Migraine Causes and Treatments

The Migraine And Headache Program

This product was created by a Christian Goodman and a woman who has been suffering from migraine problems for over a decade. As she followed the advice in the book along with easy to do stationary movements, she was able to help unlock the path of the oxygen to the brain and make her migraines stop forever. This was done not by treating migraines by the triggers, but by the cause of the migraines which was the lack of the body to send the oxygen and work well. Finally, the creator of the product was able to locate the problem along with easy to do tricks that are not known to the public. Along with that, you will also learn how to sit and walk correctly and loosen the muscles in the body for easier airflow into the brain. You will no longer have to face migraines and let them cripple your ability as a person. These easy tricks will even make you feel better immediately as you start doing them. You won't even need any experience on how to do these exercises because they are all super easy to do. In addition to that, you can get started today in stopping your migraines and headaches by getting the guide. Read more...

The Migraine And Headache Program Summary


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Cluster Headache and Other Trigeminal Autonomic Cephalalgias

Cluster headache is one of a group of disorders referred to as trigeminal autonomic cephalalgias.16 The autonomic dysfunction is characterized by sympathetic under-activity and parasympathetic activation. Similar to migraine, the pain of a cluster headache is believed to be the result of vasoactive peptide release and neurogenic inflammation. The exact cause of trigeminal activation is not clear.9 One hypothesis is that hypothalamic dysfunction, occasioned by diurnal or seasonal changes in neurohumoral balance, are responsible for headache periodicity.6 Serotonin affects neuronal activity in the hypothalamus and trigeminal system and may play a role in the patho-physiology of cluster headache. The precipitation of cluster headache by high-altitude exposure also implicates hypoxemia in the pathogenesis of trigeminal autonomic

Treatment of Medication Overuse Headache

Treatment of MOH is as varied as the proposed revisions to its definition, due in large part to lack of understanding of the natural biology and history of this headache disorder. Certain principles, covered in Chap. 11, can be used as a bedrock for therapy, and should be observed in any attempt to treat MOH. These include 1) absolute detoxification, 2) addition of preventive medication, and 3) behavioral steps for maintaining health. Table 12.10 Basic principles of Medication overuse headache treatment Table 12.11 Stratification of Medication overuse headache treatment Table 12.12 Prospective trials of relapse rates after wean of medications in Medication overuse headache patients Table 12.13 The three components of outpatient Medication overuse headache therapy

Headaches Associated with Vascular Disease

Headaches may occur within the context of cerebrovascular disease, including ischemic stroke and intracranial hemorrhages. Onset of head pain is typically sudden, with associated neurological deficits. The headache pain gradually diminishes with time, usually lasting only days in duration. In a small subset of patients, the pain persists. Therapies are aimed at the specific headache type following the cerebrovascular event. Headache medications to avoid A tiered approach may be the best approach for treatment of pain in patients with cerebrovascular risk (see Table 14.4). Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to increase the chance of stroke. Naproxen has been reported to have the lowest risk. If NSAIDs are to be used for acute headache management in individuals at increased risk for cerebrovascular disease, they should be used only intermittently at the lowest effective dose.

Cervicogenic Headache

Headache pain that is referred from the bony structures or soft tissues of the neck can be treated with mild analgesics or muscle relaxers but may require additional preventative therapies, non-pharmacological therapy, or invasive procedures if persistent (see Table 14.11). Using a combination of available therapies seems to provide greatest pain relief. Since diagnosis often involves median branch blocks, procedures are frequently called upon in true cervicogenic headache. Table 14.10 Treatment of low CSF pressure headache

Low Pressure Headache

The most common cause of low pressure headache is a lumbar puncture. Head or back trauma, craniotomy, and spinal surgery can produce CSF hypotension as a result of a dural tear or a traumatic avulsion of a nerve root resulting in a CSF leak. In addition, craniotomy and trauma can produce intracranial hypotension not associated with a CSF leak. This may be a result of decreased CSF formation, decreased CBF, or both. Low pressure syndromes can occur secondary to CSF rhinorrhea, either spontaneous, post-traumatic, or due to a pituitary tumor. Spontaneous dural tears must be ruled out in all cases of spontaneous intracranial hypotension. Infusion of hypertonic solution or a systemic medical illness, including severe dehydration, hyperpnea, meningoencephalitis, uremia, and severe systemic infection, can cause CSF hypotension. Postural headache can also occur in patients who have had CSF shunts, Epidemiology and Risk Factors. The incidence of spontaneous...

Other Headache Syndromes

HEADACHE OF INTRACRANIAL NEOPLASMS Headache occurs at presentation in up to half of patients with brain tumors and develops in the course of the disease in 60 percent. Headache is partly dependent on the location of the tumor, and it is a rare initial symptom in patients with pituitary tumors, craniopharyngiomas, or cerebellopontine angle tumors. y In a modern series, 111 consecutive patients with primary (34 percent) or metastatic (66 percent) brain tumor were diagnosed using neuroimaging. In this series, headache was present in 48 percent of patients with primary and metastatic tumor and was similar in quality to TTH in 77 percent and migraine in 9 percent of patients. Unlike primary TTH, brain tumor headaches were worsened by bending in 32 percent, and nausea or vomiting was present in 40 percent. y Increased intracranial pressure was defined by the presence of papilledema, obstructive hydrocephalus, communicating hydrocephalus from leptomeningeal metastasis, or a lumbar puncture...

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 is common and often results in siginificant relief. Attacks may also remit with sleep. These features, including the short duration of the attacks, are important facts to keep in mind when treatment options are contemplated. Ideally, medications should have a rapid onset of action and a short-half life to avoid lingering side effects once the headache has resolved. Also, a non-oral route should be considered. Children may also have difficulty describing the location of the pain and should be...

