe intensity, inhibits or prohibits activities (mild to moderate) Note Migraine, not TTH,...

The Spectrum of Migraine

There is evidence that patients with migraine have a spectrum of episodic headaches across time. That is, some of their attacks will meet criteria for ETTH, some for PM, and some for migraine. There is also evidence that the lower level headaches of migraineurs respond to migraine-specific medications such as triptans. However, ETTH attacks in people who never get migrainous headaches, so called pure ETTH, do not respond to triptans any better than placebo. The lower level headaches of...

Typical Aura with Migraine Headache

Typical aura is defined as a reversible neurologic event, lasting generally from 5 to 60 min, followed within an hour by headache. Aura only occurs in about 20 of migraineurs, and often does not occur with each attack. In addition, the headache which accompanies aura does not always meet ICHD-2 criteria for migraine, and sometimes headache does not occur with aura at all. The ICHD-2 criteria for typical aura are quite specific, and include types of neurologic migrainous events that were...

Diagnosis of Trigeminal Autonomic Cephalalgias and Other Primary Headache Disorders

Abstract The trigeminal autonomic cephalalgias (TACs) and other primary headache disorders are defined by several important characteristics. They are all severe, short-duration headaches. They possibly share a common hypothalamic generator. Workup for posterior fossa or pituitary pathology is warranted before making these diagnoses. Many of the entities in these two groups, with important exceptions, respond to indomethacin. TACs often demonstrate ipsilateral parasympathetic hyperactivity and...

Word to the Wise on the Other Primary Headaches

Because of the paucity of clinical and pathophysiological data, these primary headaches require special attention and clinical vigilance. It is incumbent upon the treating clinician to assure that these headaches are not secondary to a treatable condition. Clinical complacency may overlook that rare case in which the cause turns out to be a serious lesion This is particularly true with the thunderclap headache, in which a primary classification should be considered the exception, not the rule.

Primary Stabbing Headaches

Primary stabbing headaches are also referred to as ice-pick pains or jabs and jolts and are actually quite common. They are brief, lasting 3 s or less, occur in a Vj distribution, and can come in volleys or single jabs (see Table 2.13). Some patients have to stop short in their tracks and move the head from one side to another. Table 2.12 Differential points among the TACs Table 2.12 Differential points among the TACs Adapted from Goadsby et al. (2010) M male, F female, C cervical, Vtrigeminal...

Primary Cough Headache

Clinically, cough headache is a paroxysm, a quick upstroke of pain in less than a second, with a gradual resolution of generally < 5 min. The sound Puh is associated with the quick, almost instantaneous peak of pain with cough, sneeze, or valsalva. There are no associated features. Table 2.14 Secondary causes of cough headache Arnold Chiari malformations with or without hydrocephalus Acute obstructive hydrocephalus Idiopathic intracranial hypertension Secondarily raised intracranial pressure...

Primary Thunderclap Headache PTH

Primary thunderclap headache distinguishes itself by its rapid onset to peak pain it reaches its apex within seconds to a minute. Patients often will claim they were Table 2.20 Primary thunderclap headache, ICHD-2 diagnostic criteria A. Severe head pain fulfilling B and C B. Both of the following characteristics 1. Sudden onset, reaching maximum intensity in < 1 min C. Does not recur regularly over subsequent weeks or months Table 2.21 Secondary causes of thunderclap headache Intracranial...

Diagnosis of Primary Chronic Daily Headaches

Tepper Abstract Chronic daily headache (CDH) is a term of art meaning headaches present at least 15 days month, at least 4 h day untreated, present at least 3 months. CDH is generally primary, but many clinicians include Medication Overuse Headache (MOH) in the term. CDH is not a diagnosis in the International Classification of Headache Disorders. The four primary chronic daily headaches are Chronic Tension-Type Headache (CTTH), Hemicrania Continua (HC), New...

Clinical History of Secondary Headaches

Some patients with secondary headache have a preexisting history of primary headaches. Therefore, clinicians must be vigilant for any change in pattern, character, or an overall worsening of the patient's headaches, as this may suggest a new secondary etiology. Obtaining a detailed headache history is essential in evaluation of secondary headaches. It is important to know whether the onset was preceded by an unusual event or provocation, whether there is a trend in pain intensity since onset,...

Headache Due to Head or Neck Trauma

Following trauma to the head or neck, it is not uncommon for patients to report the onset of new headache. These posttraumatic headaches (PTHA) may be associated with mild, moderate, or severe head injury along with whiplash-type injuries. Traumas may worsen preexisting headache conditions. PTHA is frequently associated with other somatic, psychological, and cognitive symptoms which are referred to as posttraumatic syndrome (previously referred to as postconcussion syndrome) (see Table 4.7)....

Headaches Associated with Vascular Disease

Headache is a relatively common symptom in a variety of underlying cerebrovascular diseases (see Table 4.8). Intracranial hemorrhages are most often associated with abrupt onset of severe headache, which has been termed thunderclap headache. Thunderclap headache is defined as a severe headache reaching maximal intensity within seconds to a minute. Headaches may be a consequence of stroke, particularly hemorrhagic infarction. Migraine is also a known risk factor for stroke or vascular...

