HEADACHE
Southern Neurology
MIGRAINE
 Migraine is derived from the word
‘hemicrania’ or ‘half-a-head’
 Episodic, lasting 4-72 h, associated with
nausea and/or vomiting, photophobia and
phonophobia and interferes with day-to-day
functioning.
 Headache has a throbbing or pulsatile
quality and is often unilateral (2/3rds of
patients) although may become generalised
IHS diagnostic criteria for migraine
without aura
A. At least 5 attacks fulfilling B-D in the absence of
another alternative disorder (eg metabolic,
vascular, substance abuse)
B. Headache lasting 4-72 h (untreated or
unsuccessfully treated)
C. Headache with at least 2 of following- unilateral,
pulsating, moderate or severe intensity (inhibits
daily activities) or aggravation by walking stairs
or similar activity)
D. During headache at least one of (i) nausea and/or
vomiting, or (ii) photophobia and phonophobia
Migraine epidemiology
 Approximately 5% of men and 10-15% of
women.
 First attack occurs in majority during
adolescence and early 20s. Uncommon to
occur for first time after age 40 years.
Remission common after menopause or in
fifth and sixth decades.
 50-70% report a family history
Migraine –other symptoms
 Prodromal symptoms occur in 25-40% in the 24 h
prior to a headache and include mood changes eg
elation, food cravings, thirst and excessive
yawning. Presumably of hypothalamic origin.
 Hypersensitivity of scalp, hypersensitivity to smell
 Auras – blurring of vision or ‘spots’ more
common than fortification spectra which are
experienced in 10-15%. Paraesthesia is next
commonest. Dysphasia and hemiparesis less
common. Auras usually occur 1 hour prior to a
migraine and last less than 1 hour.
IHS diagnostic criteria for migraine
with aura
A.
B.
At lease 2 attacks fulfilling B
At least 3 of the following characteristics:
 One or more fully reversible aura symptoms
indicating focal cerebral cortical and/or brainstem
dysfunction.
 At least one aura symptom develops gradually over
more than 4 minutes, or 2 or more symptoms occur
in succession.
 No aura symptom lasts more than 60 minutes. If more
than one aura symptom is present, accepted duration
is proportionally increased.
 Headache follows aura with a free interval of less
than 60 minutes (but it may also begin before or
simultaneously with aura).
Factors associated with an attack
 Increased incidence on weekends and holidays
 Menstrual pattern
 Reduced frequency in first trimester of pregnancy
 Stress (often as crisis is resolving)
 Fasting or missing a meal
 Certain foods eg chocolate, alcohol, cheese
 Extreme changes in weather
Drug therapy
 Acute attacks – analgesics, NSAIDS,
dopamine antagonists, ergotamines and
triptans
 Preventive therapy – propranolol, tricyclic
antidepressants, pizotifen, methysergide,
valproate, natural therapies eg feverfew,
high dose riboflavin; ? Newer AEDs –
gabapentin and topiramate
 ? Role of acupuncture etc
Unusual migraine manifestations
 Migraine with prolonged aura – aura lasts > 60 minutes




and < 7 days with normal neuroimaging.
Migrainous infarction (prev called complicated migraine) –
auras not fully reversible within 7 days and/or
neuroimaging confirmation of ischaemic infarction.
Status migrainosus – attack lasts > 72 h whether treated or
not.
Childhood periodic syndromes – abdominal migraine and
cyclical vomiting, benign paroxysmal vertigo of childhood,
alternating hemiplegia of childhood (typical age onset < 18
months).
Familial hemiplegic migraine – migraine with aura
including hemiparesis with at least one affected first
degree relative.
Other headaches – “Normal”
headaches
 Excessive stimulation of scalp nerves eg wearing
tight goggles, diving into cold water
 Ice-cream headache –holding very cold ice-cream
in mouth or swallowing ‘cold’ ice-cream.
Increased frequency in migraineurs
 Hot dog headache – eating cured meats ? Nitrites
 MSG
 Hangover – secondary to acetaldehyde/acetate
 Fasting
 Exertion
Tension headaches
 Two to three times more common in women
 Bilateral in 90%
 Dull and pressure-like; some patients experience
jabs of pain
 10% may also suffer from migraine
 In up to 50% of patients, the headache is daily
 If associated with regular analgesic usage consider
diagnosis of headache induced by chronic
substance use or exposure
IHS diagnostic criteria for episodic
tension-type headache
A.
B.
C.
D.
At least 10 previous headache episodes fulfilling B-D.