Migraine with Aura Classic Migraine

Headache follows aura with a free interval of less than 60 minutes (it may also begin before or simultaneously with the aura) Migraine Without Aura Headache lasting 4 to 72 hours (untreated or unsuccessfully treated) Headache has at least two of the following characteristics 4. Aggravation by walking stairs or similar routine physical activity During headache at least one of the following History, physical and neurological examinations, and appropriate investigations must adequately exclude secondary disorders. If a secondary condition co-exists, the migraine is considered primary only if the original migraine onset did not occur in close temporal relation with the other disorder. phase, no phase is obligatory for its diagnosis. Migraine with aura may occur with or without the headache, but migraine without aura requires the headache for its diagnosis (Ta.ble, 5.3.-2) . Premonitory phenomena occur hours to days before the onset of headache in about 60 percent of migraineurs (Table. S...

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. Use SC sumatriptan or nasal spray zolmitriptan or sumatriptan formulations for rapid onset migraine or migraine with significant nausea and vomiting from the onset The subcutaneous (SC) preparation of sumatriptan is the most rapidly absorbed and has the most side effects. It is particularly useful in those individuals who have a rapid onset to peak and who have significant nausea and vomiting from the onset. There may be a transient increase in headache ( head rush ), for 10-20 min after use of the SC formulation. The SC formulation is currently available with a self-administered needle (generic and brand name STATDOSE and brand name ALSUMA) and in a needleless injection form (brand...

Neuroanatomy of cervicogenic headache and experimental evidence

Ironically, despite remaining controversies regarding diagnosis, the neuroanatomical mechanism for cervicogenic headaches is one of the best understood (Bogduk 2001). Cervicogenic headache appears to be a form of referred pain from the upper three cervical segments (Bogduk 1994 Pollman et al. 1997) The mechanism for this is the 'trigeminocervical' nucleus in the upper part of the spinal cord (Bogduk 1994). Within this area, terminals from the trigeminal nerve and the upper three cervical nerves overlap and ramify in the same section of spinal cord. The trigeminal is the fifth cranial nerve, and its branches provide the cutaneous nerve supply for most of the head and face (Williams et al. 1980). This convergence of afferents from two separate regions of the body into neurons in the central nervous system provides the anatomical substrate for referred pain. Furthermore, cervical rami 2 and 3 provide the cutaneous innervation to the areas of the occiput, and the area of the head...

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 a return to that pattern is reasonable. Table 12.3 Clinical pearls on treating Chronic migraine o Note that these principles are the same for CM and episodic migraine Outcome of Chronic Migraine Treatment With prolonged preventive treatment and wean from overused medications -between 3 and 6 months or longer - the chances for reverting to episodic migraine and remaining episodic at 1 year run 50-70 . Some clinical pearls for success in treating CM are listed in Table 12.5. Chronic Tension-Type...

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 Older age onset new onset and progressive headache, especially in age 50 (giant cell arteritis, cancer) Pattern change first headache or different, change from P revious headache history attack frequency, severity or clinical features Dr. David Dodick, Professor of Neurology at the Mayo Clinic, first suggested the use of a mnemonic for red flags suggesting sinister or secondary headaches. His mnemonic, which will be repeated in Chap. 4, tells the clinician when to snoop for secondary headaches, adapted in Table 1.3. If the red flags are not present, it is time to decide which primary headache is presenting.

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, vomiting) without meeting criteria for this disorder. The key feature is that patients with NDPH can remember the exact date on which the headache starts. This abrupt onset is the most useful distinguishing feature separating NDPH from other forms of CDH. A study in 2004 by Mack et al in pediatric patients with NDPH found that a potential physical stressor could be identified in 88 of patients, preceding the onset of the headache. The most common identified triggers included (in order of frequency)...

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 the pattern of migraine.

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 more rare.

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 gabapentin. Cluster headache therapy encompasses transitional or bridge therapy, abortive therapy, and preventive therapy. Steroids, in the form of bolus therapy or ipsilat-eral greater occipital nerve blocks, constitute the commonly used transitional therapy. A variety of acute remedies abort acute clusters, including high flow oxygen therapy, non-oral triptans and dihydroergotamine. For prophylaxis, escalating doses of verapamil are prescribed, with or without supplemental melatonin, lithium,...

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. Natural supplements such as magnesium oxide and vitamin B2 have demonstrated benefit in double-blind studies for migraine prophylaxis, and can be used when needed (see Chap. 9). Other non-medication options include biofeedback and other pain and stress management techniques. Yoga may also be of benefit in some women. Table 18.13 Emergency treatment of pregnancy migraine Acupuncture has not been proven to be useful for migraine prevention in sham-controlled studies thus far. Caution should be used with acupuncture...

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 3. Do your headaches have impact on work, home, school, or recreational activities 2 3 yes answers suggest migraine Table 1.8 Migraine Disability Assessment Scale (MIDAS) MIDAS is a five-item questionnaire on headache disability which can be summarized as How many days in the last 3 months were you at least 50 disabled at work, home, a diagnosis of migraine Adapted from Stewart et al. (1999)

Treatment of the Trigeminal Autonomic Cephalalgias TACs Cluster Headache

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 asleep at night, as headaches commonly crash into the REM sleep onset. Because alcohol triggers CH, I have seen a male patient with well-entrenched alcoholism opt to suffer delirium tremens rather than look at a bottle of gin, much less take a drink from it, during a cluster period This section will discuss treatments that are effective and safe, using the principles of evidence-based medicine (EBM), in which prospective, randomized, controlled trails with clearly defined outcomes and inclusion exclusion criteria (i.e., Class I studies) are included, and...

Mechanical diagnosis and therapy and headaches

Patients who attend musculoskeletal specialists with a primary complaint of headaches may be suitable for mechanical diagnosis and therapy. Patients who have a secondary complaint of headache, but a primary complaint of neck pain, are managed as explained in other parts of the book. Amongst those with primary headache it must be remembered that the symptom can indicate serious pathology, although rare, and such patients must always be screened for the existence of other 'red flag' features (Table 24.2). Furthermore, headache may be due to migraine or other conditions that may not be amenable to mechanical therapy. Because of problems with the validity and reliability of diagnostic classifications, the proportion of headache patients that belong in each category is as yet unclear. It may in the future be revealed that far more patients with headache are in fact amenable to mechanical therapy than traditionally thought. Hopefully also in the future clinical features of those who do and...