Headache Attributed to Intracranial Hemorrhage

For patients presenting with acute focal neurologic deficits consistent with a stroke pattern, the concurrent report of headache raises great concern for the presence of an intracranial hemorrhage. Indeed, headache is reported in up to 70 of patients diagnosed with intracerebral hemorrhage. Hemiparesis and decreased Table 4.11 Differential diagnosis of thunderclap headache Subarachnoid or intracerebral hemorrhage Sentinel leak, arteriovenous malformation, or aneurysmal bleed Unruptured cerebral...

Headache Attributed to Subarachnoid Hemorrhage

Patients with subarachnoid hemorrhage (SAH) usually present with the sudden onset of the worst headache of my life or thunderclap headache. The headache may be associated with alteration of consciousness, vomiting, photophobia, drowsiness, agitation, or neck stiffness. In 50 of patients, an unruptured aneurysm may produce a warning headache referred to as a sentinel headache. Sentinel headaches occur in the days to weeks prior to aneurysm rupture. Although thunderclap headache is the classic...

Headache Attributed to Carotid or Vertebral Artery Pain

Spontaneous dissection of the vertebral or carotid artery may produce head pain. The diagnosis should be considered in individuals reporting new onset of head pain along with neck pain. Clinical suspicion should be raised if the patient endorses a recent history of known provocative factors such as chiropractic manipulation, severe vomiting, or neck trauma, including whiplash-type injuries. Patients with collagen vascular disease or fibromuscular dysplasia are at particular risk. The headache...

Diagnosis of Major Secondary Headaches 2 Nontraumatic and Nonvascular Disorders

Abstract This chapter on secondary headaches focuses exclusively on headaches which are due to non-vascular causes. The chapter begins with considerations on diagnosis of idiopathic intracranial hypertension (IIH, pseudotumor cerebri) and headaches of low CSF pressure or intracranial hypotension. Next, the author provides a discussion on headaches associated with intracranial neoplasm, disorders of infectious disease, disorders of homeostasis, and toxic headaches, along with clinical pearls for...

Headache Attributed to Intracranial Neoplasm

Headache may be the initial presentation in approximately 20 of patients with brain tumors. Later in the course of their illness, headache incidence increases to 50-70 of patients. Most individuals with underlying brain tumor will present with headache along with other focal neurologic symptoms such as seizures, confusion, or hemiparesis. Brain tumor headache is characterized as progressive, diffuse, and nonpulsating, and associated with nausea and or vomiting. The headache worsens with...

Headache Attributed to Infectious Diseases

Any underlying infection may produce a headache or worsen a preexisting primary headache condition. The infection may be systemic or intracranial. Patients with headache related to systemic infection generally have fever, malaise, and diffuse myalgias. Headache is common in HIV-infected patients at any stage of the illness and has been noted to occur with HIV seroconversion related to primary infection. Later in HIV illness, any presentation of headache or change in pattern of headaches should...

Cervicogenic Headache

Headache may be a referred pain originating from the neck. This type of headache must be distinguished clinically from those patients with neck pain as an associated symptom of a primary headache disorder. Patients at risk for cervicogenic headache include those with a history of arthritis with cervical spondylosis and degenerative disc disease, or those with a history of neck trauma, particularly whiplash type injuries. Examination may reveal tenderness or muscle spasm of the cervical...

Headache in Children and Adolescents Evaluation and Diagnosis Including Migraine and Its Subtypes

David Rothner Abstract This chapter reviews the evaluation and diagnosis of children and adolescents who present with episodic migraine and its subtypes. The first part of the chapter describes the evaluation of headaches in children and adolescents. Clinical pearls on common temporal patterns, likelihood of secondary headache, proper examination, and shortcuts to diagnosis are presented. An extensive section on pediatric headache characteristics is provided to expedite...

Evaluation of Headache in Children and Adolescents

Headache in the pediatric population is one of the most common symptoms in primary care settings and accounts for 30 of neurologic referrals. Headache frequently worries both health practitioners and parents, as headache in children may be the heralding symptom of serious intracranial pathology. This can lead in many instances to unnecessary testing. A thorough history taking, physical, and neurological examinations will help the care provider determine if further diagnostic testing is needed...

International Headache Classification as It Applies to Children

In 1988, the International Headache Society (IHS) published the first system for diagnosis and classification of headache disorders. Although diagnostic criteria for children were included, these were derived, for the most part, from adult criteria. A second edition was published in 2004, and multiple revisions have focused on features of primary headaches in children that are unique to this population. The following section reviews the most common primary headache syndromes in children and...

Migraine and Related Disorders

Migraine headache is the most common primary headache disorder in the pediatric population. According to epidemiologic studies by Stewart and colleagues, migraine begins earlier in males than females. Male incidence peaks at 5 years of age (6.6 1,000 person-years), while in females migraine peaks between 10 and 14 years (18.9 1,000 person-years). Migraine incidence and prevalence are illustrated in Tables 6.9 and 6.10, respectively. The American Migraine Prevalence and Prevention Study (AMPP)...

