Primary Headache vs.

Secondary Headache
Primary:
Tension Migraine Cluster

Frequency episodic and chronic episodic and chronic clustering pattern

Duration hours 4-72 hr 30 minutes - 3 hr

Location Band like, bilateral Unilateral Always Unilateral,

(classic)/bilateral always on same side

Quality of Pain pressure pulsatile Sharp, boring

Intensity mild-moderate moderate - severe severe

Associated Photo OR Photo AND rhinorrhea

Symptoms phonophobia BUT phonophobia OR
NO nausea nausea

Aggravated by
moderate activity;
Aura

Treatment NSAIDs Tx: NSAIDs, triptans Transitional:

Preventative: TCA PPx: Topiramate, Prednisone (to break
beta blockers, TCA, the cluster)
Valproic Acid Abortive: 100% O2 or
subq triptan
Preventative:
Verapamil

**Episodic (less than ½ days), chronic (more than 15 days/month)

Can disappear for a long time, the come back for a few weeks/month or two then disappears.
Primary: Intrinsic neurologic problem, patients brain genetically/chemically wired to have
headaches.
**Vomiting WITHOUT nausea = ALARM symptoms. Makes you think of increased ICP

Aura: Lasting 20-30 minutes, occuring before headache starts. Usually visual. **Only 30% have
aura. Most patients DON’T have it.

Fun fact: Risk of stroke in females with aura higher.

Patient comes in w/ headache; Check: Vital Signs, Fundoscopy

Medications -
Topiramate​ : Anti epileptic
Dont give to pregnant women - causes cleft palate
Don’t give to patients who have kidney stones

Beta Blockers:​ Give to - Patients who have essential tremor

Don’t give to patient with asthma, with brittle diabetes or a long distance runner

TCA:
Side effects: urinary retention, dry mouth, confusion (all anticholinergics)

Valproic Acid:
Don’t give to pregnant women or even considering pregnancy - teratogenic → neural tube
defects

Secondary:
Subarachnoid Hemorrhage
CNS Infection
Disorders that increase or decrease ICP
Giant Cell Arteritis: more common in women
ANY visual symptoms (then immediately give prednisone); if no visual symptoms the just get a
sediment rate.

Red Flags:
- Nuchal Rigidity
- Fever
- Started NEW headache, where you wake up EVERY morning with headache (**few
times a month in morning is NOT a red flag)
- Vomiting WITHOUT nausea (if with nausea, not red flag)
- Older age of onset (50+)

Increased ICP → can cause false localizing 6th nerve palsy (because of stretching of 6th nerve)

If suspecting SAH -
1st Step : get CT; IF NORMAL, ​do LP​ (only way to be confident that there is NO SAH is to have
zero WBCs on LP)