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 suprachias-matic nucleus of the hypothalamus, by way of the retinal-hypothalamic-pineal pathways. Approximately 85 of all cluster headaches are episodic. As noted above, in episodic cluster, the period or cycle, as it is called, spontaneously remits, and there will be freedom from pain for a month or longer each year. The remaining cluster sufferers have chronic clusters in which they will have headaches daily or near daily, and will not be free from a cluster headache for any period of a month or more in...

Management of mechanical cervical headache

If it has been established that the headache is cervical in origin and mechanical in nature by the previous test movements, management usually consists of postural advice and an exercise component. The exercise involves the movement thathasbeenfound to abolish or decrease symptoms for derangement and reproduce symptoms for dysfunction, whilst for postural syndrome, posture correction is the key component. The sequence below describes the normal force alternatives and force progressions that may be added to affect symptoms If after two to three days headache severity or frequency is improving, management continues with retraction. However, the length of time needed to evaluate the effect of repeated movements depends partly on the pattern of headache frequency that the patient reports in the history. If there is limited improvement or failure to maintain improvement, ensure that the patient has followed the postural advice and performed the exercises in the correct manner. Force...

Headache or facial pain associated with disorders of cranium neck eyes ears nose sinuses teeth mouth or other facial or

During the aura of classic migraine, a wave of decreased CBF spreads forward from the occipital cortex, preceding the aura symptoms and persisting into the headache phase. This change in CBF may be caused by cortical spreading depression (a short-lasting wave of neuronal activation, followed by inhibition), which may also produce the aura symptoms and activate trigeminal nerve endings. In the headache of migraine with aura (classic migraine), increased CBF occurs after the headache begins, and this change continues until the headache subsides. There is no change in CBF in migraine without aura (common migraine). 6 It is unclear how the brain stem nucleus for facial pain (the nucleus caudalis trigeminalis) is activated, but it may be due to cortical spreading depression or biochemical dysfunction, or both, that stimulates its peripheral nerve terminals. Activation of the central midbrain region during migraine has been demonstrated and has resulted in the speculation that...

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 patient is at risk for medication overuse headache. Use of opioid analgesics should be limited to the acute setting or to those patients using opioids within the context of palliative care. This chapter offers clinical advice on treatment of posttraumatic headache, stroke headache, giant cell arteritis, primary angiitis of the central nervous system, reversible cerebral vasoconstriction syndrome, idiopathic intracranial hypertension (pseudotumor cerebri), low CSF pressure headache, Chiari I...

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 recognizing red flags, when to order neu-roimaging and appropriate laboratory testing, as well as other workup. Posttraumatic headaches must start within 7 days of precipitating trauma and are most often associated with milder headache and neck trauma. They can bring about a syndrome of symptoms frequently best treated with a multidisciplinary plan. Vascular headaches are those associated with ischemia, vasculitis, hemorrhage, or alteration in brain circulation. While stroke, aneurysm, and TIA...

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 Headache Therapy (anecdotally) Once prevented, attempt a trial of med taper Lasts seconds to minutes after valsalva Not commonly seen in patients younger than 40 Not usually seen with nausea and vomiting Is a separate entity from exertion-induced headache May last minutes to 2 days Unlike primary cough headache, more common in young adults and in those with migraine diatheses Advising the patient to be more passive during intercourse may help prevent the headache Trial of tapering preemptive therapy after several months to...

Headaches Riot on the Rooftop

If you suffer from headaches, you're not alone. According to the American Council for Headache Education, an estimated 50 million Americans experience some form of severe headache. About 26 million Americans have migraine headaches, either with an aura (classic migraine) or without (common migraine). Migraines are the most common cause of recurring headaches, but other conditions can cause your head to ache as well, including high blood pressure, glaucoma, or sinusitis. Less likely causes are cerebral tumors and meningitis. Your acu-pro can work with your conventional physician to ensure everyone fully understands from both a western and eastern perspective what's causing your head to throb before you begin treatment. Watch out for the rebound One of the most common causes of chronic daily headaches is an analgesic rebound headache. Taking analgesics (painkillers) on a daily basis or consuming excessive amounts of caffeine (coffee and soda are common culprits) are clues. The headaches...

Treatment Of Headache Disorders Desired Outcomes

The primary short-term treatment goal of migraine is to achieve rapid pain relief is to prevent headache recurrences and to diminish headache severity. Similarly, the goal of TTH is to lessen headache pain, while the long-term goal is to avoid analges-22 ic dependence. The short-term goal in cluster headache therapy is to achieve rapid pain relief. Prophylactic therapy may be necessary to obtain the intermediate-term outcome of reducing the frequency and severity of headaches within a periodic cluster

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 related to the underlying condition in addition to the headache. Diagnostic testing is required to confirm the diagnosis. Upon treatment of the underlying condition the headache will resolve.

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 therapy is useful to treat underlying muscle spasms and improve restricted cervical range of motion. Some clinical pearls in the management of PTHA are included in Table 14.1. Posttraumatic or post-concussion syndrome is seen in patients following head or neck trauma. Headache is the cardinal feature, along with other somatic, psychological, and cognitive symptoms. These symptoms may be noted soon after injury or may be delayed in onset. Treatment of this condition focuses on the commonly...

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 related to mechanical syndromes of the neck, cervicogenic headache, which may overlap, occurring with vestibular symptoms. There are also a number of systemic entities that can cause both dizziness and headache covered in this chapter. Keywords Vertigo Dizziness Migraine-associated dizziness Migrainous vertigo Orthostatic intolerance Cervicogenic dizziness Cervically mediated dizziness

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 contraception in female migraineurs are considered, with special discussion on stroke risk. An extensive set of parts on migraine and pregnancy and lactation, with emphasis on practical treatment follows. The chapter ends with clinical pearls on treatment during perimenopause and menopause. Keywords Menstrual migraine Contraception and migraine Migraine stroke Pregnancy migraine Lactation and migraine Perimenopausal headache Menopausal headache

Chronic Cluster Headache

*Begin early in the cluster period and continue until the patient has been headache-free for at least two weeks. Most patients with cluster headache require preventive treatment because each attack is too short in duration and too severe in intensity to treat with only abortive medication. In addition, ergotamine, DHE, sumatriptan, and oxygen may just postpone rather than abort the attack. Preventive therapy for episodic cluster, in order of preference, includes ergotamine, calcium channel blockers, methysergide, lithium, corticosteroids, divalproex, and capsaicin. Occasionally, indomethacin is effective. If medical therapy fails completely, surgical intervention may be beneficial for the psychologically stable patient with strictly unilateral chronic cluster. The surgery consists of neuronal ablation procedures directed toward the sensory input of the trigeminal nerve and autonomic pathways, and is generally effective in 75 percent. y The prognosis of cluster headaches is guarded it...