Episodic Tension Type Headache

Episodic Tension-Type Headache (ETTH) is considered to be the most frequent headache encountered in adult headache population-based studies. Based on pediatric population studies, it is estimated to occur in anywhere from 10 to 72 of school-age children, while clinic based studies have reported an incidence of approximately 30 . Its true prevalence may be underestimated, as many patients with tensiontype headache do not seek medical attention. Also, since most studies are done in school-age...

The Pediatric Chronic Daily Headaches

Chronic Daily Headache (CDH) is one of the most common headache problems resulting in referral to pediatric neurologists or headache specialists. It often results in significant disability, school absenteeism, and economic burden, due to frequent emergency room and office visits, hospitalizations, parental work loss in order to care for the patient, and unnecessary testing. Chronic Daily Headache, as a primary headache disorder, often results in significant anxiety in patients and parents, as...

Less Frequent Primary Headaches in Children and Adolescents

The Trigeminal Autonomic Cephalalgias (TACs) constitute another group of primary headache disorders. This group encompasses Cluster Headache, Paroxysmal Hemicrania, and Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing (SUNCT). The common features to this group of disorders are the ipsilateral autonomic manifestations such as conjunctival injection, lacrimation, and nasal congestion. Although the TACs account for less than 1 of primary headache disorders in...

Acute Treatment of Episodic Migraine

Abstract All patients with migraine need to be provided acute treatment, even those on preventive medications. Setting clinical goals and expectations with patients improves adherence and outcomes. Goals for acute treatment include quick onset with consistent response, low recurrence, restoration of normal function with reduced disability, minimal side effects, and minimal use of rescue meds, at lowest possible cost. When patients are surveyed as to their desires for acute treatment and given...

Nonspecific Acute Migraine Treatment Nonsteroidal Antiinflammatory Drugs NSAIDS

There are at least 20 different NSAIDs available in the USA. All are well absorbed and have a negligible first-pass hepatic effect. They are highly protein bound and may interfere with other protein-bound drugs. NSAIDS have both a prostaglandin and non-prostaglandin mediated mechanism of action. In migraine treatment, NSAIDS prevent prostaglandin formation through the inhibition of cyclooxygenase. Some NSAIDS have more of an anti-inflammatory effect and others an enhanced analgesic effect....

Preventive Treatment of Episodic Migraine

Abstract Frequent and disabling migraines should be treated with preventive therapies, whether pharmacologic or natural supplements. Many options are available, and treatment should be tailored to consideration of each patient's comorbidities. It is trial and error finding the most effective drug with the least amount of side effects for each patient. Successful treatment will decrease disability and improve quality of life for the patient. This chapter lists the preventive medications with...

Medications Used for Prevention of Migraines

Preventive medications commonly used for prophylaxis can include antihypertensives, antidepressants, antiepileptic drugs, NSAIDs, and supplements (see Table 9.2). Only five drugs are approved by the FDA for migraine prevention in the USA pro-pranolol, timolol, valproic acid, topiramate, and methysergide (no longer available in the USA). All other drugs for prevention are used off-label. OnabotulinumtoxinA now has FDA approval for chronic migraine (at least 15 headache days per month), but not...

Other Primary Headaches

The treatment of most other primary headaches is not well studied, but is summarized in Table 10.13. This is an amalgam of recommendations and time-tested therapies. With the exception of HC, these are not Class I data. The first and foremost therapeutic approach to these headaches is actually diagnostic, particularly for headaches associated with cough, exertion, and sexual activity, and especially with thunderclap headaches. It is the primary responsibility of the care provider to investigate...

Treatment of Medication Overuse Headache

Tepper Abstract Medication overuse or rebound headache (MOH) is a secondary chronic daily headache (CDH), defined by a worsening and transformation of episodic migraine into daily or near-daily headache, associated with overuse of acute antimigraine medications. The frequency at which acute medication results in MOH varies, and can be as little as 5 days of use per month for butalbital, 8 days per month for narcotics, and 10 days per month for triptans and...

Chronic Migraine CM Therapeutic Approach

Our approach is to incorporate the techniques used in aborting and preventing episodic migraine headache. To this we initially attempt to alter and eliminate modifiable risk factors, at the same time educating the patient to avoid reliance on immediate relief medications, which may induce further transformation to MOH (see below). Treatment routinely includes addressing the modifiable risk factors associated with the development of CM dietary consultation and counseling for patients with...

Psychological Assessment and Behavioral Management of Refractory Daily Headaches

Abstract While true psychosomatic headaches are rare in clinical practice, psychological factors frequently influence the course of a headache and the degree of disability associated with it. Psychological stress, defined as situations in which an individual perceives demands upon themselves exceeding their ability to adapt effectively, produces autonomic responses which escalate headaches. Further psychological risk factors include reinforcement of attention to pain and disability, diminished...

Low Cerebrospinal Fluid Pressure Headache

Headache present when the patient is upright but resolving in the supine position is often related to low cerebrospinal fluid (CSF) pressure. This may occur spontaneously, but most often is the result of prior lumbar puncture resulting in persistent leak of CSF. The headache pain and other clinical manifestations can be quite debilitating. Table 14.9 Clinical pearls in the management of idiopathic intracranial hypertension (pseudotumor cerebri) o Evidence is not clear, but might be useful o Low...

