Case: 30-year-old Woman with Episodic Headache

00:01 In this lecture we'll talk about the paroxysmal and episodic headaches.

00:05 This is a large group of really important conditions both for seeing patients clinically and evaluating vignettes.

00:12 So let's start with a case.

00:14 This is a 30-year-old woman who has a history of sick headaches since high school.

00:18 She sometimes describes seeing silver sparkles at the onset of the headache.

00:23 The headaches are described as pulsating and throbbing in her temporal that is worsened with bright lights and loud noises.

00:30 So she goes into a dark room and tries to sleep.

00:33 She presents to the emergency department with a severe headache 10 out of 10 pain, nausea and vomiting that's lasted about 2 days.

00:41 She previously took propranolol but at the current time her oral meds are ineffective.

00:47 On exam, we find a normal neurologic exam.

00:51 So what's this headache syndrome? 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.

01:04 We don't see red flags symptoms, signs of thunderclap or neuralgia form headache, high or low pressure or visual disturbances.

01:12 So this sounds like a chronic recurrent paroxysmal headache syndrome.

01:17 In addition, we see some key associated symptoms for this patient.

01:20 She has photophobia, phonophobia, nausea, vomiting.

01:23 All those things we associate with migrainous headaches.

01:28 So is this a primary or a secondary headache syndrome? This headache falls into the primary headache syndrome category.

01:35 And while some patients may need additional evaluation, this is someone where we're going to focus initially on treatment of this migrainous headache.

01:44 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.

01:59 Subarachnoid haemorrhage presents with a thunderclap headache and this doesn't have that abrupt severe onset.

02:06 Tension type is opposite from migraine.

02:08 Tension type headaches are often bilateral, a band-like sensation with no nausea, no vomiting, no photo or phonophobia.

02:15 And so this patient has classic migraine.

02:18 She presents with nausea vomiting, photo/ phonophobia, unilateral head pressure.

02:23 All the symptoms that we see with migraine headaches.