In this lecture we'll talk about the
paroxysmal and episodic headaches.
This is a large group of
really important conditions
both for seeing patients clinically
and evaluating vignettes.
So let's start with a case.
This is a 30-year-old woman
who has a history of sick
headaches since high school.
She sometimes describes seeing silver
sparkles at the onset of the headache.
The headaches are described as
pulsating and throbbing in her temporal
that is worsened with bright
lights and loud noises.
So she goes into a dark
room and tries to sleep.
She presents to the emergency department
with a severe headache 10 out of 10 pain,
nausea and vomiting that's
lasted about 2 days.
She previously took propranolol but at the
current time her oral meds are ineffective.
we find a normal neurologic exam.
So what's this
Once we look at some of
the clinical features,
we have someone who presents with
recurrent headaches that are episodic
and it fits that episodic
recurrent headache syndrome.
We don't see red flags symptoms, signs of
thunderclap or neuralgia form headache,
high or low pressure
or visual disturbances.
So this sounds like a chronic
recurrent paroxysmal headache syndrome.
In addition, we see some key
associated symptoms for this patient.
She has photophobia,
phonophobia, nausea, vomiting.
All those things we associate
with migrainous headaches.
So is this a primary or a
secondary headache syndrome?
This headache falls into the
primary headache syndrome category.
And while some patients may
need additional evaluation,
this is someone where we're
going to focus initially
on treatment of this
So what type of
headache is this?
Is this a migraine, a tension
type headache, pseudotumor cerebri
or a subarachnoid haemorrhage?
Well, this doesn't sound like the typical
description of a high pressure headache,
and pseudotumor would be much
lower on our differential.
Subarachnoid haemorrhage presents
with a thunderclap headache
and this doesn't have
that abrupt severe onset.
Tension type is
opposite from migraine.
Tension type headaches are often
bilateral, a band-like sensation
with no nausea, no vomiting,
no photo or phonophobia.
And so this patient
has classic migraine.
She presents with nausea vomiting, photo/
phonophobia, unilateral head pressure.
All the symptoms that we
see with migraine headaches.