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...

Headache Due to Head or Neck Trauma

Posttraumatic headache (PTHA), by ICHD-2 criteria, occurs within 7 days following head injury or whiplash injury. PTHA may be acute, with resolution within 3 months following injury, or chronic, with symptoms persisting for greater than 3 months. The symptoms of PTHA are non-specific, often resembling those of primary headache disorders, and treatment follows the recommended guidelines for those disorders. Opioid analgesics should be avoided due to the risk of dependency and overuse. Physical...

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...

Drug Therapy of Chronic Migraine CM

Medical therapy of CM incorporates the same preventive medications used to treat episodic migraines and frequent migraines with and without auras, with the addition of onabotulinumtoxinA, the only FDA-approved treatment for CM. The goal of treatment is to transform the chronic daily headache (CDH) patient back to episodic migraine, making the episodic migraine amenable to acute treatment. Since criteria for CM often include a previous history of episodic migraine, setting the therapy outcome as...

Diagnosis of Sunctsuna

SUNCT (Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing) and SUNA (Short-lasting Unilateral Neuralgiform headache with cranial Autonomic symptoms) are very brief headaches. The prominent cranial autonomic features can deceive the clinician, because they can be triggered by cutaneous stimuli, similar to trigeminal neuralgia. These headaches are characterized by paroxysms of short-lasting (5-240 s) stabbing tic-like pain. Average duration of each attack is...

Migraine Dizziness and Orthostatic Intolerance OI

Orthostatic intolerance (OI) covers a spectrum of symptoms including presyncope and syncope, weakness and fatigue, tachycardia or palpitations, nausea, and difficulty concentrating. Symptoms can be aggravated by prolonged standing, physical exertion, environmental warming, post-prandial states, and menses. Diagnosis is based on history and results of heads-up tilt table testing. Orthostatic intolerance is a subset of dysautonomia. Common OI disorders include vasovagal response, cardioinhibitory...

Migraine Specific Treatment Triptans

Except in the presence of coronary artery disease, uncontrolled hypertension, stroke, hemiplegic or basilar-type aura, and pregnancy, triptans are the drugs of choice for acute migraine management. Triptans not only improve the headache, but the associated symptoms of nausea, photophobia, and phonophobia. Triptans were introduced in the 1990s. They are serotonin (5-HT)1B 1D selective agonists (some 5-HT1F), and block the release of Calcitonin Gene-Related Peptide (CGRP), a potent, naturally...

Cyclical Vomiting Syndrome CVS

First described by Heberden in 1806, Cyclical Vomiting Syndrome (CVS) is characterized by recurrent episodes of nausea, vomiting, and lethargy separated by symptom-free intervals. Its estimated pediatric prevalence is 0.4-1.9 , with girls more affected than boys (see Table 7.3 for diagnostic criteria). Patients of Northern European ancestry are more frequently affected. Attacks commonly occur in the early morning hours or soon after waking. Patients develop several episodes of emesis per hour,...

Migraine Without Aura

Migraine without aura is the most frequent migraine type encountered in the pediatric population, comprising 60-85 of migraine cases. Clinical characteristics of migraine without aura are summarized in the ICHD-2 diagnostic criteria listed in Table 6.12. Special considerations must be taken into account when diagnosing migraine in children (see Table 6.13). Attacks tend to be shorter in duration, with a short time to peak, although 1-72 h is usually quoted, most attacks last 1-4 hours. Vomiting...

DHE Bridge Therapy

Despite no head-to-head randomized controlled trials comparing one bridge therapy with another, DHE treatment is the gold standard of bridging therapy to bring the patient as painlessly as possible through detoxification. This may, in part, be due to the pharmacology of DHE, its long half life, and its low recurrence rate. The Raskin protocol, published by Callaham and Raskin in 1986 for refractory migraine, has been adapted and refined through years of experience. It can be provided to all...