Origin: The most common cause of migraines/headaches can relate to neck complications. From spending excessive time looking down at a laptop, desktop, iPad, and even from constant texting, an incorrect posture for extended periods of time can begin to place pressure on the neck and upper back leading to problems that can cause headaches. The majority of these type of headaches occurs as a result of tightness between the shoulder blades, which in turn causes the muscles on the top of the shoulders to also tighten and radiate pain into the head.

Origin Of Head Pain

• Arises from pain sensitive structures in the head
• Small diameter fibers (pain/temp) innervate
• Meninges
• Blood vessels
• Extracranial structures
• TMJ
• Eyes
• Sinuses
• Neck muscles and ligaments
• Dental structures
• The brain has no pain receptors

Spinal Trigeminal Nucleus

• Trigeminal nerve
• Facial nerve
• Glossopharyngeal nerve
• Vagus nerve
• C2 nerve (Greater occipital nerve)

Occipital Nerves

http://dailymedfact.com/neck-anatomy-the-suboccipital-triangle/

Sensitization Of Nociceptors

• Results in allodynia and hyperalgesia

http://slideplayer.com/9003592/27/images/4/Mechanisms+associated+with+peripheral+sensitization+ to+pain.jpg

Headache Types

Sinister:

• Meningeal irritation
• Intracranial mass lesions
• Vascular headaches
• Cervical fracture or malformation
• Metabolic
• Glaucoma

Benign:

• Migraine
• Cluster headaches
• Neuralgias
• Tension headache
• Secondary headaches
• Post-traumatic/post-concussion
• “Analgesic rebound” headache
• Psychiatric

HA Due To Extracranial Lesions

• Sinuses (infection, tumor)
• Cervical spine disease
• Dental problems
• Temporomandibular joint
• Ear infections, etc.
• Eye (glaucoma, uveitis)
• Extracranial arteries
• Nerve lesions

HA Red Flags

Screen for red flags and consider dangerous HA types if present

Systemic symptoms:

• Weight loss
• Pain wakes them from sleep
• Fever

Neurologic symptoms or abnormal signs:

• Sudden or explosive onset
• New or Worsening HA type especially in older patients
• HA pain that is always in the same location

Previous headache history

• Is this the first HA you’ve ever had?
  Is this the worst HA you’ve ever had?

Secondary risk factors:

• History of cancer, immunocompromised, etc.

Dangerous/Sinister Headaches

Meningeal irritation

• Subarachnoid hemorrhage
• Meningitis and meningoencephalitis

Intracranial mass lesions

• Neoplasms
• Intracerebral hemorrhage
• Subdural or epidural hemorrhage
• Abscess
• Acute hydrocephalus

Vascular headaches

• Temporal arteritis
• Hypertensive encephalopathy (e.g., malignant hypertension, pheochromocytoma)
• Arteriovenous malformations and expanding aneurysms
• Lupus cerebritis
• Venous sinus thrombosis

Cervical fracture or malformation

• Fracture or dislocation
• Occipital neuralgia
• Vertebral artery dissection
• Chiari malformation

Metabolic

• Hypoglycemia
• Hypercapnea
• Carbon monoxide
• Anoxia
• Anemia
• Vitamin A toxicity

Glaucoma

Subarachnoid Hemorrhage

• Usually due to ruptured aneurysm
• Sudden onset of severe pain
• Often vomiting
• Patient appears ill
• Often nuchal rigidity
• Refer for CT and possibly lumbar puncture

Meningitis

• Patient appears ill
• Fever
• Nuchal rigidity (except in elderly and young children)
• Refer for lumbar puncture – diagnostic

Neoplasms

• Unlikely cause of HA in average patient population
• Mild and nonspecific head pain
• Worse in the morning
• May be elicited by vigorous head shaking
• If focal symptoms, seizures, focal neurologic signs, or evidence of increased intracranial pressure are present rule our neoplasm