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. Migraine according to the criteria of the International Headache Society (IHS) At least one of the following migrainous symptoms during at least two vertiginous attacks o Migrainous headache In 2001, Neuhauser set forth criteria for migrainous vertigo. Requirements included an established history of migraine headaches (see Table 20.3). Furman developed subsequent criteria discussing definite vs. probable migrainous vertigo, with inclusion of vertiginous symptoms triggered by typical migraine precipitants.

Miscellaneous Headaches

Episodic and chronic paroxysmal hemicrania is an unusual headache that tends to occur in women. The attacks are short, and the pain is similar to that of a cluster headache. These headaches respond to indomethacin, with a maximum of 150 mg day in divided doses. Posttraumatic headaches can follow a head injury, with presentation similar to migraine headache. No clear correlation appears to exist between intensity of the head trauma and development of headache. These headaches may be associated with dizziness and impaired concentration. Treatment is difficult, but many of the migraine compounds are effective.

Migraine Headache in Children and Adolescents

Migraine headaches are common in children and their prevalence increases in the ad- olescent years. The diagnosis and evaluation of headaches is especially difficult in children, given their decreased ability to articulate symptoms. Treatment presents another challenge to the practitioner, because medications used for headache management in adults have not been fully evaluated for efficacy and safety in children. Consensus panel recommendations identify ibuprofen as effective and acetaminophen as probably effective in the acute treatment of headache in patients older than 6 years.26 Aspirin use is avoided due to the risk of precipitating Reye's syndrome. Antiemetic therapy can be used alone or in combination with analgesics promethazine is usually prescribed, as it is less prone to cause extrapyr-amidal reactions than other antiemetics. For adolescents older than 12, triptans are effective and are beneficial for abortive migraine therapy. Medication prophylaxis for migraines in...

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 patients with a history of episodic migraine who later developed CDH with migrainous features and accompanying exacerbations. More recently, the ICHD-2 has included the term Chronic Migraine to describe this headache pattern as a primary complication of migraine.

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 disorder Headache attributed to nonvascular intracranial disorder Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disorder of homoeostasis Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures Headache attributed to psychiatric disorder Table 4.2 Diagnostic criteria for secondary headaches A patient with secondary headache must have A disorder...

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 Migraine-associated dizziness should only be diagnosed in an individual with an established history of migraine. There can be an overlap between orthostatic intolerance and migraine, with a spectrum of symptoms from palpitations and tachycardia to presyncope to actual syncope. Cervicogenic headache may overlap with vestibular symptoms. Treatment of cervicogenic headache with subsequent resolution of the vestibular symptoms may suggest cervically mediated dizziness. There are also a number of systemic entities that can cause both dizziness and headache (see Table 20.10).

Postdural puncture headache PDPH

The incidence of PDPH is 0.5-1 and is often higher in teaching hospitals. It may occur at the time of epidural insertion or be caused later by catheter migration into the intrathecal space. The clinical presentation is of an occipital headache which may radiate anteriorly, aggravated by sitting and possibly associated with nausea, photophobia and, rarely, diplopia resulting from stretching of the Vlth cranial nerve as it passes through the dura. The differential diagnosis of meningitis, subarachnoid haemorrhage or even cerebral space-occupying lesions should be considered and excluded by history and simple clinical examination.

Migraine and Oral Contraception

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 and weight gain. Progesterone is not associated with menstrual migraine, so for women who cannot use oral estrogens due to headache, these can be an option (see Table 18.7). Table 18.7 Pearls on migraine and hormonal contraception Consider other forms of contraception if migraine worsens Do not use oral contraceptives in smokers with migraine with aura, as smoking dramatically increases the risk of stroke A woman may have her first migraine when using oral contraception. In general, the neurological rule of thirds can be applied to women, migraine, and oral contraception. In one...

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

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 recognized as a precursor of migraine, and, in particular, to Basilar-Type Migraine (BTM) and is also included. Secondary causes are discussed as well as key diagnostic criteria. A section deals with diagnosis of pediatric tension-type headaches. The chapter also includes several parts on pediatric chronic daily headache syndromes, including chronic tension-type headache, chronic migraine, new daily persistent headache, and pediatric medication overuse headache. The chapter concludes with a discussion of more rare pediatric headache...

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 qualifies as a thunderclap headache or the worst headache in the patient's life. This is obviously a serious concern for the patient and the treating physician (and sometimes the patient's intimate partner). Every effort should be made to determine if this is a subarachnoid bleed that the patient has luckily survived (i.e., a sentinel bleed). In such a situation, a good quality non-contrast CT of the brain reveals subarachnoid blood in over 95 of cases if done in the first 12 h post-ictus. For the...

Low Cerebrospinal Fluid Pressure Headache

Headache caused by low CSF pressures is either the result of previous LP, a CSF fistula, or idiopathic in etiology. The clinical manifestations are similar whatever the cause of the intracranial hypotension (see Table 5.4). Dull, constant, daily, non-throbbing headache Headache that worsens within 15 min after sitting or standing and improves when recumbent Headache is bilateral, throbbing, localized occipitally or frontally Classically, patients report an ongoing headache in the upright position, with relief of symptoms when recumbent. CSF opening pressure is measured at below 60 mmHg H2O. Studies of the CSF may reveal a normal to slightly elevated protein level and even a mild lymphocytic pleocytosis. Approximately a third of patients will develop headache following LP. The post-LP headache generally occurs within 2-5 days after the dural puncture. Spontaneous improvement can occur within 1 week of onset of symptoms. The symptoms are most likely related to persistent dural tear...

