Headaches

Approach to headaches

	Migraine	Cluster	Tension
Sex predilection	Female > male	Male > female	Female > male
Family history	Often present	±	None
Onset	Variable	During sleep or similar timing daily	Under stress
Location	Often unilateral	Behind one eye	Band-like pattern around the head (bilateral)
Character	Pulsatile & throbbing	Excruciating, sharp & steady	Dull, tight & persistent
Duration	4-72 hr	15-180 min	30 min to months/years
Associated symptoms	Photophobia, phonophobia & nausea, ± aura	Ipsilateral autonomic symptoms: Ipsilateral sweating, facial flushing, nasal congestion, pupillary changes & lacrimation	Muscle tenderness in the head, neck, or shoulders

Migraine

Cluster headache

Epidemiology & Risk Factors

• Demographics: Males aged 20–40 yo (M:F ≈ 3:1).
• Risk Factors: Tobacco use / smoking (>80%), heavy alcohol use.
• Triggers: Alcohol ingestion during an active cycle.
• Pattern: Strict circadian rhythmicity (nocturnal attacks waking pt from sleep).

Pathophysiology

• Hypothalamic Dysregulation: Posterior hypothalamic activation disrupts circadian rhythms and autonomic output.
• Trigeminovascular Activation: Trigeminal nerve (V1 branch) stimulation releases vasodilatory neuropeptides (CGRP, Substance P), causing excruciating unilateral periorbital pain.
• Autonomic Dysfunction:
  • Parasympathetic hyperactivity: Via the pterygopalatine ganglion → lacrimation, rhinorrhea, nasal congestion.
  • Sympathetic impairment: Internal carotid wall edema compresses pericarotid sympathetic plexus → partial Horner syndrome (ptosis, miosis, anhidrosis).

Clinical Features

• Pain: Unilateral, severe, sharp/stabbing periorbital or retro-orbital pain lasting 15–180 min (occurs 1–8x/day in clusters lasting weeks to months).
• Autonomic Signs (Ipsilateral): Lacrimation, conjunctival injection, rhinorrhea, nasal congestion, and ptosis/miosis.
• Behavior: Severe restlessness and agitation (pt rocks/paces; does NOT lie still).

Treatment

• Acute / Abortive Therapy (First-Line):
  • 100% High-Flow Oxygen: 12–15 L/min via non-rebreather (NRB) mask for 15–20 minutes (fastest, safest first-line treatment). c
  • Subcutaneous (SQ) or Intranasal (IN) Triptans: Sumatriptan (6 mg SQ) or Zolmitriptan (5–10 mg IN). Oral triptans are ineffective due to slow onset.
  • Contraindications to Triptans: Coronary artery disease (CAD), Prinzmetal angina, uncontrolled HTN, stroke/TIA history.
• Acute / Abortive Therapy (Second-Line / Adjuncts):
  • Intranasal lidocaine, octreotide (SQ), or IV/IN dihydroergotamine (DHE).
• Prophylaxis (Maintenance):
  • First-Line: Verapamil (high-dose, titrated upward; requires baseline and periodic ECG monitoring for PR prolongation/heart block).
  • Transitional / Bridging Therapy: Short course of oral glucocorticoids (e.g., Prednisone taper) or greater occipital nerve block while titrating maintenance verapamil.
• Refractory Prophylaxis:
  • Lithium, topiramate, or galcanezumab (CGRP monoclonal antibody).

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Tension-type headache

Tip

• Tension-type headache (TTH) is a primary headache disorder, meaning it is idiopathic and not secondary to hypertension c
• “Tension” means muscle tension: Sustained involuntary contraction and spasm of the pericranial, scalp, and cervical muscles (e.g., frontalis, temporalis, trapezius) producing a tight, band-like constriction.

Epidemiology & Risk Factors

• Most common primary headache.
• F > M; triggered by stress, fatigue, sleep deprivation, poor posture.

Clinical Features

• Bilateral, dull, aching, non-throbbing pain in a “tight band” distribution.
• Differentiating features:
  • No nausea/vomiting.
  • Not aggravated by routine physical activity.
  • Photophobia OR phonophobia (never both).
• PE: Pericranial/cervical muscle tenderness; normal neuro exam.

Diagnosis

• Initial & Confirmatory: Clinical diagnosis (no labs/imaging required).
• Neuroimaging (Brain MRI/CT): Indicated only if “Red Flags” present (focal neuro deficits, onset >50 yo, “thunderclap” onset, systemic signs).

Differential Diagnostics

• Migraine: Unilateral, pulsating, + nausea/vomiting, + photophobia AND phonophobia, aggravated by physical activity.
• Cluster Headache: Unilateral, severe periorbital pain + autonomic signs (lacrimation, rhinorrhea, ptosis/miosis).
• Medication Overuse Headache: Rebound daily HA from analgesic use ≥10–15 days/month for >3 months.
• Giant Cell Arteritis: Age >50, temporal tenderness, jaw claudication, ↑ ESR/CRP.

Management

• Acute / Abortive (First-line): NSAIDs (ibuprofen, naproxen) or APAP.
  • Note: Limit to <2–3 days/wk to prevent medication overuse headache. No opioids or triptans.
• Prophylaxis (First-line): Amitriptyline (TCA) if chronic (≥15 days/mo) or disabling + CBT/stress reduction.

Complications

• Medication Overuse Headache (rebound).
• Progression to Chronic TTH (≥15 days/month for >3 months).

Primary stabbing headache

• Overview & Associations:
  • Brief, paroxysmal “ice-pick” head pain.
  • Highly associated with migraines and cluster headaches.
  • F > M.
• Clinical Features:
  • Duration: 1–3 seconds (strictly < 1 min).
  • Character: Sudden, severe, “ice-pick” sharp stabbing.
  • Location: Usually V1 distribution (orbit/temple); characteristically shifts locations.
  • Key Negatives:
    • No cranial autonomic symptoms (no tearing, eye redness, rhinorrhea).
    • No cutaneous trigger zones (touching skin/chewing does not trigger pain).
• Diagnosis:
  • Clinical diagnosis.
  • Brain MRI or ESR/CRP (if age > 50) reserved for “red flags” or fixed unilateral pain to r/o mass or GCA.
• High-Yield Differentials:
  • Trigeminal Neuralgia: V2/V3 distribution, triggered by light touch/chewing, responds to carbamazepine.
  • SUNCT/SUNA: Brief stabs accompanied by prominent autonomic signs (conjunctival injection, lacrimation).
  • Paroxysmal Hemicrania: Attacks last longer (2–30 min) with autonomic features.
• Management:
  • Abortives: Ineffective (attacks resolve too quickly).
  • First-line Prophylaxis: Indomethacin (treatment of choice).
  • Second-line: Melatonin, Gabapentin, or Topiramate (if indomethacin contraindicated).
• Key Complications:
  • Indomethacin toxicity: GI bleeding/ulcers (requires PPI co-prescription), AKI, and worsening HTN.