Sub-Acute Headache, Chronic Headache and Migraine

by Carlo Raj, MD

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    00:01 Our topic now brings us to sub-acute and chronic headache.

    00:07 Up until now, we’ve looked at acute headache.

    00:09 We’ve closed the chapter on that.

    00:11 Let’s get into chronic and subacute.

    00:13 Migraine, pseudotumor cerebri, mass lesion, tumor, abscesses, tension type headache, chronic daily headache, trigeminal neuralgia.

    00:23 All of these extremely common in our society.

    00:27 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.

    00:36 We'll first take a look at migraines.

    00:38 Unilateral, throbbing, throbbing.

    00:42 “Doc, I feel like my head is throbbing, pulsating.” Associated nausea and vomiting.

    00:49 Typically, unfortunately, begins in childhood, adolescence, young patient, 90% of your patients will be less than 40 years of age.

    00:58 Much more common in females, migraines.

    01:01 What about cluster? Much more common in males, young.

    01:05 Patients generally want to still lie in the dark because if they are exposed to light, it bothers them.

    01:13 Be careful. Differential obviously here, meningitis, migraine headache.

    01:18 Classification: Classic, you have the aura.

    01:22 Common, without the aura.

    01:27 Migraine variants, maybe there’s involvement of the eye, so ophthalmic or retinal, menstrual, hemiplegic, and basilar.

    01:37 These are variants.

    01:38 Common without aura, classic with aura.

    01:44 All are based on, well, sterile inflammation of blood vessels.

    01:47 Sterile, not infective.

    01:49 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.

    02:26 And they’re near the meninges with activation of the trigeminal nerve, perhaps.

    02:34 This may seem to be the trigger.

    02:36 Not exactly sure but that is a theory that you want to be familiar with.

    02:38 Remember, this is sterile inflammation.

    02:42 Classic, with or without aura, please? Good.

    02:50 With aura.

    02:51 15% to 20% of migraines are these.

    02:53 Associated with preceding neurologic symptom.

    02:56 That’s your aura.

    02:58 You have a predisposition that, “Oh my goodness, I’m about to have a headache,” which is stereotype for that patient.

    03:05 That sucks to know that it’s coming and there might be nothing you can do about it.

    03:10 Progresses over 30 to 60 minutes.

    03:13 That’s a lot longer than what? Cluster.

    03:16 A cluster headache, when was that? An acute headache.

    03:20 Where are we now? Subacute chronic.

    03:23 Nausea.

    03:25 “Doc, I don’t feel well. I feel like I’m going to pass out.” Vomiting is not uncommon.

    03:33 Associated with photophobia, phonophobia.

    03:36 Loud sounds and lights are difficult.

    03:39 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.

    03:49 And for that, I apologize, but there’s nothing we can do about it at this point, so I feel you.

    03:53 So, thank you for being here.

    03:54 Next, the headaches persist for 4 to 72 hours without treatment, although can often be terminated by sleep, if possible.

    04:05 Obviously, easier said than done.

    04:06 Classic migraine.

    04:08 Common, without, without aura.

    04:14 Similar to classic, without preceding aura or neurologic dysfunction.

    04:18 More likely to be bilateral than classic, and often coexistent patients with classic.

    04:24 So, just because you have one doesn’t mean that you’re not going to have the other.

    04:28 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.

    04:36 Management of your migraine: Abortive therapy; triptans, ergotamine, and caffeine, perhaps, NSAIDs, IV steroids, valproate IV, narcotics.

    04:53 Triptans are a big thing here.

    04:55 Preventive: Avoid the trigger such as light, maybe the sounds.

    04:59 Treat attacks early if possible.

    05:03 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.

    05:15 Beta-blockers, tricyclics, antiepileptics even, and calcium-channel blockers are all preventive therapies for your migraines.

    05:27 Summary of migraine.

    05:30 Female.

    05:31 Age: Young.

    05:32 Most of your patients, 90% less than 40.

    05:36 Preventive: As we said, avoid the triggers.

    05:39 Your medications that we talked about earlier, with calcium channel blockers.

    05:42 Signs and symptoms: Unilateral throbbing, nausea, photophobia.

    05:47 But as you said earlier with common, it could be bilateral.

    05:52 Differential: We talked about tension type, sinusitis.

    05:54 Earlier, we talked about temporal arteritis with acute and mass lesion.

    05:59 H and P for sure.

    06:02 Image to make sure that rule out other possible underlying issues.

    06:06 The triptan can cause chest pain and flushing in such patients.

    06:11 Look for this.

    06:11 And ergotamines that we talked about, prolonged use can cause gangrene.

    06:15 Be careful with ergotamine, it may result in gangrene, if that helps you.

    About the Lecture

    The lecture Sub-Acute Headache, Chronic Headache and Migraine by Carlo Raj, MD is from the course Headache. It contains the following chapters:

    • Sub-Acute and Chronic Headache
    • Classic Migraine
    • Common Migraine

    Included Quiz Questions

    1. Venous sinus thrombosis
    2. Migraine without aura
    3. Tension headache
    4. Migraine with aura
    5. Trigeminal neuralgia
    1. Bilateral and stabbing pain
    2. Unilateral and throbbing pain
    3. Common in females
    4. Associated nausea and vomiting
    5. Associated photophobia
    1. Activation of trigeminal meningeal nociceptors by the release of substance P and calcitonin gene-related peptide (CGRP)
    2. Activation of the innate immune system
    3. Activation of the adaptive immune system
    4. Release of inflammatory cytokines
    5. Stretching of the meninges
    1. Paroxetine
    2. Propranolol
    3. Valproate
    4. Amitriptyline
    5. Verapamil

    Author of lecture Sub-Acute Headache, Chronic Headache and Migraine

     Carlo Raj, MD

    Carlo Raj, MD

    Customer reviews

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    Great complement
    By Daniel Y. on 15. September 2020 for Sub-Acute Headache, Chronic Headache and Migraine

    i was reading the reviews and there is a big mistake, this lecture it's a resume, it can't be your only source of information, so don't cry about it and use it with your books.

    severely disappointed
    By Joseph S. on 14. December 2018 for Sub-Acute Headache, Chronic Headache and Migraine

    seriously these series of lectures are the absolute worst. no explanation at all, no physiopathology, no images...just a pathologist who seems to be severely under qualified to teach a comprehensive clinical neurology lecture , reading a bunch of bullet points off the most lazily prepared power point presentation. seriously strating to wonder what the point of lecturio is. I do the q bank right after the lectures and literally nothing that is asked is mentioned in these lectures.

    Needing more details
    By Hamed S. on 16. March 2017 for Sub-Acute Headache, Chronic Headache and Migraine

    It would have been good to further discuss migraine headaches and tensions headaches. I would have like to learn more about the features of aura (incl scotomas). Moreover, a discussion on what constitutes medication overuse headache is warranted given the ease of access to OTC analgesics. Finally an opportunity has been missed to discuss if which circumstances you would consider the use of prophylactic therapies