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 cervicogenic headache it is necessary to identify a lesion in the cervical spine or neck soft tissues, known to be a valid cause of headache. Establishing a cervical etiology may include the abolition of headache following diagnostic Table 20.8 Cervicogenic headache ICHD-2 criteria B. Clinical, laboratory and or imaging evidence of a disorder or lesion within cervical spine or neck generally accepted as causing headache 2. Headache elimination after diagnostic blockade of a cervical structure or...

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

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 normal audiometric and vestibular testing, particularly in early cases of Meniere's disease. Furthermore, the lifetime history of migraine does not preclude a non-migraine etiology of dizziness. To address these diagnostic problems, some authors use the terms migrainous vertigo and migraine-associated vertigo differently, in which the former refers to episodic vertigo spells that occur concurrently with other migraine features and the latter refers to episodic vertigo in an individual with a...

Cervicogenic Headache and Occipital Neuralgia

This is a controversial entity whose existence has been questioned. Pain from cervical structures is referred to the head through the C1 to C4 cervical roots. Accepted causes of head pain from the neck include developmental abnormalities, tumors, ankylosing spondylitis, rheumatoid arthritis, and osteomyelitis. Controversial causes include cervical disc herniations, degenerative disc disease, and whiplash injuries. y Occipital neuralgia is thought by some to occur as a result of an injury to the occipital nerve, which may be vulnerable to compression as it passes through the semispinalis capitis muscle. Referred pain of cervical origin has often been referred to as occipital neuralgia, modifying the definition of this disorder. The prevalence of cervicogenic headache and occipital neuralgia is unknown. Risk factors include whiplash injury. Some patients who are said to have cervicogenic headache have a pattern of unilateral pain that originates in the neck and spreads to the...

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. 3. Menstruation Migraine may be induced by ovulation, hormonal replacement, birth control pills, and menstruation irregularities. Educate patients to keep a diary of their menses. 4. Lifestyle Irregular sleep habits, including too much or too little sleep, and napping can all contribute to headaches. Encourage patients to maintain a diary and record the time that they get into bed for the night, the time they get out of bed for the day, and the actual number of hours they slept during that time. Many patients only see a lack of sleep as the potential problem, although oversleeping can be equally critical in triggering migraines. Development of a bedtime routine is essential for good control of this headache trigger. Generally, a lack of sleep as well as an...

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 role in patient education about diagnosis. They help monitor consistent preventive medication use, acute medication frequency and efficacy, and appropriate use of rescue strategies. Nurses can teach patients the effective use of headache diaries and how to interpret the results. Nurses can help develop headache support groups. The chapter provides a list of resources for headache nurses to gain the support and education necessary for success in their roles. Keywords Nursing headache management...

Perimenopause Menopause and Migraine

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 menopause causing an abrupt cessation of female hormones may actually experience a worsening of their migraine (see Table 18.18). Hormone replacement therapy (HRT) has a variable effect on migraine. The Women's Health Study, a population-based study of 17,107 postmenopausal women, reported that those using HRT were 1.42 times more likely to report migraine than non-users. Other studies have shown a variable response, with approximately 50 of women demonstrating no change and approximately 25 who worsen and 25 who improve with HRT. If HRT is necessary, using a transdermal formulation of hormones may be preferable to oral medications, because there is more...

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 menstrually-related migraine (Tepper 2006) Fig. 18.3 Decision tree for menstrually-related migraine (Tepper 2006) Table 18.6 Menstrual migraine miniprophylaxis Naproxen sodium 550 mg bid 3 days before onset of flow or headache and continuing throughout menses Miniprophylaxis of Menstrual Migraine Use of triptans in miniprevention of menstrual migraine is not an FDA-approved indication, but multiple randomized controlled trials on triptans used in this way have showed efficacy. Naratriptan, 1 mg or 2.5 mg...

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 treatment. Menstrual migraine miniprophy-laxis can be used for PMM or if the headache is predictable (see Fig. 18.3). Abortive Treatment of Menstrual Migraine

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 1 in 4 women have migraine 60-70 have menstrually-related migraine

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 treatment. However, in the majority of women, migraines around the time of menses are perceived to be more difficult to treat and longer in duration than migraines at other times of the month. Migraine can occur before, during, and after Table 18.1 Definition of 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 This is a rare syndrome ( 10 of women...

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 additionally at other times during the month. This is by far the most common form of menstrual migraine.

Headaches in Older Adults

A serious headache that presents in the older adult population is giant cell arteritis, or temporal arteritis. The pain can be bitemporal or unilateral, moderate to severe in intensity, and is diffuse, not always throbbing, and persists throughout the day and often worsens at night. This headache is often associated with systemic complaints (e.g., weight loss, joint tenderness) and can be aggravated with jaw movement. It is important to treat giant cell arteritis because it can be associated with blindness. The Westergren erythrocyte sedimentation rate (ESR) is frequently elevated. If temporal arteritis is suspected, a diagnostic temporal artery biopsy is performed. It is important not to delay treatment while waiting for the biopsy. Steroid treatment can be initiated up to 2 weeks before the biopsy without compromising the results. The patient with headache of giant cell arteritis requires high doses of prednisone, usually for several months or longer. Ophthalmic zoster is another...

Medication Overuse Headaches

Headache sufferers can begin to experience daily or almost daily headaches when medication doses are excessive or too frequent. Rebound can occur with opioids, acetaminophen, aspirin, analgesic-codeine or analgesic-barbiturate combinations, NSAIDs, ergotamines, and triptans. Characteristics of rebound headaches include a diffuse, bilateral, almost daily headache, often aggravated by mild physical or mental exertion. The headache is frequently present on waking and can be associated with restlessness, nausea, forgetfulness, and depression. Tolerance develops to abortive medications, and there is decreased responsiveness to preventive medications. Treatment of rebound headaches can be difficult. The causative medications must be identified, and there may be some psychological as well as physical dependence. The key to treatment is to discontinue the overused medication and thus break the cycle. Stopping the medication may result in withdrawal symptoms and an initial period of increased...