Subdural Or Epidural Hemorrhage

• Due to hypertension, trauma or defects in coagulation
• Most often occurs in the context of acute head trauma
• Onset of symptoms may be weeks or months after an injury
• Differentiate from the common post-concussion headache
• Post-Concussive HA may persist for weeks or months after an injury and be accompanied by dizziness or vertigo and mild mental changes, which will all subside

Increase Intracranial Pressure

• Papilledema
• May cause visual changes

https://openi.nlm.nih.gov/detailedresult.php?img=2859586_AIAN-13-37- g001&query=papilledema&it=xg&req=4&npos=2

Temporal (Giant-Cell) Arteritis

• >50 years old
• Polymyalgia rheumatic
• Malaise
• Proximal joint pains
• Myalgia
• Nonspecific headaches
• Exquisite tenderness and/or swelling over the temporal or occipital arteries
• Evidence of arterial insufficiency in the distribution of branches of the cranial vessels
• High ESR

Cervical Region HA

• Neck trauma or with symptoms or signs of cervical root or cord compression
• Order MR or CT cord compression due to fracture or dislocation
• Cervical instability
• Order cervical spine x-rays lateral flexion and extension views

Ruling Out Dangerous HA

• Rule our history of serious head or neck injury, seizures or focal neurologic symptoms, and infections that may predispose to meningitis or brain abscess
• Check for fever
• Measure blood pressure (concern if diastolic >120)
• Ophthalmoscopic exam
• Check neck for rigidity
• Auscultate for cranial bruits.
• Complete neurologic examination
• If needed order complete blood cell count, ESR, cranial or cervical imaging

Episodic Or Chronic?

>15 days per month = Chronic

Migraine HA

Generally due to dilation or distension of cerebral vasculature

Serotonin In Migraine

• AKA 5-hydroxytryptamine (5-HT)
• Serotonin becomes depleted in migraine episodes
• IV 5-HT can stop or reduce severity

Migraine With Aura

History of at least 2 attacks fulfilling the following criteria

One of the following fully reversible aura symptoms:

• Visual
• Somatic sensory
• Speech or language difficulty
• Motor
• Brain stem

2 of the following 4 characteristics:

• 1 aura symptom spreads gradually over ≥5 min, and/or 2 symptoms occur in succession
• Each individual aura symptom lasts 5-60 min
• 1 aura symptom is unilateral
• Aura accompanied or followed in
• Not better accounted for by another ICHD-3 diagnosis, and TIA excluded

Migraine Without Aura

History of at least 5 attacks fulfilling the following criteria:

• Headache attacks lasting 4-72 h (untreated or unsuccessfully treated)
• Unilateral pain
• Pulsing/pounding quality
• Moderate to severe pain intensity
• Aggravation by or causing avoidance of routine physical activity
• During headache nausea and/or sensitivity to light and sound
• Not better accounted for by another ICHD-3 diagnosis

Cluster Headache

• Severe unilateral orbital, supraorbital and/or temporal pain
• “Like an ice pick stabbing me the eye”
• Pain lasts 15-180 minutes

At least one of the following on the side of headache:

• Conjunctival injection
• Facial sweating
• Lacrimation
• Miosis
• Nasal congestion
• Ptosis
• Rhinorrhea
• Eyelid edema
• History of similar headaches in the past

Tension Headache

Headache pain accompanied by two of the following:

• Pressing/tightening (non-pulsing) quality
• “Feels like a band around my head”
• Bilateral location
• Not aggravated by routine physical activity

Headache should be lacking:

• Nausea or vomiting
• Photophobia and phonophobia (one or the other may be present)
• History of similar headaches in the past

Rebound Headache

• Headache occurring on ≥15 days a month in a patient with a pre-existing headache disorder
• Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
• Due to medication overuse/withdrawal
• Not better accounted for by another ICHD-3 diagnosis

Sources

Alexander G. Reeves, A. & Swenson, R. Disorders of the Nervous System. Dartmouth, 2004.