Headache Associated with Chiari I Malformation

A Chiari I malformation is a congenital malformation characterized by herniation of the cerebellar tonsils below the foramen magnum. Some cases may have associated syringomyelia or may have obstruction of CSF flow as documented by a CINE MRI study. Common presenting symptoms are listed in Table 14.12 they are reproduced here to remind the clinician that without these cardinal clinical manifestations, surgery should not be considered. MRI is used to measure the degree of tonsillar ectopia in...

Treatment of Pediatric and Adolescent Headaches

Abstract The treatment of headaches in children and adolescents is a combination of art and science. Treatment requires taking into consideration the diagnosis, the temperament of the family, and the personality of the child. A model or overall paradigm for treatment of headaches and children in adolescence is outlined. Sections on stress, patient education, lifestyle, sleep, and diet all precede the use of medications. Pediatric rescue or acute medications are described, followed by sections...

Introduction A Model for Pediatric Headache Treatment

The treatment of headaches in children and adolescents is a combination of art and science. Take into consideration the diagnosis, the temperament of the family, and the personality of the child. A model or overall paradigm for treatment of headaches and children in adolescence is outlined in Table 15.1. The above approach varies somewhat when dealing with chronic pediatric headache as opposed to an acute headache syndrome. The patient's headache frequency, its severity, its duration, and its...

Alternative Approaches in the Treatment of Pediatric Headache

Many patients and families wish to avoid medication and explore nonpharmaco-logic measures to treat their headaches. Table 15.9 lists some of these approaches. Column A includes those with data to support their use, although not always Table 15.9 Alternative approaches for pediatric headache Riboflavin (vitamin B2) Coenzyme Q10 Butterbur root Feverfew Physical therapy OnabotulinumtoxinA in pediatrics. Column B lists those with less data but potential usefulness. Any of these approaches should...

Multidisciplinary Rehabilitation Treatment of Refractory Pediatric Headache

An inpatient rehabilitation program for the treatment of pain in pediatrics is useful. At the Cleveland Clinic, four forms of chronic pediatric pain are treated using a rehabilitation model complex regional pain syndrome, fibromyalgia, chronic recurrent abdominal pain, and CDH, especially those associated with frequent school absences and medication overuse. A limited medication true rehabilitation model is used, stressing psychological and physical rehabilitation modalities. Follow-up data...

Acute Pediatric Headache

Children and adolescents are often seen in the emergency room and in their primary care physician's office for the evaluation of an acute headache with no previous history of recurrent headache. The overwhelming majority of patients with acute headache do not have any underlying structural or neurological abnormalities. Often, the patients have a headache related to fever or upper respiratory infection. Table 15.11 Clinical pearls The principles of treatment of an acute pediatric migraine...

Pediatric Migraine Headache Acute Urgent Treatment

Migraine headaches are among the most common headaches seen in pediatrics, and care providers are often called upon to treat urgently in office or ER. In younger children, migraines are more common in the afternoon, while in teenagers they are more common in the morning. Principles of treatment, acutely, as noted above, include sedation, anti-emetics, analgesics, and abortives (see Table 15.11). For the average size teenager, begin with 25 mg of diphenhydramine and 10 mg kg of naproxen sodium....

Status Migraine Treatment

Status migraine was described in 1983. It is less common in children and adolescents than it is in adults (see chapter 8). It is a disabling headache of the migraine type which has lasted for at least 72 hours and which has been refractory to the usual analgesics. It is rarely the patient's first attack of migraine. Status migraine results in disruption of social and school functioning. Underlying provoking etiologies must be ruled out. Attempt to treat status migraine in an out-patient...

Migraine with Neurologic Features

At times patients presenting with migraine will have associated neurological features. This can be seen in migraine without aura, migraine with aura, basilar-type migraine, and hemiplegic migraine. If symptoms or signs of increased intracranial pressure are present, a workup for underlying structural abnormality is indicated. Migraine with neurologic features requires close follow-up. Specialized testing for hemiplegic migraine may be needed. Do not use triptans in the treatment of these types...

Posttraumatic Headache

Many patients are seen with daily headache or almost daily headache following a head injury or concussion, usually in the absence of serious intracranial pathology. Patients frequently have associated symptoms such as lethargy, personality change, irritability, and dizziness. Once intracranial structural abnormalities have been excluded, these patients should be treated as if they have CDH. This, too, is a difficult group of patients to treat, and often stress management is indicated.

Behavioral Treatment of Headaches

Abstract Scientific research and headache literature suggest that psychological factors play a significant role in the maintenance, if not genesis, of primary headache disorders, as well as strongly influencing levels of functional disability. In patients with headache, there appears to be a reciprocal relationship between psychological variables and functional status, with each strongly influencing the other. This chapter deals with psychological variables affecting headache and their...