Tension Type Headaches

Tension-type headaches can be episodic or chronic. There is a slight female preponderance, and the prevalence may be directly related to socioeconomic status. Chronic tension headaches can sometimes develop in migraine patients and are frequently associated with overuse of analgesics. The International Headache Society has further subdivided tension-type headaches into those with and without pericranial tenderness (Sarchielli, 2004). Headaches can be classified by cause, such as temporomandibular joint dysfunction, psychosocial stress, and analgesic overuse. Tension-type headaches require a comprehensive assessment to determine whether any comorbid conditions exacerbate the headache. The diagnostic criteria for episodic tension-type headaches include at least 10 previous headache episodes fulfilling the following criteria 1. Headaches lasting for 30 minutes to 7 days, with at least Frequently, the initial symptoms of a tension headache are described as a bandlike, squeezing, or tight...

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 treatment, including stress, activity pacing, depression, anxiety, coping, trauma and abuse, and flare ups. Guidelines for behavioral treatment for patient and family are outlined, along with when and how to refer. Keywords Behavioral headache treatment Headache stress Headache activity pacing Depression Anxiety Headache trauma Abuse

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.

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 of headaches.

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 infusion setting. In this scenario, an IV line is started and the patient is sedated with diphenhydramine. This is followed by an antiemetic such as ondansetron. Neuroleptics are avoided. Magnesium is very effective, and we infuse 1-2 grams. Depending on the patient's response, we consider intravenous valproic acid and hydrocortisone. If after 2-3 hours the patient is not significantly better, dihydroergotamine (DHE) is infused in four 0.25 mg aliquots. It is important to keep in mind that DHE can...

Epidemiology of headache

Headaches are extremely common in the general population and a very common reason for seeking health care. The literature on the prevalence of headache in forty-four studies was summarised in 1999 (Scher et al. 1999). At age 40 there was an estimated prevalence in males of 25 in Europe and just over 60 in North America, and in females of 70 - 80 in both these areas (Scher et al. 1999). It is unclear why there is such a marked difference between European and North American males. Lifetime prevalence may be higher, with recent population studies giving figures of 83 - 93 of respondents reporting headache ever (Boardman et al. 2003 Ho and Ong 2003). These studies make clear that headache is extremely common. About 2 - 4 of the general population report chronic daily headache, which may have persisted for years (Hagen et al. 2000 Lanteri-Minet et al. 2003). Complaints of headache have constituted 1.5 -7 of patients visiting primary care physicians in North America (Becker et al. 1987...

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. In younger children aged 8-12, use the 5 mg sumatriptan nasal spray or 2.5 mg zolmitriptan orally dissolvable tablet. If nausea and vomiting are important components of a patient's migraine syndrome, use 4-8 mg of ondansetron orally dissolvable tablet prior to initiating the diphenhydramine and analgesic abortive combination (see Table 15.12).

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 Principles of treatment sedation, anti-emetics, analgesics, and abortives (triptans) Table 15.12 Treatment of an acute pediatric migraine Some are seen for a primary headache such as a migraine or tension-type headache. The most important aspects of treating these patients are to rule out a major secondary cause, or to treat an associated illness when present, such as a strep throat. If the physician feels this is a primary headache, sedation and analgesia should be effective. If the patient has any...

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 over a period of 3 years indicates a decrease in headache severity, school absences, and time lost by the parents due to their children's headaches. Table 15.10 Special situations in treating pediatric headache 1. Acute pediatric headache 2. Migraine Acute, urgent treatment 3. Migraine with neurologic features 4. Menstrual migraine 8. New daily persistent headache (NDPH)

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 The use of onabotulinumtoxinA has recently been approved in adults for treatment of CDH or chronic migraine, headaches that occur at least 15 days month for at least 4 h day. Data concerning onabotulinumtoxinA in pediatric CDH are sparse. At the time of this writing, onabot should be used only if the standard measures of medication, lifestyle changes, diet, and counseling for CDH have been unsuccessful. It is not a first-line pediatric therapy.

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 temporal pattern must be taken into consideration. In addition, take into account the degree of disability when considering treatment. Making a diagnosis is key. Do not begin treatment of a child's headache without a diagnosis. Either a tentative or a definite diagnosis is necessary for initiation of therapy, as different therapies are available depending on the specific diagnosis. This chapter reviews the treatment paradigm for pediatric patients with either recurrent or chronic headaches. The...

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 on preventive medications. These sections include how and when to intervene, optimizing prophylaxis choice by consideration of comorbidities, and alternative prevention approaches. Dr. Rothner describes appropriate use of multidisciplinary care. He concludes this chapter with special circumstances in pediatric treatment, including acute pediatric headache, acute urgent treatment, migraine with neurologic features, menstrual migraine, cyclical vomiting, chronic daily headache, post-traumatic...

Headache Associated with Chiari I Malformation

Patients may be treated conservatively with indomethacin, topiramate, or aceta-zolamide. However, if headache is severe and unremitting, or clinical signs of significant cerebellar dysfunction or myelopathy are present, patients should be referred to a neurosurgeon for consideration of posterior fossa craniocervical decompression surgery.

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 activity as a pain coping strategy, depression, anxiety, a history of childhood physical or sexual abuse, or markedly altered family functioning. Astute clinicians attend to these issues, and assist their patients in seeking appropriate care when indicated. Guidelines for assessment and referral are offered. Keywords Behavioral headache treatment Chronic daily headache Headache psychological assessment Chronic migraine Medication overuse headache Rebound headache Biofeedback Cognitive behavioral...

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 aims to reduce chronicity and return to the episodic pattern of the headache. A headache-free state should not be the goal. It is unobtainable, as migraine headaches are a generally inherited deficiency in central nervous system modulation of pain. As such, success in clinical research and practice is defined as a reduction in the frequency of headaches of 50 or more for the individual patient. Many studies utilize different measures of outcomes headache days per month, headache episodes per month or calculated variable headache indices. For simplicity, use the number of headache days per month, as measured on a headache diary, and combine this...

