Chronic, Recurrent, and Episodic Headaches

by Roy Strowd, MD

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    00:01 So let's talk more about chronic, recurrent, episodic headaches.

    00:05 Let's understand migraine and tension type headaches.

    00:08 And then we'll talk about some of the less common causes of an episodic or recurrent headache syndrome.

    00:13 What we're talking about here can be seen in this flow diagram, this algorithm.

    00:17 These are the chronic, recurrent and episodic headaches and that's important.

    00:20 These common go, there are a series of attacks that relapse and then periods of remission where patients may be headache free.

    00:29 Our first question when evaluating these patients is, are there prominent autonomic features? We can see autonomic signs.

    00:36 Meiosis or mydriasis with any of these headaches.

    00:40 But prominent autonomic features should point us in the direction of the trigeminal autonomic cephalalgia.

    00:47 If they're not prominent autonomic features, we're going to focus on migraine and tension.

    00:51 And those are really the two most common causes of a recurrent, episodic headache without prominent autonomic findings, migraine tension-type.

    00:59 And then there's a list of other things, obstructive sleep apnea cervicogenic headache, chronic daily headaches, medication overuse headaches, there's a number of other conditions we can also consider.

    01:11 When we're evaluating these migrainous or tension-type headaches, they're all should be chronic and recurrent.

    01:16 They should come and go with periods of relapse and periods of remission.

    01:21 Typically, these headaches occur in episodes and each individual headache class between 4-72 hours.

    01:28 And migraine and tension lie on a spectrum.

    01:31 And some patients may present in the middle of the spectrum with migraine without aura or with migrainous headaches that also have a tension-type component.

    01:39 But here we're going to define the extremes of the spectrum.

    01:43 Migraine with aura lies on one end of the extreme.

    01:46 This is a lateralized headache, it's unilateral.

    01:49 Patients have prominent nausea, vomiting, photo- and phonophobia and we often see aura.

    01:55 On the other end of the spectrum lie tension-type headaches.

    01:58 They're almost the opposite of migraines.

    02:01 The symptoms are not lateralized, this is holocephalic head pain, a band like sensation over the entire head.

    02:08 We don't see nausea vomiting, photo-, phonophobia and often don't see aura.

    02:13 So what are the diagnostic criteria on for migraine and tension-type? And in this slide, we'll compare and contrast them right next to each other.

    02:20 Again, migraine should be unilateral, with associated nausea and vomiting.

    02:26 Phono-, photo-, or osmophobia can be seen and that's worsening with bright lights, loud noises or smells.

    02:33 Headaches last 4-72 hours and are often relieved by sleep or worsened by activity or exercise.

    02:39 And this is classic migraine.

    02:40 Not every patient will meet all of these criteria.

    02:43 And in fact, some patients may meet very few of these criteria.

    02:46 But this is the classic presentation of migraine.

    02:50 Tension-type is the opposite.

    02:52 Headache is bilateral holocephalic, a band-like pressure over the entire head.

    02:58 There's rare nausea and vomiting with these headaches.

    03:01 Photo-, phono-, and osmophobia are quite rare.

    03:04 And episodes can be shorter than migraine but also worsened with activity and exercise.

    03:11 So how do we approach patients who may present with migraine or tension-type headaches? What are the things we ask on history? Well, it's a pretty in depth history.

    03:19 These diagnoses are made and patients are managed based on the history and physical exam alone.

    03:24 And so we need to think about a comprehensive evaluation.

    03:27 First, we asked about prior history of headache.

    03:30 There should be a long history of headache often beginning in the teens or 20s of life but sometimes in some patients presenting later.

    03:39 Patients can have multiple headache types.

    03:42 And that's not inconsistent with the diagnosis of migraine or tension.

    03:46 Age of onset is important.

    03:48 Most migraine and tension patients will have headaches that began in the late teens or early 20s period of time.

    03:55 The location and radiation is important.

    03:57 Again, we said migraine is unilateral, tension-type bilateral.

    04:01 The pain quality and severity is important though most patients will tell you that with a severe episode, the pain can be the worst that they've experienced.

    04:09 The key is that onset and these headaches usually come on over the course of several hours.

    04:14 Headache frequency and duration is important.

    04:16 The mode of onset and termination is also important.

    04:20 Sleep is one of the most important terminating events or procedures or interventions for these patients.

    04:25 And so if you can get the patient to sleep, usually the headache will go away.

    04:29 Precipitating and exacerbating factors are important to explore.

    04:33 Alleviating factors in associated symptoms can help us to manage patients once we've made a diagnosis.

    04:39 And then we think about medications patients are currently taking or previously taking and a general medication history.