Menstrual Migraine Diagnosis

Pure Menstrual Migraine Without Aura (PMM) Meets criteria for migraine, and attacks occur exclusively on days (-2) to (+ 3) of menstruation in at least 2 3 of menstrual cycles and at no other times. Note that the first day of flow is considered (+1). It is unusual to have migraine only occurring with menstruation. Menstrually-Related Migraine Without Aura (MRM) Meets criteria for migraine and attacks occur on days (-2) to (+3) of menstruation in at least 2 3 of menstrual cycles, and...

Epidemiology Menstrual Migraine Is Very Common

Migraine affects 25 of the female population during the childbearing years (18-49). Migraine is influenced by hormonal changes in the reproductive cycle. Menstrually-related migraine (MRM) begins at menarche in approximately one third of women. Between 60 and 70 of women with migraine suffer from MRM during their lifetime. Pure menstrual migraine is less frequent and occurs in 7-14 of women with migraine. Menstrually-related migraine is predictable in some women making them more amenable to...

Pathophysiology What You Need to Know to Explain Menstrual Migraine to Your Patients

The primary mediator of hormonal migraine is the fall in estrogen which occurs at ovulation and menstruation. It is not the absolute fall, but the relative decrease in hormone which provokes migraine attacks (see Fig. 18.2). Table 18.3 Clinical pearls on women with migraine 60-70 have menstrually-related migraine Critical time (-2) to (+3) days of menstrual cycle Dalton, 1973 (42) MacGregoretal., 1990(1) Johannes etal., 1995(43) Stewart etal., 2000 (29) Our study

Treatment of Menstrual Migraine

In general, treatment is the same for menstrual as for non-menstrual migraine. If migraine is infrequent, use abortive or rescue therapy. In general, triptans are the treatment of choice. For many women, nonsteroidal anti-inflammatory drugs (NSAIDs) alone or in combination with a triptan are particularly helpful since they are beneficial in treating menstrual cramps as well. If migraine is frequent, prolonged, or poorly responsive to acute therapy, consideration should be given to prophylactic...

Prevention of Menstrual Migraine

Ovulation Related Migraines

There is some consensus that increasing the dose of certain preventive medications, such as valproic acid or tricyclic antidepressants (TCAs) 5 days before and during the menstrual cycle may be of benefit. This is not possible with some preventive medications, such as beta blockers. Adding magnesium 500 mg starting around ovulation and maintaining through menses, or taking it daily may prevent or decrease the severity of migraine attacks (see Table 18.5). Fig. 18.3 Decision tree for...

Perimenopause Menopause and Migraine

Perimenopause is described as the decade preceding menopause when hormonal fluctuations may begin. Menopause is defined as the absence of menstruation for 1 year. The average age of menopause is approximately 53, and an increase in migraine due to the fluctuating hormones of perimenopause may present a challenge to both the patient and physician. Following a natural menopause, approximately 60-70 of women have an improvement in their migraine. In contrast, 40-70 of women who undergo a surgical...

Nursing Issues in the Diagnosis and Treatment of Headaches

Abstract Nurses can play five key roles in headache management history documentation, patient education, participation in follow-up visits and phone calls, and leading groups. Nursing history includes a description of the headaches, allergies, medications, past medical and surgical history, social history, habits, sleep, family history, quality of life, disability information, review of symptoms, and, most importantly, what the patient hopes to gain from the visit. Nurses provide a critical...

Common Migraine Triggers

Stress The most common trigger in inducing migraines, including, but not limited to anxiety, worry, anger, depression, crying, poor coping abilities, weekend or vacation activities, and including letdown after these activities. 2. Foods Diet Alcohol, MSG, nitrites, chocolate, caffeine, etc. Educate patients that dietary triggers do not mean that a patient is allergic to that food item. This should eliminate the need for patients to seek a consultation with an allergist for expensive allergy...

Pitfalls in the Diagnosis of Migraine Associated Dizziness

The Neuhauser criteria are sufficiently limited as to make it difficult to definitely pinpoint a syndrome. It is possible to have a person with a history of migraine, now with vertigo and phonophobia but no headache, and meet criteria for MAD. The issue becomes whether one can fully rule out other central or peripheral vestibular disorders causing vertiginous symptoms that are not related to migraine. Vertigo and phonophobia together can co-exist in an otogenic (inner ear) disorder even with...

Treatment of Migraine Associated Dizziness

Treatments that may be helpful to treat MAD include trigger avoidance, conventional acute and preventive migraine pharmacotherapy, acetazolamide, and vestibular physical therapy. These are listed in Table 20.4. Table 20.4 Clinical pearls on treatment of migraine-associated dizziness Typical migraine treatments should be considered o Preventive migraine treatment such as topiramate (has been demonstrated in randomized, controlled trials) o Acute migraine treatment such as triptans Acetazolamide...

Cervicogenic Headache and Cervically Mediated Dizziness

Cervicogenic headache is classified in the ICHD-2 and was covered in Chap. 14. Because of its relation to dizziness, it is reviewed again here. Cervicogenic headache is generally a unilateral headache syndrome referred from a source in the neck and perceived in the head and or face. The etiology of cervicogenic headache is not singular a number of cervical spine disorders are possible causes, although cervical abnormalities alone do not establish the cervicogenic diagnosis. For diagnosis of...