Postdural Puncture Headache

PDPH is a complication of spinal or epidural anesthesia. It must be differentiated from other causes of postpartum headache. The incidence of PDPH is approximately 1 after dural puncture with a 25-G pencil-point spinal needle. The incidence of unintentional dural puncture during induction of epidural analgesia or anesthesia also is approximately 1 . Of these patients, 75 to 90 develop PDPH.1 1123 Treatment of PDPH depends on the severity of the symptoms. Mild headaches that do not interfere with activities of daily living can be treated conservatively. Conservative treatment includes lying supine, hydration, and caffeine (intravenous11961 or oral11921 ). However, conservative treatment is often not effective for the newly delivered mother, because the activities of daily living include the care of a newborn. The standard treatment for moderate to severe headaches is an epidural blood patch. A single epidural blood patch results in complete cure in 33 to 68 of patients.1201 11951 11921...

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 and rule out causation with all these headaches. Similar to primary stabbing headaches, if deemed primary, these headaches are best treated by prevention of the inciting cause (of course, with the exception of thunderclap headaches). As expected, a recommendation to patients to modify their behavior does not sit well with them. In such cases, after an appropriate workup, reassurance that the short-lived but severe headache is primary, and thus benign, might suffice.

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 episodic migraine. Mechanisms of action for preventive medication comprise a variety of not mutually exclusive actions. These include inhibition of cortical spreading depression, raising the threshold to migraine activation by stabilizing the hyperexcitable migraine brain, enhancement of antinociception, inhibition of central and peripheral sensitization, and modulation of sympathetic, parasympa-thetic, or serotonergic tone. The US Headache Consortium published practice guidelines in 2000 based...

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 instructions on how to administer them, along with careful consideration of adverse effects. Keywords Migraine Treatment Prophylaxis Headache Preventive therapy Beta blockers Anti-epilepsy drugs Tricyclic antidepressants

Nonspecific Acute Migraine Treatment Nonsteroidal Antiinflammatory Drugs NSAIDS

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. NSAIDs work centrally to reverse central sensitization, so their effects on migraine are both peripheral, in inhibiting neurogenic inflammation, and central on trigeminal neurons. Randomized, placebo-controlled studies in migraine have shown efficacy with aspirin, ibuprofen, naproxen, tolfenamic acid, and recently, with diclofenac potassium in a powder sachet form which dissolves in water (CAMBIA), the latter now FDA-approved for acute treatment of episodic migraine. There is benefit to trying different classes of NSAIDS, since response to therapy with equipotent doses of NSAIDS varies among individuals. Table 8.10 lists the classes of NSAIDs. NSAIDS are suggested for use in moderate headache. Although it...

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 choices, they choose a pain-free response by 2 h. Clinical pearls for acute treatment are provided, followed by specific sections on use of triptans, ergots, NSAIDs, and other nonspecific medications such as acetaminophen, butalbital, antiemetics, steroids, and narcotics. Special sections discuss the potential for drug-drug interactions, including serotonin syndrome, as well as emergency acute treatment. Keywords Acute migraine treatment Acute treatment goals Triptans Ergots NSAIDs Butalbital...

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 children, these entities are important to recognize, because specific therapy such as indomethacin may lead to significant improvement and even resolution of certain TACs, such as Paroxysmal Hemicrania. More extensive diagnostic descriptions of the TACs are contained in Chap. 2, while treatment is described in Chap. 10. Pediatric cases have similar features to adults, and respond to the same medications.

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 the symptom persists without specific identifiable etiology. Therefore, one of the key features in managing these patients is the treating physician's ability to provide confident reassurance, as well a comprehensive, often multidisciplinary, treatment plan. This can only be done after a careful evaluation of the patient has been accomplished. All subtypes of CDH are characterized by being present for at least 3 months, with headache occurring in at least 15 days month. It may be intermittent or...

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 children, the very young patients (below 7-8 years of age) are not accounted for. Episodic Tension-Type Headache is equally prevalent in boys and girls before puberty, but becomes more prevalent in young women later on. Patients with ETTH often have comorbid mood disorders such as anxiety and depression. Episodic Tension-Type Headache may also coexist with migraine in some pediatric patients (6 ), and the predominant entity may alternate from time to time. The clinical features of ETTH are...

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) is, to date, the largest epidemiological study on migraine. It included data from adolescents between 12 and 19 years of age. The prevalence of migraine among males remained relatively stable throughout the pediatric years (2.9-4.1 ), while in females it continued to increase and reached 6.3 by 19 years of age. Before puberty, the prevalence of migraine is higher in boys than in girls. With the onset of puberty, migraine prevalence increases more rapidly in girls and continues to do so until the...

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 adolescents as established by the IHS, in the ICHD-2.

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 and the likelihood of a secondary cause. As in adults, two major categories of headache occur in children primary headache disorders (e.g., migraine, tension-type), and secondary headache due to serious intracranial pathology or systemic disease (brain tumor, hydrocephalus, infection, hypertension, etc.). The most frequent cause of recurrent headache in the pediatric population is a primary headache disorder such as migraine and its variants, tensiontype headache, and chronic daily headache. New...

Tension Type Headache

TTH pain differs from migraine pain in that it is usually reported to be mild-to-moderate, nonpulsating, and bilateral.6 The pain is described by sufferers as a band-like tightness or pressure around the head. No transient neurologic deficits are noted, and systemic symptoms are rare.4 TTHs infrequently disrupt normal activity. Muscle palpation in the frontotemporal and parietooccipital may identify localized tender points.4 Neuroimaging and laboratory testing are unrevealing, and such tests are unnecessary if the presentation and clinical history is classic for TTHs.

Clinical Presentation Of Headaches Migraine Headache

Migraine presents as a recurrent headache that is severe enough to interfere with daily functioning. Migi'ciine headaches are classified as migraine with aura and migraine without aura.6 The correlating terms of classic and common migraine are no longer employed. Aura is defined as a transient focal neurologic symptom that can be positive or negative, which can occur prior to or during an attack.18 Examples of positive symptoms include the visual perception of flickering lights, spots, or wavy lines, whereas a partial loss of vision, a scotoma, is considered a negative finding characteristic of migraine aura. The International Classification of Headache Disorders (ICHD) outlines diagnostic criteria that differentiate migraine without and with aura.6 The pain of a migraine headache is typically described as moderate to severe, throbbing, unilateral and retro-orbital in location. The pain is accompanied by nausea, sensitivity to light and sound, and difficulty in concentrating.19...

