Objectives• Describe how to diagnose migraine

with/without aura• Give examples for each of secondary

headache disorders (5-12)• Give examples for each of cranial

neuralgias and facial pains (13-14)

INTERNATIONAL CLASSIFICATION

ofHEADACHE DISORDERS

2nd Edition(ICHD-II)

ClassificationPart 1:

Primary headache disordersPart 2:

Secondary headache disordersPart 3:

Cranial neuralgias, central and primary facial pain and other headaches

Primary or Secondary Headache?

Primary• No other causative disorder

Primary or Secondary Headache?

Secondary• Caused by another disorder• New headache occurring in close

temporal relation to another disorder that is a known cause of headache

Part 1: Primary Headaches

1. Migraine2. Tension-type headache3. Cluster headache and other

trigeminal autonomic cephalalgias

4. Other primary headaches

Cephalalgia = headache

Part 2: Secondary Headaches

5. Headache attributed to head and/or neck trauma

6. Headache attributed to cranial or cervical vascular disorder

7. Headache attributed to non-vascular intracranial disorder

8. Headache attributed to a substance or its withdrawal

9. Headache attributed to infection

10.Headache attributed to disorder of homeostasis

11.Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth and other facial or cranial structures

12.Headache attributed to psychiatric disorder

Part 3

Cranial neuralgias, central and peripheral facial pain and other headaches

13.Cranial neuralgias and central causes of facial pain

14.Other headache, cranial neuralgia, central or peripheral facial pain

Neuralgia = pain extending along the course of one or more nerves(any cause)

Reason for Imaging Request (111 Patients) %Onset of new or different headache 57.7Nausea or vomiting 29.7Worst headache ever experience 28.8Progressive visual or neurological changes (5) 18.0Paralysis (3) 13.5Weakness, ataxia or loss of co-ordination 12.6Impaired consciousness (2) 11.7Onset of headache after age of 50 years 10.8Papilloedema (1) 9.0Stiff neck 5.4Onset of headache with exertion 5.4Systemic illness 4.5Numbness 3.6Asymmetry of pupillary response (4) 1.8Sensory loss 0.9Signs of meningeal irritation 0.9

2nd Headache Red Flags, Positive Imaging

From these reasons for imaging request, only 5 show correlation with positive findings on imagingSobri et al. The British Journal of Radiology, 76 (2003), 532–535

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What Questions to Ask Your Patients

• Pattern• Onset• Location• Frequency• Duration• Severity• Prodrome/aura• Associated symptoms• Sleep habits• Precipitating factors• Emotional factors

• Relationship profile• Family history• Seasonal relationship• Menstruation• Medical history• Surgical history• Allergy• Previous investigation• Past treatment and

responses• Present medication

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1.1 Migraine without Aura (Common Migraine)

Diagnostic Criteria: A. At least 5 attacks fulfilling B-DB. Headache attacks lasting 4-72 hoursC. Headache has at least two of the following:

1. Unilateral location2. Pulsating quality3. Moderate or severe intensity4. Aggravation by exertion

D. During headache at least one of the following:1. Nausea and/or vomiting2. Photophobia and phonophobia

E. Not attributed to another disorder

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Migraine with AuraA. At least 2 attacks fulfilling B-D.B. Aura consisting of at least one of the following, but

no motor weakness:1. fully reversible visual symptoms including positive

features (e.g., flickering lights, spots or lines) and/or negative features (i.e., loss of vision)

2. fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness)

3. fully reversible dysphasic speech disturbance

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Migraine with AuraC. At least two of the following:

1. homonymous visual symptoms and/or unilateral sensory symptoms

2. at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes

3. each symptom lasts ≥5 and <60 minutesD. Headache fulfilling criteria B–D for 1.1 Migraine

without aura begins during the aura or follows aura within 60 minutes

E. Not attributed to another disorder

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Aura

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AuraA. Takes many formsB. Migraine with aura = 1/3 total migraine casesC. In Migraine with Aura, first attack associated with aura = 40%,

aura with every attack = 20%D. 57% has aura before headacheE. Most auras last less than 30 minutesF. Most headache follows within 30 minutesG. 75% has single aura but combinations do occurH. Small blind dots > flashes of light > blind spot > foggy visionI. No association between headache side and aura side

Queiroz LP, Rapoport AM, Weeks RE et al. Headache. 1997 Mar; 37(3): 137-41.

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Differential Diagnoses

Transient Neurological Deficit:A. Transient Ischemic AttackB. SeizureC. HypoglycemiaD. SyncopeE. Etc.

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Case Study

1. 19-year-old man, unilateral throbbing and at times non-throbbing headache, onset at age 12. Duration of headache 6-12 hours, very severe with aura of twinkling lights, worsening when straining or working. Associated symptoms include nausea, vomiting, phonophobia and photophobia. Sleep may result in free of headache when waking up. Precipitating factors include chocolate, cheese.

2. Frequency of 4-6 times a year.

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Case Study

1. Does he have a migraine headache?2. What is your plan of treatment?

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Case Study

1. 22-year-old woman, bilateral non-throbbing headache, onset at age 18. Duration of headache 6-12 hours, activity must stop when under attack, worsening if working continues. Associated symptoms include nausea only. Sleep does not result in free of headache when waking up. Precipitating factors include white wine and smoked salmon.

2. Frequency of 10-12 times a year.

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Case Study

1. Does she have a migraine headache?2. What is your plan of treatment?