    04:44 Some medicines can exacerbate migraines, history of head trauma and family history of headache.

    04:52 What are the causes of migraines? How do we classify them? Not all migraines are the same and there are certain classifications that we can use to subcategorize and diagnose patients.

    05:02 Classic migraine has a proceeding aura.

    05:05 Patients present often with the prodrome, they can tell it's coming on, strange taste or something along those lines, and that builds into a frank aura.

    05:13 Many people describe an aura that is visual, either with a scotoma, a dark spot where they cannot see.

    05:21 And sometimes with scintillating quality, where there's bright lights or flashes around that.

    05:26 That aura usually lasts about 30 minutes and then patients will describe the onset of pain and that would be migraine, classic migraine with aura.

    05:35 Common migraine has no proceeding aura.

    05:37 So you don't have to have the aura to still have the migraine.

    05:41 Other less common types of migraine include basilar migraine.

    05:44 And basilar migraineurs will have prominent posterior fossa symptoms, vertigo or hearing dysfunction or gait dysfunction and abnormality present.

    05:53 During their migraine attacks that then remits resolves in between attacks.

    05:59 We also see acephalgic migraines.

    06:00 So that sounds a little strange, that's a migraine without the pain.

    06:04 So that maybe just an aura, or just the posterior fossa symptoms if a patient has an acephalgic basilar migraine.

    06:13 The key is there's no pain.

    06:14 But we do see characteristic symptoms and usually the episodes follow a very similar course from occurrence to occurrence.

    06:23 We can see ocular acephalgic migraines.

    06:25 Patients present with vision loss or vision dysfunction.

    06:28 Ophthalmoplegia or diplopia or disconjugate gaze can sometimes be present but really should prompt evaluation for other causes initially before making this diagnosis.

    06:37 And then again, we can see some basilar variance with variable posterior fossa symptoms potentially without headache.

    06:43 Acephalgic migraines should be evaluated more in depth than the classic or common migraine to rule out other offending causes.

    06:52 What are other types of chronic, recurrent headaches? Cervicogenic headache is typically a posterior predominant headache that is triggered with neck pain, and it's common after neck manipulation or neck surgery or can be seen in patients with cervical spondylosis.

    07:07 Familial hemiplegic migraine is a migraine variant that must be recognized.

    07:12 Patients present with hemiplegia, weakness on one side of the body that can present during or just preceding their headache.

    07:21 This can look like a stroke.

    07:22 Patients have headache and a hemiparesis.

    07:24 And patients will be evaluated initially for a vascular aetiology or some other underlying cause.

    07:30 And when normal that patients can be given a diagnosis or a diagnosis of familial hemiplegic migraine can be made.

    07:36 This is an underlying genetic event.

    07:39 We know several genes that predispose patients to familial hemiplegic migraine and can run in families.

    07:46 And then in pediatric patients, everything can look different.

    07:49 So manifestations of migraines.

    07:51 Migraines and kids can show up with cyclic vomiting.

    07:54 The patients just vomit and that's a manifestation of migraine by treating migraine, the vomiting will go away.

    08:01 Abdominal migraine causes recurrent episodes of abdominal pain and discomfort and again treating with migraine treatments can result in remission of the abdominal pain and episodes.

    08:13 And benign paroxysmal vertigo of childhood.

    08:16 So episodes of vertigo can be a childhood migraine variant.

    08:21 And again, we treat that with antimigraine medications and interventions.

    About the Lecture

    The lecture Chronic, Recurrent, and Episodic Headaches by Roy Strowd, MD is from the course Headache.

    Included Quiz Questions

    1. Associated photophobia, phonophobia, and nausea
    2. Pain that is bilateral
    3. Band-like tightness around the head
    4. Improvement with physical activity
    5. Association with autonomic features
    1. An ocular migraine is not associated with a headache.
    2. An ocular migraine does not have a visual aura.
    3. Ocular migraines are associated with nausea and vomiting.
    4. Classic migraines are more often associated with posterior fossa symptoms of imbalance.
    5. Ocular migraines are associated with a painful headache.
    1. Cyclical vomiting or abdominal pain
    2. Hemiplegic symptoms
    3. Ophthalmoplegic symptoms
    4. Psychiatric symptoms
    5. Neck pain without headache
    1. Tension headache
    2. Trigeminal neuralgia
    3. Venous sinus thrombosis
    4. Headache due to a brain tumor
    5. Idiopathic increased intracranial pressure

    Author of lecture Chronic, Recurrent, and Episodic Headaches

     Roy Strowd, MD

    Roy Strowd, MD

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