Chronic Migraine CM

Unlike the other three chronic daily headaches, CM is a controversial diagnosis, with multiple suggestions and positions on criteria vying for position. The history of the terms used in diagnosis helps the clinician attempting to accurately diagnose this group of patients. Chronic migraine is often used to mean CDH. Thus, many clinicians include both primary CDH and secondary CDH (Medication Overuse Headache, MOH, analgesic rebound) in the definition of CM. This was done historically, and is...

Primary Headache Associated with Sexual Activity

This headache disorder includes the subtypes, preorgasmic and orgasmic headaches. The former is associated with sexual excitement, and the second headache occurs at the coup de gras. It is not unusual to see one of these headaches cohabiting in a patient who also has exercise-induced headaches. Primary sex headache can be short lived or can last several hours, and in any fresh case, a workup is required. For many who present for the first time, it can present as an explosive headache that...

Diagnosis of Childhood Periodic Syndromes Tension Type Headaches and Daily Headache Syndromes

David Rothner Abstract This chapter is divided into three sections on pediatric headache diagnosis Childhood Periodic Syndromes (considered by some to be migraine precursors), Tension-Type Headache, and Pediatric Daily Headache. The Childhood Periodic Syndromes covered include Cyclical Vomiting Syndrome (CVS), Abdominal Migraine (AM), and Benign Paroxysmal Vertigo of Childhood (BPVC) as migraine precursors. More recently, Benign Paroxysmal Torticollis (BPT) has been...

Migraine and Oral Contraception

There are three types of oral contraception fixed dose, triphasic, and progesterone only. Use of triphasic oral contraception may increase migraine due to constantly changing levels of hormones. In general, these types of contraceptive pills should be avoided. Use the lowest-dose estrogen pill possible (15 ug or less). There are fewer side effects and the incidence of migraine is lower than with the higher estrogen pills. Oral progesterone preparations have many side effects including bleeding...

Conclusions on Diagnosis and Treatment of Dizziness and Headache

Dizziness and headache are separately quite common. There are, however, a number of scenarios where the two can be interconnected. An area of significant clinical interest at this time is migraine-associated dizziness in which the migraine generator produces the vestibular symptoms. Table 20.10 Factors linking headache and dizziness Chronic post-bacterial meningitis Migraine-associated dizziness should only be diagnosed in an individual with an established history of migraine. There can be an...

Diagnostic Criteria for Secondary Headaches

By definition, a secondary headache must be either in close temporal relation to another disorder, or there is evidence of a causal relationship (see Table 4.2). Patients may present to the emergency department when a new headache is acute in onset, or seek outpatient evaluation when the headache is subacute or chronic. Table 4.1 Secondary headaches and cranial neuralgias as classified by ICHD-2 Headache attributed to head and or neck trauma Headache attributed to cranial or cervical vascular...

Ancillary Testing

The American Academy of Neurology (AAN) first published its practice parameter for the evaluation of children and adolescents with recurrent headaches in 2002. Their key recommendations are summarized in Table 6.6. Variables that predict the presence of intracranial pathology in pediatric patients with headache are summarized in Table 6.7. As repeatedly stated, the most important factors in accurate evaluation and correct diagnosis of pediatric headache are a thorough clinical history,...

Childhood Periodic Syndromes

The term Childhood Periodic Syndrome was first introduced by Wyllie and Schlesinger in 1933 to describe stereotypical, recurrent episodes of vomiting, headache, and or abdominal pain, separated by symptom-free intervals. Several years later, Barlow described how these periodic syndromes were common precursors of migraine. The ICHD-2 has included Cyclical Vomiting Syndrome (CVS), Abdominal Migraine (AM), and Benign Paroxysmal Vertigo of Childhood (BPVC) as migraine precursors. More recently,...

Transformed Migraine Chronic Migraine TMCM

It is not infrequent, when evaluating children and adolescents with CDH, to encounter two different types of headache in their description of symptoms. Patients often describe a daily headache, of moderate to severe intensity with exacerbations, sometimes several times per month. These exacerbations are often accompanied by classic migrainous features, such as nausea, vomiting, photophobia, and phonophobia. Auras may also occur. The term Transformed Migraine was initially applied to those...

Migraine Associated Dizziness MAD

The concept of migraine-associated dizziness has been around for many years but has been recognized more frequently in the past few years. There are a variety of similar terms used for MAD including migrainous vertigo, migraine-associated vertigo, migraine-associated dizziness, and vestibular migraine. Migraine-associated dizziness can occur ictally or interictally with typical migraine episodes. The diagnosis is not recognized by the International Headache Society. Table 20.3 Neuhauser...

Treatment and Consideration of Womens Issues in Headache

Abstract At menarche the incidence of migraine in girls increases. Migraine also changes at other key times in a women's life during menses, with the use of oral contraceptive therapy, and with pregnancy, lactation, and menopause. Each of these hormonal milieus is discussed in this chapter with relation to headache. The chapter includes sections on diagnosis of menstrual migraine, followed by discussion of acute, preventive, and miniprevention strategies. The impact and controversies of...