Less than 180 attacks/yr
Headache lasts 30 minutes to 7 days
At least 2 of the following: pressing or tightening quality
(no-pulsating), mild to moderate intensity (may inhibit
but does not prohibit activities), bilateral, no aggravation
by walking stairs or similar routine activity
Both of the following (i) no nausea or vomiting (may
have anorexia); (ii) photophobia and phonophobia are
both absent (or one but not the other is present).
Chronic tension headache has same features but
headache is present for at least 15 days a month during at
least 6 months.
Headache induced by chronic
substance use or exposure
 Occurs after daily doses of substance for > 3
months. Headache is chronic (15 days or more per
month) and headache disappears within 1 month
after withdrawal of substance.
 Ergotamine induced headache – preceded by daily
ergotamine ingestion (oral  2mg, rectal  1mg).
 Analgesic abuse headache (> 100 tablets a month
or aspirin or equivalent of other mild analgesics).
 Caffeine withdrawal headache – patient consumes
caffeine daily and > 15 g/month. Occurs witin 24
h of last caffeine and is relieved within 1 hour by
100 mg caffeine.
Cluster headache
 Severe, unilateral pain, orbitally, supraorbitally
and/or temporally, lasting 15-180 minutes,
occurring from once every other day to 8 times a
day.
 Bouts may last weeks or months (or so-called
cluster periods) and then remit for months or years
(average 1/year)
 80-90% are episodic (as above), 10-20% are
chronic. 85% with episodic cluster headaches are
males vs F>M for chronic
IHS diagnostic criteria for episodic
cluster headache
A.
B.
C.
D.
At least 5 attacks fulfilling B-D
Severe unilateral orbital, supra-orbital and/or temporal
pain lasting 15-180 minutes untreated.
Headache associated with at least one of the following
signs: conjunctival injection; lacrimation; nasal
congestion; rhinorrhea; forehead and facial sweating;
miosis, ptosis, eyelid oedema.
Frequency once every other day to 8 per day.
Chronic refers to similar attacks but occurring for > 1
year without remission or with remission lasting < 14
days.
Cluster headache (continued)
 Associated features – Horner’s syndrome,
nasal blockage and rhinorrhoea,
conjunctival injection
 Alcohol and vasodilators may trigger pain
during an attack
 Treatment – acute: 100% oxygen,
ergotamines and triptans; preventive:
ergotamines, methysergide, corticosteroids,
verapamil, lithium
Chronic paroxysmal hemicrania
 Attacks with same characteristics of pain
and associated symptoms and signs as
cluster headache but short lasting (2-45
minutes), more frequent (attack frequency 5
a day or more for more than half of the
time), occur mostly in females and there is
absolute effectiveness of indomethacin (150
mg or less).

Trigeminal neuralgia
 F:M = 2:1
 Most commonly after age 40 years
 Pain affecting gums, cheek or chin as single or repeated
stabs although in less than 5% forehead (CNV division 1)
may also be affected
 Important characteristics are pain intensity, brevity and
tendency to recur in cycles
 Pain never crosses to opposite side but may be bilateral in
3-5%.
 Majority are idiopathic although compression of trigeminal
nerve by blood vessel in brainstem most likely cause
(>85%). Tumour or angioma can be seen in up to 6% and
<5% of patients may have MS. Hence, MRI is diagnostic
test of choice.
Other ‘non-serious’ headaches
 Post-herpetic neuralgia
 Occipital neuralgia
 Cervicogenic headaches
 Analgesia rebound headaches
 TMJ dysfunction
 “Sinusitis”
 Low pressure headache – post lumbar puncture
 BIH
Serious causes of headache
 Raised ICP secondary to structural lesion eg
haemorrhage or tumour
 Subarachnoid haemorrhage
 Meningo-encephalitis
 Temporal arteritis
 Cerebrovascular disease
Case history 1
 25 y.o.female
 Previously well. No past medical history.
 1 day history of gradual onset generalised
headache, throbbing quality
 Vomited x 1, photophobia, phonophobia
 ? Diagnosis
 ? Investigation
 ? Treatment
Case history 2
 80 year old female
 3 week history of intermittent but daily
bifronto-temporal headache
 Non-specific visual disturbances with
episodic blurring
 Associated myalgias
 ? Diagnosis
 ? Investigations
Case history 3
 35 year old male
 Sudden onset of severe generalised headache
whilst lifting weights at gym
 Resolved within 10 minutes of ceasing activity but
recurred at same level of activity if repeated
 ? Diagnosis
 ? Investigations
 ? Treatment
Case history 4
 15 year old female
 Non-specific generalised headache of
gradual onset with visual obscurations and
diplopia on lateral gaze
 Past medical history – acne treated with
vibramycin
 Clinical examination – papilloedema
 ? Diagnosis and investigations