Migraine and Other Headaches
Primary headaches come from within the brain’s pain centers (trigeminal nucleus, thalamus,
periaqueductal gray).These are medically and anatomically benign, but can be debilitating
Migraine is a primary headache.
Secondary Headaches
Usually caused by blood vessel pathology, often emergent, dangerous, and last for days.
DATA C2A2N are potentially-lethal secondary headaches:
Dissection of cerebral arteries or carotids is the leading cause of stroke in younger
adultsMay present with Horner’s Syndrome Dissection causes continuous headache, usually after
some head trauma. Dissections and large vessel embolisms are the only hemorrhagic situations i
n which anti-coagulants (heparin) are used.
Arteritis (giant cell) is the most common vasculitis and can cause permanent blindness. May present
with fatigue, fever, jaw claudication/cramping, arthralgias, monocular blindness. Immediate steroid treatment is required to prevent blindness.
Thrombosis causes cerebral hemorrhage, often in young women just after giving birth
Continuous headache, worse when recumbent. Often presents with papilledema or pulsatile tinnitus.
Aneurysms are highly lethal blood leaks that come on within minutes. May present with neck stiffness or photophobia. Often mistaken for migraine. Get a CT scan.
Carbon monoxide poisoning is the number one cause of poisoning. Often occurs in winter, and goes away when people go on vacation. Presents with dizziness, light-headedness, lethargy.
Colloid cyst of the 3rd ventricle will have severe, episodic sudden-onset headaches associated
with fainting. Relieved by lying down. Treated surgically. Colloid cysts are the only type of headache
that can be excluded by head CT.
Angle-closure glaucoma headaches are brought on by darkness, relieved by light. Eye will be red.
Angina causes episodic, exercise-induced headaches. May or may not be chest pain.
Norepinephrine neoplasm (pheochromocytoma) causes episodic, sudden-onset headaches. Usually associated with palpitations, sweating, anxiety, dizziness, tremors.
Other dangerous secondary headaches include cavernous sinus infection, encephalitis (herpes, listeria), hydrocephalus, meningitis, eclampsia, lead poisoning, pituitary apoplexy, stroke, tumors/cysts.
Signs of dangerous headaches: SNOOP
Systemic diseases or symptoms (malignancy, fever, weight loss, myalgias, tachycardia)
Neurologic symptoms (diplopia, confusion, papilledema)
Onset within minutes
Older patients
Pattern changes (new type/quality of headache, increased severity/continuity)
Diplopia + Headache is a very bad sign, but is never a sign of migraine!
Rather, diplopia + headache signals elevated ICP, pituitary apoplexy, meningitis, stroke, etc.
Brain tumors in the absence of elevated ICP do not require urgent diagnosis. Any condition with
elevated ICP (signs include vomiting, worse with Valsalva/recumbancy) is an emergency.
“Analgesic rebound headaches” are due to headache medication overuse and tolerance.
These headaches are daily, cyclic, worse in the morning, and increase in severity over days.
Migraine Headaches
Migraines are recurrent headache attacks with a unilateral location, pulsating quality, aggravated by physical activity, and associated with nausea. If it’s not episodic, it’s not migraine.
If there is aura, it usually lasts from minutes to one hour, and precedes the migraine headache.
Migraines are more common in male children, but female adults.
Migraines usually start with a trigger (dietary, hormonal, stress, strong visual or olfactory stimuli)
Some of the most common triggers are dehydration, hunger, red wine, and menstrual periods.
Migraines triggered by menstrual periods are called “catamenial migraines.”
Aura
The classic aura is called a “fortification spectrum” or “teichopsia” lasting 5-20 minutes.
Visual auras are geometric zig-zagging, flickering arcs. Usually white/gray, not colorful.
Auras tend to leave a blur or “scotoma” in their wake.
There are also other sensory, vestibular, auditory, linguistic, cognitive, etc. auras as well.
**Auras are followed by a hemicranial (contra-aura) headache. During a migraine there is
polysensory phobia, anorexia, nausea, vomiting. Headache is ipsilateral to the brain changes,
but contralateral to the visual auras.
“Familial Hemiplegic Migraine” is a basilar migraine with motor manifestations, hemiplegia,
hemisensory loss, and aphasia. Caused by mutations in FHM1 (causes gain-of-function
calcium influx à hyperexcitability) or FHM2 (causes high extracellular potassium à hyperexcitability).
**FHM, like all migraines, is episodic and probably caused by calcium channelopathy.
Glutamate is also likely involved in FHM.
What causes migraines
It was thought that vascular spasm ischemia caused auras and migraines. But this doesn’t explain the spatial characteristics or slow onset of aura. Also, auras have both positive and negative visual and somatosensory auras, which is very unusual with cerebral ischemia.
The current explanation is a “spreading depression” hypothesis. There is a wavefront of intense neural activity across visual cortex, followed by a wave of complete inhibitory activity.
This explains the visual auras and the slow-moving scotoma that follows an aura.
Spreading depression also activates the trigeminal nucleus, which causes cerebral pain.
Pain persists because of neurogenic inflammation of cerebral blood vessels
WEST AZARBIJAN URMIA--Dr.RAHMAT SOKHANI.
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