Diagnosis and Treatment of Dizziness and Headache

Abstract Dizziness and headache are separately quite common. There are, however, a number of scenarios where the two can be interconnected. An area of significant clinical interest at this time is migraine-associated dizziness, in which the migraine generator produces vestibular symptoms. Also, there can be an overlap between orthostatic intolerance and migraine, with a spectrum of symptoms from palpitations and tachycardia to presyncope or actual syncope. A third important area of overlap is...

Suggested Reading

The differential diagnosis of chronic daily headaches an algorithm-based approach. J Headache Pain. 2007 8 263-72. Dodick DW. Clinical clues and clinical rules primary versus secondary headache. Adv Stud Med. 2003 3 S550-5. De Luca GC, Bartleson JD. When and how to investigate the patient with headache. Semin Neurol. 2010 30 131-44. Edlow JA, The American College of Emergency Physicians Clinical Policies Subcommittee. Clinical policy critical issues in the evaluation and...

Diagnostic Testing

Many patients, particularly those presenting with an episodic occurrence of a typical primary headache, do not warrant further investigation if their physical and neurological examination are normal and no red flags are elicited in the history. Fortunately, less than 5 of the patients presenting to the emergency department or physician's office with headache will be found to have significant underlying causative pathology. Despite the relatively low odds of finding such pathology, clinicians...

Headaches Associated with Disorders of Homeostasis

There are a number of systemic disorders and metabolic conditions frequently associated with headache (see Table 5.7). The patient will exhibit signs and symptoms Table 5.8 Some of the substances known to provoke headache Nitric oxide donor (nitroglycerin, nitrates, and nitrites of cured meats) Phosphodiesterase inhibitor (e.g., sildenafil, vardenafil for erectile dysfunction) Food components and additives (MSG, aspartame, tyramine) Calcitonin gene related peptide (CGRP) related to the...

Primary Thunderclap Headache

Primary thunderclap headache distinguishes itself from other primary headaches by its random, unexpected presentation. Treatment is palliative while a workup ensues to rule out an ominous cause. Many emergency departments must resort to opioids to control the pain. As noted, Table 10.13 summarizes the treatment of the listed other primary headaches. Hypnic headache is discussed below separately. Primary thunderclap Table 10.13 Treatment of other primary headaches stabbing - Indomethacin 25-250...

Diagnosis of Major Secondary Headaches 1 the Basics Head and Neck Trauma and Vascular Disorders

Abstract The recognition of secondary etiologies is critically important to all those treating patients with headaches. Secondary headaches occur in close temporal relation to another disorder, or there is evidence of a causal relationship. Secondary headache, by definition, should improve or go away within 3 months spontaneously or after successful treatment of the cause. While the ICHD-2 lists eight different classifications of secondary headaches, this clinically focused chapter delves into...

Treatment of Major Secondary Headaches

Abstract There are a variety of medications that are used to treat the secondary headaches, although the evidence to support their use is often limited. Medications commonly used are often the same as those used to treat primary headache disorders such as migraine and tension-type headache. Clinicians must use caution when prescribing medications that may worsen an underlying condition or cause a recurrence of symptoms. Because secondary headaches are often daily and constant in nature, the...

Springer

Cleveland Clinic Lerner College of Medicine Cleveland Clinic, Cleveland, OH, USA Cleveland Clinic, Cleveland, OH, USA ISBN 978-1-4614-0178-0 e-ISBN 978-1-4614-0179-7 Springer New York Dordrecht Heidelberg London Library of Congress Control Number 2011933474 Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York,...

Treatment of Cervically Mediated Dizziness

Cervicogenic dizziness can be successfully treated with a combination of neck physiotherapy, occipital nerve blocks, and oral antineuritic pain medications such as gabapentin or amitriptyline. Thus, nonsurgical treatment for both cervicogenic headache and dizziness overlap. Further understanding of cervicogenic dizziness comes from treating dizzy patients without headache and cervicogenic headache patients without dizziness. The disorder is suggested by not meeting IHS criteria for either...

Benign Paroxysmal Torticollis BPT

First described by Snyder in 1969, Benign Paroxysmal Torticollis (BPT) is characterized by sudden onset of recurrent dyskinesias involving the neck. During the attack, there is abnormal rotation of the head and neck toward the affected side, which may be accompanied by vomiting and ataxia. Other symptoms frequently encountered in migraine such as pallor, drowsiness and photophobia may occur. Each episode may last hours to days, and resolves spontaneously without sequelae. Patients develop...

Diagnosis of Cluster Headache

Cluster headache, the most common of the TACs, is generally more common in males. It can start as early as the second decade and persist well into life, even into the seventh decade. The headaches are called clusters because they tend to cluster at the same time(s) of the year. Episodic cluster cycles last for weeks to months with remissions of months to years. This headache pattern is thought to reflect the circa-dian and circannual periods and the effect of light-dark cycles on the...

