Headache Disorders

Headache Basics - Pinpointing Pain Patterns

• Primary: No structural cause (Migraine, TTH, TACs).
• Secondary: Symptom of underlying pathology.
• Pain Patterns: Assess Onset, Location, Duration, Character, Aggravating/Relieving factors, Timing, Severity (OLD CARTS).
• 📌 Red Flags (SNOOPP): Systemic sx, Neuro deficits, Sudden Onset, Older (>50), Pattern change, Papilledema.

⭐ IHS Primary Headache Classification:

• Migraine
• Tension-Type Headache (TTH)
• Trigeminal Autonomic Cephalalgias (TACs)
• Other Primary Headaches

Migraine - Throbbing Trouble

• Episodic, often unilateral, pulsating headache; duration 4-72 hrs.
• 📌 POUND mnemonic: Pulsating, One-day duration (untreated: 4-72 hrs), Unilateral, Nausea/vomiting, Disabling intensity.
• Aura: Reversible neurological symptoms (visual, sensory, speech) preceding or accompanying headache.
• Triggers: Stress, hormonal changes (menses), certain foods (chocolate, cheese), alcohol, sleep disturbances.

⭐ Diagnostic Criteria (Migraine without Aura):

• At least 5 attacks fulfilling criteria.
• Headache duration: 4-72 hours.
• Headache has ≥2 of: unilateral, pulsating, moderate/severe pain, aggravation by routine physical activity.
• During headache, ≥1 of: nausea and/or vomiting; photophobia and phonophobia.

• Acute Management:
  • Mild-Moderate: NSAIDs (Ibuprofen), Paracetamol.
  • Moderate-Severe: Triptans (Sumatriptan 50-100mg PO), Gepants (Ubrogepant).
  • Antiemetics (Metoclopramide) if nausea/vomiting prominent.
• Prophylaxis (if ≥4 attacks/month, disabling, or triptan overuse):
  • Beta-blockers (Propranolol), TCAs (Amitriptyline), Anticonvulsants (Topiramate, Valproate), CGRP mAbs.
• Chronic Migraine: ≥15 headache days/month for >3 months (≥8 days with migraine features).

Tension-Type Headache - The Daily Grind

• Most common primary headache; bilateral, non-pulsating, pressing/tightening quality.
• Mild to moderate intensity; not aggravated by routine activity.
• No nausea/vomiting; photophobia or phonophobia may be present (not both).
• Types:
  • Infrequent episodic: <1 day/month.
  • Frequent episodic: 1-14 days/month.
  • Chronic: ≥15 days/month for >3 months.
• Pathophysiology: Peripheral (myofascial tenderness) and central mechanisms.

⭐ Tension-Type Headache is characterized by bilateral, pressing/tightening (non-pulsating) quality, mild to moderate intensity, and not aggravated by routine physical activity.

• Management: Analgesics (NSAIDs, paracetamol), amitriptyline for prophylaxis in chronic TTH.

Trigeminal Autonomic Cephalalgias - TACs Attack!

Unilateral headache, ipsilateral cranial autonomic symptoms.

• Cluster Headache (CH)
  • Severe orbital/temporal pain; 15-180 min; 1 qod to 8/day.
  • Autonomic features, restlessness.
  • Acute: 100% O2, SC Sumatriptan (6mg). Prophylaxis: Verapamil.
• Paroxysmal Hemicrania (PH)
  • Severe pain; shorter (2-30 min), frequent (>5/day).
  • Autonomic features.
  • Key: Responds to Indomethacin (25-75mg TID).
• SUNCT/SUNA
  • Short (1-600 sec) stabbing pain; very frequent.
  • SUNCT: Conjunctival injection & Tearing. SUNA: Other autonomic features.
  • Rx: Lamotrigine.

⭐ Acute treatment for Cluster Headache: 100% oxygen (12-15 L/min), SC sumatriptan (6mg).

Secondary Headaches & Red Flags - Danger Signals

• Headaches from underlying pathology; prompt ID vital.
• 📌 SNOOP4 Red Flags:
  • Systemic: Fever, wt loss, cancer.
  • Neurologic: Focal deficits, seizures, AMS.
  • Onset: Sudden (thunderclap); New >50 yrs.
  • Ps: Pattern change, Progressive, Papilledema, Positional, Precipitated (cough/Valsalva).
• Key Causes:
  • SAH: Thunderclap. CT (LP if neg).
  • Meningitis: Fever, nuchal rigidity. LP.
  • GCA: Age >50, jaw claudication, ESR >50 mm/hr. Biopsy.
  • Tumor: Progressive, focal. Neuroimaging.
  • IIH: Papilledema, LP opening pressure >25 cm $H_2O$.

⭐ The SNOOP4 mnemonic (Systemic symptoms, Neurologic signs, Onset sudden, Older age, Pattern change, Papilledema, Positional, Precipitated by cough/exertion, Progressive) helps identify red flags for secondary headaches.

High‑Yield Points - ⚡ Biggest Takeaways

• Migraine prophylaxis includes Propranolol, Topiramate, and Amitriptyline.
• Triptans are first-line for acute migraine; avoid in CAD.
• Cluster headache: Unilateral, periorbital pain, autonomic signs; acute: 100% O2/Sumatriptan; prophylaxis: Verapamil.
• Tension-type headache: Bilateral, "band-like" pressure; treat with NSAIDs.
• MOH: From frequent acute drug use; stop offending drug.
• Secondary headache red flags: SNOOP (Systemic, Neuro, Onset, Older, Pattern).
• Trigeminal neuralgia: Lancinating facial pain; Carbamazepine is DOC.