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HEADACHE DISORDERS
2nd edition
(ICHD-II)
Headache:
a clinical tour
foraresidents
clinical part
tour2:
Secondary for residents
headache disorders
March 2010
Lucy Vieira MD
Headache is the Most Common Symptom that
Humans Experience
Primary headaches (No underlying cause)
Migraine
Tension-type
TACs
Other
Secondary headaches (Underlying cause)
Medication overuse
Head/neck injury
Space-occupying lesion (i.e. brain tumour)
Vascular cause (i.e. Subarachnoid hemorrhage, intracranial
bleed) >65% in
Infectious cause (i.e. meningitis patients
or upper respiratory tract
infection) older
+ many others than 50
Chronic
Daily Headache
(CDH)
Chronic Hemicrania
Tension Continua
Type
Headache
Other
Increased ICP
Other (tumour/mass,
pseudotumour cerebri,
hydrocephalus)
What are the Headache “Red Flags”?
Systemic symptoms (fever, weight loss)
Secondary risk factors (cancer,
HIV/immunocompromised)
Neurologic symptoms or abnormal signs
Onset (i.e. new-onset chronic headache)
Older patient (i.e. new headaches at age >50 yrs)
Previous headache different (i.e. significant
change in headache frequency or clinical
features)
Positional component (i.e. increases when
upright)
Provocative factors (precipitated by coughing,
exercise, sex)
Vitals (particularly BP)
Pupil symmetry, reactivity and fundoscopy
Visual fields
Eye movements
Motor – look for asymmetrical weakness R vs L
Reflexes – look for asymmetry (increased
reflexes) R vs L
Sensation – extinction to double simultaneous
tactile stimuli
Coordination – finger-nose-finger, gain and
tandem gait
Examine/touch the head and neck
• Less common:
– Focal deficit, seizures, coma, CN palsy, papilledema, ocular
hemorrhage
*sentinel bleed
First primary sexual or exertional
headache
adapted from D. Capobianco June 2006 AHS and Wityk, R. J. JAMA 2001;285:2757-2762
• Why coming now to MD?
– “My husband thought I should because of
ringing in my ear.”
6.4.1
6.4Headache attributedattributed
Headache to giant cell arteritis
to
(GCA)
arteritis
6.4.2 Headache attributed to primary central
nervous system (CNS) angiitis
6.4.3 Headache attributed to secondary central
nervous system (CNS) angiitis
Laboratory Data
Erythrocyte sedimentation rate
normal 1.1 (1.02-1.2) 0.2 (0.08-0.51)
>50 mm/h 1.2 (1.0-1.4) 0.35 (0.18-0.67)
>100 mm/h 1.9 (1.1-3.3) 0.8 (0.68-0.95)
6.7
6.7.1 Headache
Cerebral attributed to
Autosomal Dominant
Arteriopathy with Subcortical Infarcts and
other intracranial
Leukoencephalopathy vascular
(CADASIL)
disorder
6.7.2 Mitochondrial Encephalopathy, Lactic
Acidosis and Stroke-like episodes (MELAS)
6.7.3 Headache attributed to benign angiopathy
of the central nervous system
6.7.4 Headache attributed to pituitary apoplexy
Diffuse severe HA (can be TCH), string and beads on MRA, CSF normal, 1-2months
Leonard H. Calabrese, DO; David W. Dodick, MD; Todd J. Schwedt, MD; and Aneesh B. Singhal, MD
Ann Intern Med. 2007;146:34-44.
ESR CSF
GCA N
Toxins/meds
-vitamin A
-Nalidixic acid,tetracycline,nitrofurantoin,indocid,steroids/withdrawal,others
Medical conditions
CRF, SLE, Anemia/polycythemia
Infectious-
meningitis,encephalitis,Lyme,HIV
Trauma
CASE
40-year-old woman:
posterior neck pain and orthostatic
headaches (severe at times, dull or
throbbing), worse with cough.
Water-soluble
Myelo – myelogram/CT-myelogram
meningeal showed frank extravasation
diverticulum of contrast to the paraspinal
soft tissues at the L C7 root
sleeve.