Neurology: Day 2

I had another day in the outpatient clinic - and I saw several more patients with headaches. It is such a common complaint in neurology - I honestly didn't realize that before. I had thought I would be seeing a lot of strokes, movement disorders, cerebral palsy, multiple sclerosis...I didn't realize just how many people suffer from headaches. Also, we can categorize headaches into several distinct categories; clearly, not all headaches are caused by the same things which also means that not all treatments for headaches are exactly the same either. Here is a little bit of what I have learned about headaches in the past two days:

Migraines:
   Characteristics:
        Onset: Teens to 40.  Occurs at any time of the day
        Location: Half of face; Frontal. Usually in or about eye or cheek
        Precipitating Factors: Fatigue, Stress, Hypoglycemia, Diet, Alcohol, Sunlight, Hormonal Changes
        Frequency: 2-4/month; Sporadic. May be cyclic (with menses)
        Sex: 70% Female; 30% Male
        Duration: Pain lasts around 4 hours typically. From aura to prodrome: 24-36 hours
        Pain type/Severity: Begins as a dull ache, increased to stabbing, intense pain.
        Associated Symptoms: Nausea/Vomiting; Photophobia; Phonophobia; Visual Obscuration
   Workup:
        CBC, HIV Testing, TFTs, Serum Protein Electrophoresis;
        ESR (if >60 years old or suspecting Temporal Arteritis);
        LP (if ddx bacterial or viral meningitis/encephalitis, SAH, or Pseudotumor cerebri)
                    *need to do an imaging study prior to LP
   Treatment of Migraines:
        Abortive Therapy: treating a migraine attack once it has occurred
                1.) Triptans (Sumatriptan, Almotriptan, Rizatriptan, Zolmitriptan, Eletriptan, Naratriptan, Frovatripan):
                         Mechanism of Action: 5-HT-1D receptor agonist
                         Efficacy: 80% if used early/at onset of headache
                         Adverse Effects: Nausea/Vomiting; Numbness/Tingling in Fingers/Toes
                         Contraindications: CAD or HTN or if hemiplegia or blindness as aura
                2.) Ergotamine Derivatives: only use if triptan failed
                3.) Dihydroergotamine
                4.) Midrin: Acetaminophen + Dichloralphenazone (muscle relaxant) + Isometheptene Mucate (vasoconstrictor)
          Prophylactic Therapy: if suffering from 3 or more migraines per month
                 1.) Anticonvulsants: Topiramate, Divalproex, Gabapentin
                         Adverse Effects:
                                Topiramate:numbness/tingling in fingers/toes; drowsiness;
                                            rare: eye blindness due to increased intra-ocular pressure
                                Divalproex: Alopecia; Tremor
                 2.) Beta-blockers: Propranolol
                         *Particularly useful in young females
                          Adverse Effects: Depression, Fatigue, Alopecia; Bradycardia; Cold Extremities; Postural Dizziness
                  3.) Calcium Channel Blockers: Verapamil
                  4.) Antidepressants: Duloxetine, Amitriptyline, Nortriptyline
                            2nd line agents: Methysergide maleate, lithium, clondine, captopril, MAO-I's.

Other Causes of Headaches (Ddx for Migraines):
   Postspinal Headaches: after a LP
       - Better when supine, worse when upright
   Postcoital Cephaliga: Headache before or after orgasm
       - Sudden, pulsatile pain; may involve entire head. Usually benign
   Pseudotumor Cerebri: Increased ICP without evidence of CNS malignancy
       - Often associated with visual disturbances
   Acute Glaucoma: increase intra-ocular pressure is hallmark of acute angle-closure glaucoma
       - Sudden orbital in the face of nausea/vomiting
              *may be benign after use of an anticholinergic drug
   Carotid Dissection: Orbital or Neck pain + neuro findings associated with carotid disease +/- horner syndrome
   Brain Tumor: often presents as typical tension or migraine headache awakening from sleep
        - Headache is the presentation for 40% of all brain tumors!
   Sinusitis: may contribute to headache or be misinterpreted as the cause of migraine
   Subarachnoid Hemorrhage: due to leaking of an AVM or aneurysm or due to trauma
        - "Worst Headache of my Life"; 10/10 pain. Sudden onset, N/V; stiff neck. Quick decompensation
               *50% mortality



Chronic Headaches:
  Chronic Migraine Headache: daily or almost daily headache greater than 15 days per month; suffers from headaches at least 4 hours/day; usually there is a history of episodic migraines during the chronic phase.
  Chronic Tension Type Headache: usually affected more than 15 days/month; average duration of greater than 4 hours/day; pain is usually in the temporal region, described as a pressing or tightening, which is of mild to moderate intensity; +/- pain and tenderness in the occipital area as well as in the posterior STRAP muscles of the neck
  New Daily Persistent Headache: acute development of a daily headache over a short period of time, usually less than 3 days. There may be a precipitating event, often an antecedent viral illness. Once the headache has begun, the frequency is greater than 15 days per month and a duration is ually greater than 4 hours a day without treatment. Can be exacerbated by analgesic rebound. Patient doesn't have a history of tension or migraine headaches.

  Treatment of Chronic Headaches:
       Nonmedical: biofeedback; stress management; psychological interventions; lifestyle changes
       Medical:
           1.) Removal of any OTC meds
           2.) Preventative: Anticonvulsants, antidepressants, beta-blockers, or calcium channel blockers.
                   - Initial drug of choice is Valproate, starting at 250mg/night and increasing up to 750mg
                   - Newer research has suggested the use of Botox injections with trigger points of head pain or those with significant cervical pain and spasm, and it has a 60% success rate.