Our topic now brings us to
sub-acute and chronic headache.
Up until now, we’ve
looked at acute headache.
We’ve closed the
chapter on that.
Let’s get into chronic
Migraine, pseudotumor cerebri,
mass lesion, tumor, abscesses,
tension type headache, chronic daily
headache, trigeminal neuralgia.
All of these extremely
common in our society.
We need to make sure that
you’re quite well-versed
with how to first identify it, diagnose
it, and management, you’re good to go.
We'll first take a
look at migraines.
Unilateral, throbbing, throbbing.
“Doc, I feel like my head
is throbbing, pulsating.”
Associated nausea and vomiting.
begins in childhood,
adolescence, young patient,
90% of your patients will be
less than 40 years of age.
Much more common in
What about cluster?
Much more common
in males, young.
Patients generally want
to still lie in the dark
because if they are
exposed to light,
it bothers them.
Be careful. Differential obviously
here, meningitis, migraine headache.
Classification: Classic, you have the aura.
Common, without the aura.
Migraine variants, maybe there’s
involvement of the eye,
so ophthalmic or retinal,
These are variants.
Common without aura,
classic with aura.
All are based on, well, sterile
inflammation of blood vessels.
Sterile, not infective.
Note that when we say “sterile inflammation”
in migraines, we are talking about a concept known as
“neurogenic inflammation” and not the typical
inflammatory response you see in other tissues
such as activation of immune cells and/or autoimmunity.
The neuroinflammation theory in migraines states
that the trigeminal meningeal nociceptors are activated
due to the release of the neuropeptides.
Substance P and calcitonin gene-related peptide - to be precise.
This is clearly different from the basic concept of sterile inflammation.
And they’re near the meninges
with activation of the
trigeminal nerve, perhaps.
This may seem to be the trigger.
Not exactly sure but that is a theory
that you want to be familiar with.
Remember, this is sterile inflammation.
Classic, with or without aura, please?
15% to 20% of
migraines are these.
Associated with preceding
That’s your aura.
You have a predisposition that, “Oh my
goodness, I’m about to have a headache,”
which is stereotype
for that patient.
That sucks to know that it’s coming and
there might be nothing you can do about it.
Progresses over 30 to 60 minutes.
That’s a lot longer than what?
A cluster headache,
when was that?
An acute headache.
Where are we now?
“Doc, I don’t feel well. I feel
like I’m going to pass out.”
Vomiting is not uncommon.
Loud sounds and
lights are difficult.
So if you’re, and I’m so sorry,
if you’re a migraine sufferer,
I’m probably one of the triggers
for much of your migraine.
And for that, I apologize,
but there’s nothing we can do about
it at this point, so I feel you.
So, thank you for being here.
Next, the headaches persist for 4
to 72 hours without treatment,
although can often be terminated
by sleep, if possible.
Obviously, easier said than done.
Common, without, without aura.
Similar to classic, without preceding
aura or neurologic dysfunction.
More likely to be bilateral than classic,
and often coexistent
patients with classic.
So, just because you have one doesn’t mean
that you’re not going to have the other.
There’s always going to be an overlap, but
if you’re taking an
exam or whatever,
they will be very clear about whether
that aura is present or not.
Management of your migraine:
and caffeine, perhaps,
NSAIDs, IV steroids,
valproate IV, narcotics.
Triptans are a big thing here.
Preventive: Avoid the trigger
such as light, maybe the sounds.
Treat attacks early if possible.
You don't want to have that
aura all the time, right?
And please make sure that you avoid
analgesics which the patient, for sure,
is going to be thinking about
using, if not abusing,
should be properly managed.
and calcium-channel blockers are all
preventive therapies for your migraines.
Summary of migraine.
Most of your patients, 90% less than 40.
Preventive: As we said, avoid the triggers.
Your medications that we talked about
earlier, with calcium channel blockers.
Signs and symptoms:
But as you said earlier with
common, it could be bilateral.
Differential: We talked about
tension type, sinusitis.
Earlier, we talked about temporal
arteritis with acute and mass lesion.
H and P for sure.
Image to make sure that rule out
other possible underlying issues.
The triptan can cause chest pain
and flushing in such patients.
Look for this.
And ergotamines that we talked about,
prolonged use can cause gangrene.
Be careful with ergotamine,
it may result in gangrene,
if that helps you.