1. 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)

2. INTERNATIONAL CLASSIFICATION of HEADACHE DISORDERS 2 nd Edition (ICHD-II)

3. Classification Part 1: Primary headache disorders Part 2: Secondary headache disorders Part 3: Cranial neuralgias, central and primary facial pain and other headaches

4. Primary or Secondary Headache? Primary No other causative disorder

5. Complete physical and neurological examination must be carried out. Cortical functions Cranial functions: motor, sensory, reflex Spinal functions: motor, sensory, reflex Coordination Gait and posture Funduscopic examination

6. Cortical functions: –Consciousness: wakefulness and orientation –Language function: aphasia –Short-term memory: registration and recall –Long-term memory –Calculation –Abstract thinking –Etc.

7. Cranial functions ( motor, sensory and reflex ) CN II: visual acuity, visual field, pupillary light reflexes CN III, IV, VI: extraocular muscles for eye movement CN V: muscles of mastication and facial sensation V1-3 CN VII: facial expression, chemical sense and corneal reflex CN VIII: Rinne and Weber tests CN IX: chemical sensation and gag reflex CN X: uvular elevation and gag reflex CN XII: sternocleidomastoid and trapezius CN XII: tongue movement

8. Spinal functions ( motor, sensory and reflex ) Shoulder, elbow and joint movements Hip, knee and ankle movements Dorsal column pathway: joint position sensation Anterolateral pathway: pain sensation Muscle tone: elbow, wrist, hip, knee joints Deep tendon reflexes: biceps, triceps, brachioradialis, patellar, ankle Pathological reflexes: palmomental, finger flexor, plantar reflex

9. Coordination, gait and posture Tandem walk Romberg test Gait Finger-to-nose, finger-to-finger, finger-to-nose-to- finger Funduscopic examination

10. 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

11. Part 1: Primary Headaches 1.Migraine 2.Tension-type headache 3.Cluster headache and other trigeminal autonomic cephalalgias 4.Other primary headaches Cephalalgia = headache

12. 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

13. 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

14. 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)

15. Reason for Imaging Request (111 Patients)% Onset of new or different headache57.7 Nausea or vomiting29.7 Worst headache ever experience28.8 Progressive visual or neurological changes (5)18.0 Paralysis (3)13.5 Weakness, ataxia or loss of co-ordination12.6 Impaired consciousness (2)11.7 Onset of headache after age of 50 years10.8 Papilloedema (1)9.0 Stiff neck5.4 Onset of headache with exertion5.4 Systemic illness4.5 Numbness3.6 Asymmetry of pupillary response (4)1.8 Sensory loss0.9 Signs of meningeal irritation0.9 2 nd Headache Red Flags, Positive Imaging From these reasons for imaging request, only 5 show correlation with positive findings on imaging Sobri et al. The British Journal of Radiology, 76 (2003), 532–535

16. 16 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

17. 17 1.1 Migraine without Aura (Common Migraine) Diagnostic Criteria: A.At least 5 attacks fulfilling B-D B.Headache attacks lasting 4-72 hours C.Headache has at least two of the following: 1.Unilateral location 2.Pulsating quality 3.Moderate or severe intensity 4.Aggravation by exertion D.During headache at least one of the following: 1. Nausea and/or vomiting 2.Photophobia and phonophobia E.Not attributed to another disorder

18. 18 Migraine with Aura A.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

19. 19 Migraine with Aura C.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 minutes D. 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

20. 20 Aura

21. 21 Aura A.Takes many forms B.Migraine with aura = 1/3 total migraine cases C.In Migraine with Aura, first attack associated with aura = 40%, aura with every attack = 20% D.57% has aura before headache E.Most auras last less than 30 minutes F.Most headache follows within 30 minutes G.75% has single aura but combinations do occur H.Small blind dots > flashes of light > blind spot > foggy vision I.No association between headache side and aura side Queiroz LP, Rapoport AM, Weeks RE et al. Headache. 1997 Mar; 37(3): 137-41.

22. 22 Differential Diagnoses Transient Neurological Deficit: A.Transient Ischemic Attack B.Seizure C.Hypoglycemia D.Syncope E.Etc.

23. 23 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.

24. 24 Case Study 1.Does he have a migraine headache? 2.What is your plan of treatment?

25. 25 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.

26. 26 Case Study 1.Does she have a migraine headache? 2.What is your plan of treatment?