24 What is the difference between a primary and secondary headache? Primary headache: no identifiable lesion Secondary headache: caused by an underlying lesion or condition Which is more common? Primary headaches are more prevalent than secondary headaches.1 Name the two types of primary headaches that occur most commonly. Tension-type headaches and migraines What is a chronic migraine? A headache that lasts more than 15 days a month for at least 3 months What is status migrainous? A migraine attack that lasts more than 72 hours What are indications for neuroimaging in a patient with headaches? • Unilateral nonmigrainous (“thunderclap”) headache; may be associated with subarachnoid hemorrhage • Pattern changes • Neurological deficit • High-risk populations (HIV, cancer) • New-onset headaches after age 552 What are the types of migraine headaches and their features? 1. Classic migraine: migraine with aura (syndrome of headache associated with premonitory sensory, motor, or visual symptoms). The most common premonitory symptoms are visual and often last from 1 hour to several days.3,4 • Scotomas: visual hallucinations in center of visual field (in about one third of patients) • Small paracentral scotoma which slowly expands into a C-shape (highly characteristic syndrome, seen in approximately 10% of patients) 2. Common migraine: migraine without aura. Benign periodic headaches lasting several hours and often attributed to “tension.” The most frequent type of headache. Traditional dependent features (various combinations of unilateral pain, nausea, vomiting, scalp tenderness, positive family history, responsiveness to ergotamine) are present in 60 to 80% of cases but are not required to establish the diagnosis. What are the diagnostic criteria for migraine without aura? Migraine without aura: A. At least five attacks fulfilling criteria B to D B. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following characteristics: • Unilateral location • Pulsating quality • Moderate or severe intensity (inhibits or prohibits daily activities) • Aggravation by climbing stairs or similar routine physical activity D. During headache at least one of the following: • Nausea and/or vomiting • Photophobia and phonophobia E. Not attributed to another disorder What is a migraine with “aura”? A migraine preceded by fully reversible visual or sensory symptoms or dysphasic speech disturbance5 How long should an aura last? 5 to 60 minutes What are the diagnostic criteria for migraine with aura? Typical aura with migraine headache: A. At least two attacks fulfilling criteria B to D B. Fully reversible visual, sensory, or aphasic aura symptoms (but no motor weakness) C. At least two of the following: • Homonymous positive features and/or unilateral sensory symptoms • At least one symptom develops gradually over more than 5 minute or two or more occur in succession • Each symptom lasts 5 to 60 minutes D. Headache follows aura with a free interval of less than 60 minutes (it may also begin before or simultaneously with the aura) E. Not attributed to another disorder What are the prevalence and the gender predilection for migraines? In developed nations, migraines affect approximately 15% of people; it is three times as common is women as in men. How frequent are symptoms/attacks in patients with migraines? The median frequency is one attack per month, and one fourth of patients have at least two attacks per month. What are the phases of a migraine? Migraine consists of five phases6: 1. Prodrome (e.g., food craving) 2. Aura (visual, sensory, or motor symptoms preceding the headache) 3. Headache (usually unilateral, pulsating) 4. Resolution (waning of pain) 5. Recovery Not all five phases are required to constitute a migraine attack, and there is variation among patients. What comorbidities are associated with migraine? Several rare inherited neurological diseases: • CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy), which begins with migraine with aura in 33% of cases • MELAS (mitochondrial encephalopathy with lactic acidosis and stroke-like episodes) Epilepsy has also been associated with migraine. (Migraine with aura has been associated with a fourfold increase in the risk of epilepsy in children, but migraine without aura has not been associated with an increased risk of epilepsy.7) Depression and migraine are bidirectionally associated; depression is more common in patients with migraine, and migraine is more common in patients with depression than in the general population. What is a persistent aura without infarction? Aura that lasts more than 1 week without imaging abnormalities What is a migrainous infarction? Aura symptoms coupled with imaging abnormalities in the appropriate territory What kind of treatment strategies can you use for migraines? Abortive: to control acute symptoms Prophylactic: prevention What are some of the pharmacological agents used to treat an acute migraine attack of mild severity?
Headaches
24.1 Basic Concepts
24.2 Migraines
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