Menstrual Migraine

Menstrual migraine is only defined in the appendix of the ICHD-2, but the current definitions are widely accepted and adopted. Menstrual migraine occurs in about 2 3 of women, and is just a migraine with a menstrual trigger. Hormonal issues and headache will be covered more extensively in Chap. 18. There are two forms of menstrual migraine, but it is not clear that the differences are clinically meaningful. The usual form is referred to as menstrually-related migraine (MRM), in which attacks...

Treatment of the Trigeminal Autonomic Cephalalgias TACs Cluster Headache

Table 10.1 lists the clinical goals in treating cluster. Acute or Abortive Therapy of Cluster Headache To the patient in the throes of a cluster headache (CH) attack, the most important goal is to abort the unrelenting pain. For most patients the interictal period between attacks is pain-free or only mildly uncomfortable, but the seasoned cluster veteran fears that the headache, brief though it may be, will return, recur, and persist. Many patients will voice their trepidation about falling...

Brief Screeners for Migraine Diagnosis ID Migraine

Because some care providers find the ICHD-2 criteria too cumbersome, several brief screeners have been validated. The most important of these is ID-Migraine, which consists of three questions Presence or absence of photophobia, presence or absence of nausea, and presence or absence of impact on activities. If the patient has the presence of 2 3 symptoms, ID Migraine has a sensitivity of 0.81 and a specificity of 0.75 (see Table 1.7). Table 1.7 ID migraine Yes or No answers With your headaches...

Pregnancy and Migraine

There is no evidence of altered fertility rates, toxemia, miscarriage, congenital malformations, or stillbirths in migraineurs vs. non-migraineurs. Most female migraineurs improve during pregnancy, especially in the 2nd and 3rd trimester. However, 4-8 of women worsen during pregnancy. Ten percent of migraine in women begins during pregnancy. Pre-pregnancy headache rate returns almost immediately following birth, although some women enjoy reduced migraine during lactation. The WHO International...

Treatment of Trigeminal Autonomic Cephalalgias and Other Primary Headaches

Abstract The treatment of the TACs and other primary headaches straddles the spectrum from simple to complex. At the simple end of the therapeutic spectrum is the use of indomethacin for the paroxysmal hemicranias, sexually related, cough, and primary stabbing headaches. More difficult to treat is hypnic headache. Paradoxically, the use of caffeine just prior to going to sleep has been beneficial for hypnic headache lithium is the next choice. SUNCT SUNA may respond to lam-otrigine and...

Migraine Triggered Seizure Migralepsy

As with migrainous infarction, migraine-triggered seizures can occur, but are very unusual. The seizure, when triggered by migraine with aura, must occur during the migraine or within an hour of the migrainous aura, and once again, secondary causes must be excluded (see Table 1.18). A critical part of the diagnosis of migraine-triggered seizure is that by criteria, the seizure can only be triggered in a patient with migraine with aura, not in migraine without aura. This makes the diagnosis even...

Weaning the Overused Medications

The authors believe that absolute detoxification or wean from overused medications is the crucial step in treating patients in MOH. Any compromise in this regard will increase the likelihood of failure. Four randomized controlled studies have been run on patients with daily headaches, two each for topiramate and onabotulinumtoxinA, in which patients with MOH were not completely excluded. That is, these studies examined whether topiramate and onabotulinumtoxinA could reduce headache days in a...

Pattern Recognition Diagnosis of Migraine

The duration of headache history can add to pattern recognition. Recent onset of headache should be of more concern (see Table 1.6 and Fig. 1.1). New and sudden headaches, often described as such as having thunderclap onset, raise the question of bleed. First headaches of days duration raise the question of meningitis or encephalitis. New headaches of slow, progressive onset suggest neoplasm or vasculitis. And finally, the comfort of stable, episodic headaches of at least 6 years duration is...

New Daily Persistent Headache NDPH

Increasingly recognized in clinical practice, New Daily Persistent Headache (NDPH) classically presents in a patient without a prior history of frequent headache as a headache occurring, out of the blue, that just won't go away. New Daily Persistent Headache manifests as a daily headache within 3 days of onset it is usually bilateral, pressure-like in quality, and of moderate to severe intensity. Associated symptoms may at times resemble those of migraine (photophobia, phonophobia, nausea,...

Reminder on the Red Flags of Headache Diagnosis

As noted, in Part III diagnosis of secondary headaches will be covered. However, it is worth stating at the beginning that a workup of patients with red flags is necessary before diagnosing primary headaches. When in doubt, investigate the atypical. Table 1.3 The SNOOP mnemonic for red flags for secondary headache .Systemic symptoms (fever, weight loss) or .Secondary risk factors - underlying disease (HIV, cancer, autoimmune disease) Neurologic symptoms or abnormal signs (confusion, impaired...

Benign Paroxysmal Vertigo of Childhood BPVC

Benign Paroxysmal Vertigo of Childhood (BPVC) was first described by Basser in 1964. It is characterized by abrupt loss of balance, vertigo, and even falls. The pediatric prevalence is 2-2.6 with equal distribution between boys and girls. Table 7.1 Clinical pearls secondary causes to be considered in childhood periodic syndromes Central nervous system Increased intracranial pressure Posterior fossa mass Inborn errors of metabolism Organic acidemias Acute intra-abdominal disease Bowel...