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Headache Clinical Case Seminar
COME ACROSS THE DIAGNOSTIC PITFALL
Headache adventure
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What is your diagnosis?
A. Vestibular migraine
B. Migraine with brainstem aura
C. Migraine with BPPV
D. Headache attributed to brainstem TIA
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Hx taking and PE
Feature suggest
serious secondary
headache
Red flag sign
Feature suggest
other secondary
headache
Feature suggest
primary
headache
Blue flag sign
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Healthy young age
Morning headache
Headache non-response to
medication
Headache response to
migraine specific medication
Grouping
The Northern Neuroscience Centre
Chiang Mai University
Clinical headache
syndrome
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Vestibular migraine
Hemiplegic migraine
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B. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura
1. headache with at least two of the following four characteristics: unilateral location,
pulsating quality, moderate or severe intensity, aggravation by routine physical activity
2. Photophobia/phonophobia
3. Visual aura
E. Not better accounted for by another ICHD-III diagnosis or by another vestibular disorder
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Vertigino/dizziness character
a) spontaneous vertigo:
(i) internal vertigo (a false sensation of selfmotion)
(ii) external vertigo (a false sensation that the
visual surround is spinning or flowing)
Vertigo duration
10% seconds
30% hours
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Trigemino-vascular reflex
Trigeminal pain pathway
activation
Amygdala
Insula
CGRP-Substance P-Neurokinin A
Emotional
response
Cognitive/
perceptive
changes
Spatial
memory
changes
Cochlea/vestibular hypersentitivity
Vestibular dysfunction
Sensorimotor response: eye, head, gait
Espinosa Sanchez JM et
al. Front in Neurol
2015;6(12): 1-6
Vestibular migraine
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NNC CMU
Few studies
acute; zolmitriptan
prophylactic;
CAI: acetazolamine
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NNC CMU
Typical migraine
- migraine without aura
- migraine with typical aura
(Typical aura: duration: 5-60 minutes,
visual symptoms, sensory symptoms
+/- speech symptoms, occurs in
succession , gradual onset, and slow
progression)
Atypical migraine
- migraine atypical aura (brainstem aura,
hemiplegic aura, prolonged aura)
- aura without headache (late-life
migraine accompaniments)
- migraine complication: migralepsy,
migraine infarct
Flunarizine is available in EU
AAN/AHS 2012
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NNC CMU
Case seminar-2
An 65 years old man with dull aching,
diffuse
headache triggered by stress
for 1 month. He has been diagnosed as
TTH and treated with simple analgesic ,
but no improvement
He noted that chaining position to
upright also trigger headache
PE: normal
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Just a TTH?
TTH mimicker
In context of bilateral,
mild to moderate
diffuse/temporal
headache without
significant other features
Tension-type headache
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Tension-type like headache
Headache attributed to
disorder of homeostasis
Medication overused
headache
Hypoxia/hypercapnia,
aeroplane travel, sleep
apnea headache, arterial
hypertension,
hypothyroidism, fasting
Headache attributed to
cervical dystonia
Headache attributed to
psychiatric disorder
Headache attributed to a
substance or its withdrawal
Mild intracranial
hypertension/intracranial
hypotension
Diffuse incracranial
disorder
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HT and Headache
The Northern Neuroscience Centre
Chiang Mai University
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NNC CMU
Headache and HT
Pheochromocytoma
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END
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