00:01
So let's talk more about chronic,
recurrent, episodic headaches.
00:05
Let's understand migraine
and tension type headaches.
00:08
And then we'll talk about
some of the less common causes
of an episodic or recurrent
headache syndrome.
00:13
What we're talking about here can be seen
in this flow diagram, this algorithm.
00:17
These are the chronic, recurrent and
episodic headaches and that's important.
00:20
These common go,
there are a series of attacks
that relapse and then periods of remission
where patients may be headache free.
00:29
Our first question when
evaluating these patients is,
are there prominent
autonomic features?
We can see autonomic signs.
00:36
Meiosis or mydriasis with
any of these headaches.
00:40
But prominent autonomic features
should point us in the direction
of the trigeminal
autonomic cephalalgia.
00:47
If they're not prominent
autonomic features,
we're going to focus on
migraine and tension.
00:51
And those are really the two most common
causes of a recurrent, episodic headache
without prominent autonomic
findings, migraine tension-type.
00:59
And then there's a list of other
things, obstructive sleep apnea
cervicogenic headache, chronic daily
headaches, medication overuse headaches,
there's a number of other
conditions we can also consider.
01:11
When we're evaluating these
migrainous or tension-type headaches,
they're all should be
chronic and recurrent.
01:16
They should come and go with periods
of relapse and periods of remission.
01:21
Typically,
these headaches occur in episodes
and each individual headache
class between 4-72 hours.
01:28
And migraine and tension
lie on a spectrum.
01:31
And some patients may present in the middle
of the spectrum with migraine without aura
or with migrainous headaches that
also have a tension-type component.
01:39
But here we're going to define
the extremes of the spectrum.
01:43
Migraine with aura lies
on one end of the extreme.
01:46
This is a lateralized
headache, it's unilateral.
01:49
Patients have prominent nausea,
vomiting, photo- and phonophobia
and we often see aura.
01:55
On the other end of the spectrum
lie tension-type headaches.
01:58
They're almost the
opposite of migraines.
02:01
The symptoms are not lateralized,
this is holocephalic head pain,
a band like sensation
over the entire head.
02:08
We don't see nausea
vomiting, photo-, phonophobia
and often don't see aura.
02:13
So what are the diagnostic criteria
on for migraine and tension-type?
And in this slide, we'll compare and
contrast them right next to each other.
02:20
Again,
migraine should be unilateral,
with associated
nausea and vomiting.
02:26
Phono-, photo-,
or osmophobia can be seen
and that's worsening with bright
lights, loud noises or smells.
02:33
Headaches last 4-72 hours and
are often relieved by sleep
or worsened by
activity or exercise.
02:39
And this is classic migraine.
02:40
Not every patient will
meet all of these criteria.
02:43
And in fact, some patients may
meet very few of these criteria.
02:46
But this is the classic
presentation of migraine.
02:50
Tension-type is the opposite.
02:52
Headache is bilateral holocephalic,
a band-like pressure over the entire head.
02:58
There's rare nausea and
vomiting with these headaches.
03:01
Photo-, phono-,
and osmophobia are quite rare.
03:04
And episodes can be
shorter than migraine
but also worsened with
activity and exercise.
03:11
So how do we approach
patients who may present
with migraine or
tension-type headaches?
What are the things
we ask on history?
Well,
it's a pretty in depth history.
03:19
These diagnoses are made
and patients are managed
based on the history
and physical exam alone.
03:24
And so we need to think about
a comprehensive evaluation.
03:27
First, we asked about
prior history of headache.
03:30
There should be a long history of headache
often beginning in the teens or 20s of life
but sometimes in some
patients presenting later.
03:39
Patients can have
multiple headache types.
03:42
And that's not inconsistent with the
diagnosis of migraine or tension.
03:46
Age of onset is important.
03:48
Most migraine and tension
patients will have headaches that began in
the late teens or early 20s period of time.
03:55
The location and
radiation is important.
03:57
Again, we said migraine is
unilateral, tension-type bilateral.
04:01
The pain quality and
severity is important
though most patients will tell
you that with a severe episode,
the pain can be the worst
that they've experienced.
