Extracranial causes of headache

1. Tension type headaches
   1. pain is typically bilateral, band type or squeezing; improves with exercise
   2. NOTE: tension headache does NOT get worse with jumping up and down while migraine headaches DO
2. Migraine type headache
   1. pain is mostly unilateral with throbbing, pulsing or stabbing quality; often accompanied by nausea and vomiting
   2. aura of migraine is NOT due to vasospasm as once thought; there is decreased CBF seen in some migraine patients but this may be due to decreased activity of the brain and not symbolic of the migraine
   3. cause of pain IS due to dilated, swollen, throbbing vessels in the head
   4. may be related to dysfunction of Ca channels
   5. common migraine – no aura or neurologic deficit, headache lasting 4-72 hours, and at least two of the following: photophobia, unilateral location, pulsatile nature
      1. treatment: ergotamine to abort the headache while verapamil or amitryptiline may be used as prophylaxis
   6. classic migraine – with aura and/or neurologic deficit
   7. complicated migraine – classic migraine with neurologic deficit lasting < 30 days
   8. ophthalmoplegic migraine – occurs mostly in children; headache always occurs on the same side as the ophthalmoplegia, presents with visual auras, and may last for several days; occurs equally in boys and girls
3. cluster headaches
   1. pain is always unilateral behind or next to one eye and is always the same eye (often gets better with exercise)
   2. onset is sudden and memorable by the patient
   3. typically occurs in young adult men
   4. treatment is a dose of ergotomine prior to bed or lithium long term; inhalation of oxygen at the onset of an attack may be helpful as well, acute attack may also be treated with prednisone
      1. paroxysmal hemicrania (a related disorder) may be treated with indomethacin
4. thunderclap headache
   1. possible causes:
      1. aneurysmal rupture, aneurysmal stretching, carotid dissection, cerebral venous thrombosis, pheochromocytoma, acute hydrocephalus, perimesencephalic hemorrhage
      2. Remember: Pascal V. Amore’s PhDs (Perimesencephalic, Venous thrombosis, Aneurysm rupture, Pheochromocytoma, Hydrocephalus, carotid Dissection, Stretching of aneurysm)
5. Basilar migraine of Bickerstaff
   1. migraine plus feinting, nausea, quadriplegia, vomiting, ataxia, dysarthria