Snapshot A 33-year-old woman presents to her primary care physician with headache, nausea, and visual disturbances. The patient was in her usual state of health until yesterday, when she experienced a pulsatile bilateral headache that caused her to have one episode of emesis. Her headache is accompanied by seeing a shimmering light that distorts her vision, photophobia, and phonophobia. Medical history is unremarkable, and the patient recently began menses. Ibuprofen and acetaminophen have not improved her symptoms. Neurologic examination is unremarkable. (Migraine headaches) Introduction Headache is a common neurologic symptom that can be divided into primary and secondary headache disorders primary headaches include tension-type headache migraine headache cluster headache secondary headaches describe a headache caused by some other etiology such as space occupying lesions e.g., brain tumor, hematoma, and hydrocephalus severe hypertension cerebral venous thrombosis pre-eclampsia vasculitic syndromes e.g., giant cell arteritis head trauma subarachnoid hemorrhage infections e.g., meningitis and encephalitis Note that the brain parenchyma does not have pain receptors therefore, pain leading to the headache is the result of insults (e.g., inflammation or irritation) affecting innervated head structures such as the meninges scalp skull blood vessels Warning signs for a secondary headache caused by a serious underlying etiology includes systemic symptoms e.g., weight loss, fever, and an immunocompromised state neurologic symptoms e.g., confusion, altered consciousness, papilledema, and focal neurologic deficits onset of headache new type or sudden headache other e.g., head trauma, illicit drug use, headaches that awakens the patient from sleep, headaches that worsens with valsalva maneuvers, and change in headache patterns Primary Headache Disorders Primary Headache Disorders Headache Type Clinical Features Treatment Tension-type headache Bilateral headache described as a "band-like" non-throbbing no associated features Duration > 30 minutes usually 4-6 hours Abortive NSAIDs acetaminophen Prophylactic biofeedback and relaxation therapy amitriptyline Migraine headache Unilateral (or bilateral) headache that is throbbing or pulsatile worse with activity Can be associated with photophobia phonophobia auras that can be motor sensory visual nausea and vomiting Triggers odors lights foods weather menses Duration 4-72 hours Abortive NSAIDs acetaminophen triptans ergots antiemetics metoclopramide chlorpromazine prochlorperazine Prophylactic biofeedback and relaxation therapy propranolol valproic acid calcium channel blockers topiramate amitriptyline Cluster headache Unilateral and repetitive stab-like periorbital headaches that are associated with ipsilateral autonomic symptoms such as lacrimation rhinorrhea Horner's syndrome circadian periodicity pain being severely debilitating Duration15 minutes - 3 hours Abortive 100% oxygen triptans Prophylactic verapamil topiramate Other Headaches Trigeminal neuralgia (tic douloureux) clinical definition a headache disorder secondary to disruption of the second (V2) and third (V3) branch of the trigeminal nerve presentation recurrent and brief episodes of pain most commonly in the distribution of V2 and/or V3 these headaches are often triggered by chewing shaving touching or a breeze affecting the V2 and/or V3 distrubution etiology vascular compression malignancy affecting the nerve or any other cause such as a plaque of multiple sclerosis treatment carbamazepine oxcarbazepine