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

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 diagnosis. Guidelines on ancillary pediatric workup are provided, in particular when and how to look for secondary causes of headache. Key epidemiologic features of pediatric headache that bear on diagnosis are summarized. Crucial diagnostic criteria for pediatric episodic migraine with and without aura are reviewed. The chapter concludes with a discussion of pediatric hemiplegic migraine and basilar-type migraine. Keywords Pediatric headache Pediatric migraine Familial hemiplegic migraine Basilar-type migraine Secondary pediatric...

Epidemiology Of Headache Disorders Migraine Headache

Migraine is a primary headache disorder that is estimated to affect 10 to 15 of adults in the United States.2 Less than one-half of headaches meeting the diagnostic criteria for migraine are appropriately diagnosed. Migraine prevalence depends upon age and gender. In children younger than 12 years of age, migraines are more prevalent in males. After age 12, this prevalence shifts markedly to women. The evolution in this gender difference is brought on by the hormonal changes of menarche. Onset typically occurs between the ages of 10 and 30 years, but the prevalence is highest in the age range of 35 to 45 years.4 Migraines significantly impact patient function with over one-half of sufferers reporting severe disability requiring bed rest during an attack. The economic burden of migraine due to direct and indirect costs is substantial. Migraines are the leading cause of employee absenteeism and decreased workplace productivity.5

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 be assumed to be secondary (see Table 5.6). Intracranial infections are most often bacterial or viral, but various opportunistic infections may occur, particularly in immunosuppressed patients. Evaluation for intracranial infections should be performed in individuals presenting with new onset or worsening headache associated with fever, meningismus, altered mentation, or focal neurologic deficits. Headaches associated with infection can be caused by meningitis, encephalitis, brain abscess, or...

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 physical activity, valsalva-type maneuvers, and tends to be most severe in the morning. Mass effect of the tumor and hydrocephalus contribute to the headache, causing both local pressure and or traction on pain sensitive structures of the brain. Headache is more frequent with infratentorial tumors than supratentorial tumors. Finally, patients with a history of primary headache disorders before developing brain tumor will often have some features of their preexisting headaches with their brain tumor...

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 diagnosing these myriad secondary headaches. Tips on diagnosing cervicogenic headache and temporomandibular disorder are provided. Finally, the author summarizes clinical pearls on diagnosis of classic and secondary trigeminal neuralgia, along with clinical features of other, more rare facial neuralgias and persistent idiopathic facial pain. Keywords Secondary headache Idiopathic Intracranial Hypertension Pseudotumor cerebri Intracranial hypotension Brain tumor headache HIV headache Headache...

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 tends to be ipsilateral to the side of dissection. Location of pain is frontal for carotid dissections and more occipital for vertebral dissections. Carotid artery dissection may manifest clinically with a Horner's syndrome or amaurosis fugax. Vertebral artery dissection may produce vertebrobasilar symptoms, especially a Wallenberg syndrome. Patients should undergo diagnostic evaluation with an MRI MRA with a fat-saturation protocol, CT angiogram, or conventional angiography which will also help...

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 presentation of rupture of a saccu-lar aneurysm resulting in SAH, many other diagnoses can have an abrupt presentation as well. Secondary and primary causes of thunderclap headache were described in Chap. 2, but are repeated here because of their clinical importance (see Table 4.11). Diagnosis is confirmed by emergent CT and or lumbar puncture. Cerebral angiog-raphy is usually needed to identify the source of the hemorrhage. Newly onset localized headache

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 Secondary headaches Primary headaches - Primary thunderclap headache - Primary exertional headache Primary cough headache Primary sexual headache

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, duration, associated symptoms, and particularly any reported focal neurological deficits. A workup is warranted in patients whose clinical history raises red flags or is atypical. As previously mentioned in Chap. 1, a useful mnemonic for identifying red flags is SNOOP (see Table 4.3).

Chronic Tension Type Headache CTTH

Clinically, CTTH is a featureless, low level headache that is never severe and generally lacks migrainous features. The ICHD-2 criteria do not call for neck pain as a criterion, a frequently mistaken quality ascribed to this diagnosis. Location does not define tension-type headache (TTH). Table 3.3 Chronic Tension-Type Headache (CTTH), ICHD-2 criteria A. Headache occurring on 15 days month on average for 3 months ( 180 days year) B. Headache lasts hours or is continuous C. Headache has at least two of the following Table 3.4 Clinical pearls on diagnosing chronic tension-type headache No impact from the headaches In keeping with the not migraine approach to diagnosis described in Chap. 1, CTTH is not throbbing, not severe, not unilateral, not worsened by activity, and generally has no nausea or photophonophobia. The ICHD-2 criteria have some unexpected diagnostic rules for CTTH. Patients are allowed no more than one of photophobia, phonophobia, or mild nausea, or none of these....

Diagnosis of Primary Chronic Daily Headaches

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 Daily Persistent Headache (NDPH), and Chronic Migraine (CM). CTTH is a low level, featureless headache, almost never with impact. HC is a unilateral, mild to moderate headache with periodic severe exacerbations, accompanied by autonomic signs. HC is defined by its indomethacin responsiveness. NDPH is probably best diagnosed as abrupt onset primary CDH of any phenotype. Primary CM is a primary CDH in which a patient transforms from episodic migraine to CDH without secondary causes, thereby excluding medication overuse. MOH is not a...

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 D. Secondary headache excluded Table 2.21 Secondary causes of thunderclap headache struck by lightening or hit on the head with a bat, unlike the normal trajectory of other severe headaches such as a migraine or cluster. Cough headache, neuralgias, and ice-pick pains are the only equally fast onset headaches. The diagnostic criteria for primary thunderclap headache, also known as crash headache, are listed in Table 2.20. Most patients present to the emergency department with thunderclap, where the staff will work the patient up for a subarachnoid hemorrhage or intracranial bleed, and will either consult the neurological service or send the patient to the consultant immediately after discharge. The differential diagnosis for this severe headache is very...

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. Cluster headache Migraine features Table 2.13 Diagnostic criteria for primary stabbing headaches, ICHD-2 Primary stabbing headaches are commonly seen in migraineurs (up to 40 of migraine patients) and cluster sufferers, but can occur alone.

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