DSA01 Primary Headaches, Secondary Headaches and Facial Pain

Primary = HA themselves, Secondary = Caused by exogenous issues

What is the difference between Primary & Secondary Headaches?

Is this Headache NEW or DIFFERENT?

What is the Key Question when diagnosing headaches?

recurrent

A headache can only be diagnosed as primary if it is (new/recurrent)

Approach it as a Secondary HA to rule out structural, inflammatory, infectious, etc.

What should you do if a pt has had headaches before, but this presenting headache is the "first worst headache ever"?

Same type of headache that occurs more than half a time period (week, month, etc.)

Define Chronic Headache

They cause distension or compression/traction of pain sensitive structures in head/neck

What is common about all headache pathogeneses?

distend; activates

Inflammation, either from infection, CTD/vasculitis, or "sterile inflammation," from migraine causes blood vessels and dural membranes to () and () pain fibers

Cervical Plexus

Angle of the Jaw is innervated by the (third branch of the Trigeminal Nerve/Cervical Plexus)

B/c those structures are VERY innervated by Trigeminal and Cervical Nerve Branches

Why does inflammation in the intracranial structures cause severe pain?

False - they DO NOT have intrinsic nociception

T/F - Brain Parenchyma/Ventricles DO have intrinsic nociception

- Tension-Type

- Migraine with or w/o aura

- Cluster (TAC)

What are some examples of Primary Headaches?

Tension-Type Headaches

What type of HA is this?:

-Episodic (at least 10 episodes occurring on avg <12 days/year)

-Most Common Primary HA (69% of all primary HAs)

-No associated Sx

-Bilateral

-Pressing/Tightening "Band Like Pressure"

-Photophobia OR Phonophobia (can't have both)

Migraine w/o aura

What type of HA is this?: (think "half HATS")

-Most COMMON migraine, second most common type primary HA

-More common in females

-At least 5 attacks

-Lasts 3 hours - 3 days

-Unilateral

-Pulsating

-Aggravated by physical activity (walk/climb stairs)

-N/V

-Photophobia AND Phonophobia

V1 branches feel vessels in meninges (if cut here, you’ll feel pain --> in migraine, pts sensitive to outside stimulus via migraine generator which activate afferent nerves to release inflammatory chemicals (CGRP) onto these blood vessels --> activate nerve terminals to activate nociceptive reaction --> throbbing pain)

Describe the Importance of the Trigeminovascular System

Migraine with aura

What type of HA is this?: (think "half HATS" + reversible Sx)

-"Classic" Migraine

-At least 2 attacks

-One or more fully reversible Sx:

--Visual

--Sensory

--Speech

--Motor

--Brainstem

--Retinal

-At least one of these sx spreads gradually over 5 mins & 2/more occur in succession

-At least one sx is unilateral

-Accompanied w/n 60 mins by headache pain

5 min to 60 min

Auras can last for how long?

Phenomenon in certain neurons in which an intense wave of excitation/depolarization happens which is then followed by a brief period of unresponsiveness/

hypopolarization , then a shut down in aura area --> causes the brain to produce pain sensations

Define Cortical Spreading Depression

Cluster Headache

What type of HA is this?:

-Rare Primary HA

-Trigemino-Autonomic-Cephalgia (TAC)

-At least 5 attacks, occurring every other day and eight per day, more than half the time

-Severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 mins

-Signs ipsilateral to side of HA:

--Red eye + Teary eye

--Nasal congestion

--Eyelid edema

--Face sweating/flushing

-Miosis and/or ptosis (Partial Horner's)

-Restlessness or agitation

Due to too much PNS from activation of hypothalamus

What causes the "partial Horner's syndrome" in Cluster HAs?

Trigeminal Neuralgia (TN)

What type of HA is this?:

-Secondary HA

-Paroxysmal, stabbing, unilateral pain in CN V1-3 region (esp when touched)

-WNL Exam (besides HA time)

-Tx = AEDs (Carbamezepine)

Idiopathic Intracranial Hypertension (IIH) - aka Pseudotumor cerebri

What type of HA is this?:

-Secondary HA

-Common in obese, young females

-Diffuse pressure HA

-Visual blurring

-Exam = +bilat papilledema, Inc Valsalva Effect, LP w/ High OP

-Tx = acetazolamide

Brain tumor

What type of HA is this?:

-Nonspecific, secondary HA

-Exam: +focal neuro deficits/signs/seizure

-Dx: CT/MRI

-Tx = Neurosurgery/NSG

CNS Infection - Meningitis

What type of HA is this?:

-Secondary HA

-Fever + HA + Nuchal Rigidity

-Tx = Abx

CNS Infection - Encephalitis

What type of HA is this?:

-Secondary HA

-Fever + HA + focal signs/seizures/mental status change

-Tx = Abx

Temporal Arteritis (TA)

What type of HA is this?:

-Secondary HA

-Elderly + Kidney issues (>55,>55 = age, ESR)

-May or may not have Amaurosis fugax (temporary and painless loss of vision in one or both eyes due to disruption of the blood flow to the retina - aka transient mono/binocular blindness)

-Tx = Prednisone

Subarachnoid Hemorrhages (SAH)

What type of HA is this?:

-Secondary HA

-Thunderclap HA + NAUSEA!

-Exam = +Nuchal Rigidity but NO fever, LP if CT negative

-Tx = ICU/Neurosurgery

SAH/meningitis/stroke/HTN emergency

"First/worst headache ever!? can suggest what serious secondary cause?

Meningismus (meningeal irritation, or irritation of fecal sac - caused by CNS infex OR SAH):

-Brudzinski's sign (left) - raises hips and knees when head lifted (abn)

-Kernig's sign (right) - raises leg with head (abn)

What are these examinations testing for?

Structural or inflammatory cause

Subacute progression of HA can suggest what serious secondary cause?

CNS infection/meningoencephalitis, systemic infection or inflammation

Fever or other systemic signs + HA can suggest what serious secondary cause?

Structural brain lesion, e.g. brain tumor, abscess, increased ICP, includes pseudotumor cerebri (IIH)

HA pain induced by sleep or positional changes can suggest what serious secondary cause?

Structural brain Lesion

HA + Abn Neuro Exam can suggest what serious secondary cause?

CNS infection or Tumor

HA + Immunocompromised Pt can suggest what serious secondary cause?

Posterior Fossa Mass

Vomiting THEN HA can suggest what serious secondary cause?

Brain tumor, stroke, Temporal arteritis, glaucoma

HAs beginning later in life can suggest what serious secondary cause?