04:09
The key is that onset and
these headaches usually come on
over the course
of several hours.
04:14
Headache frequency and
duration is important.
04:16
The mode of onset and
termination is also important.
04:20
Sleep is one of the most
important terminating events
or procedures or interventions
for these patients.
04:25
And so if you can get the patient to
sleep, usually the headache will go away.
04:29
Precipitating and exacerbating
factors are important to explore.
04:33
Alleviating factors in
associated symptoms can help us
to manage patients once
we've made a diagnosis.
04:39
And then we think about medications
patients are currently taking
or previously taking and a
general medication history.
04:44
Some medicines can
exacerbate migraines,
history of head trauma and
family history of headache.
04:52
What are the causes
of migraines?
How do we classify them?
Not all migraines are the same
and there are certain
classifications that we can use
to subcategorize and
diagnose patients.
05:02
Classic migraine has
a proceeding aura.
05:05
Patients present often
with the prodrome,
they can tell it's coming on,
strange taste or something
along those lines,
and that builds
into a frank aura.
05:13
Many people describe
an aura that is visual,
either with a scotoma,
a dark spot where they cannot see.
05:21
And sometimes with
scintillating quality,
where there's bright lights
or flashes around that.
05:26
That aura usually
lasts about 30 minutes
and then patients will
describe the onset of pain
and that would be migraine,
classic migraine with aura.
05:35
Common migraine has
no proceeding aura.
05:37
So you don't have to have the
aura to still have the migraine.
05:41
Other less common types of
migraine include basilar migraine.
05:44
And basilar migraineurs will have
prominent posterior fossa symptoms,
vertigo or hearing dysfunction or gait
dysfunction and abnormality present.
05:53
During their migraine attacks that then
remits resolves in between attacks.
05:59
We also see
acephalgic migraines.
06:00
So that sounds a little strange,
that's a migraine without the pain.
06:04
So that maybe just an aura,
or just the posterior
fossa symptoms
if a patient has an
acephalgic basilar migraine.
06:13
The key is there's no pain.
06:14
But we do see
characteristic symptoms
and usually the episodes
follow a very similar course
from occurrence to occurrence.
06:23
We can see ocular
acephalgic migraines.
06:25
Patients present with vision
loss or vision dysfunction.
06:28
Ophthalmoplegia or diplopia or
disconjugate gaze can sometimes be present
but really should prompt evaluation
for other causes initially
before making this diagnosis.
06:37
And then again,
we can see some basilar variance
with variable posterior fossa
symptoms potentially without headache.
06:43
Acephalgic migraines should
be evaluated more in depth
than the classic or common migraine
to rule out other offending causes.
06:52
What are other types of
chronic, recurrent headaches?
Cervicogenic headache is typically
a posterior predominant headache
that is triggered
with neck pain,
and it's common after neck
manipulation or neck surgery
or can be seen in patients
with cervical spondylosis.
07:07
Familial hemiplegic migraine is a
migraine variant that must be recognized.
07:12
Patients present with hemiplegia,
weakness on one side of the body
that can present during or
just preceding their headache.
07:21
This can look like a stroke.
07:22
Patients have headache
and a hemiparesis.
07:24
And patients will be evaluated
initially for a vascular aetiology
or some other underlying cause.
07:30
And when normal that patients
can be given a diagnosis
or a diagnosis of familial
hemiplegic migraine can be made.
07:36
This is an underlying
genetic event.
07:39
We know several genes
that predispose patients
to familial hemiplegic migraine
and can run in families.
07:46
And then in pediatric patients,
everything can look different.
07:49
So manifestations of migraines.
07:51
Migraines and kids can show
up with cyclic vomiting.
07:54
The patients just vomit and
that's a manifestation of migraine
by treating migraine,
the vomiting will go away.
08:01
Abdominal migraine causes recurrent
episodes of abdominal pain and discomfort
and again treating with
migraine treatments
can result in remission of the
abdominal pain and episodes.
08:13
And benign paroxysmal
vertigo of childhood.
08:16
So episodes of vertigo can be
a childhood migraine variant.
08:21
And again, we treat that with antimigraine
medications and interventions.