364.1 🎓 醫孞生版

364.1.0.1 📌 䞀頁重點

364.1.0.1.1 Classification (ICHD-3)

364.1.1 Primary Headaches

  • Migraine (with/without aura)
  • Tension-type (TTH)
  • Cluster + TAC (trigeminal autonomic cephalalgias)
  • Other primary (cough, exertion, sex, hypnic, primary stabbing)

364.1.2 Secondary Headaches

  • Vascular (SAH, ischemic, dissection, GCA, RCVS)
  • Infectious (meningitis, encephalitis, sinusitis)
  • Neoplastic
  • Idiopathic intracranial hypertension (IIH)
  • Low-pressure (post-LP, spontaneous intracranial hypotension)
  • Medication overuse headache (MOH)
  • Cervicogenic
  • Trauma (post-concussive)
  • Sinus, dental, TMJ
364.1.2.0.1 Red Flags (SNOOP10)
  • Systemic (fever, weight loss, immunocompromised, cancer)
  • Neurologic deficit, altered LOC, papilledema
  • Onset sudden (thunderclap < 1 minute → SAH)
  • Older > 50 (GCA)
  • Pattern change, progressive
  • Positional (low-pressure or high-pressure)
  • Precipitated by Valsalva (mass)
  • Papilledema (IIH, mass)
  • Pregnancy/Postpartum (eclampsia, CVST, PRES)
  • Posttraumatic
  • Painful eye with autonomic (cluster, GCA, angle-closure)
  • Painkillers overuse (MOH)
364.1.2.0.2 Migraine

364.1.3 Diagnostic Criteria (ICHD-3)

Migraine without aura: - ≥ 5 attacks - 4-72 hours - ≥ 2 of: unilateral, pulsating, moderate-severe, aggravated by activity - ≥ 1 of: nausea/vomiting, photophobia + phonophobia - Not better explained

Migraine with aura: - ≥ 2 attacks - ≥ 1 aura symptom (visual, sensory, speech, motor, brainstem, retinal) - ≥ 3 of: spreading over ≥ 5 min, ≥ 2 successive symptoms, each 5-60 min, unilateral, positive, headache follows within 60 min

364.1.4 Aura Types

  • Visual (most common): scintillating scotoma, fortification, hemianopia
  • Sensory: tingling, numbness
  • Speech: dysphasia
  • Motor (hemiplegic migraine): rare
  • Brainstem: vertigo, diplopia, dysarthria, ataxia
  • Retinal: monocular

364.1.5 Phases

  1. Prodrome (hours-day before): fatigue, mood, food cravings
  2. Aura (5-60 min before)
  3. Headache (4-72 hr)
  4. Postdrome (hours-day after)

364.1.6 Triggers

  • Stress, sleep changes, hormonal (menstrual)
  • Foods (tyramine, MSG, alcohol, caffeine withdrawal, chocolate)
  • Weather, sensory (bright light, odor, sound)
  • Fasting, dehydration

364.1.7 Acute Treatment

Mild-moderate: - NSAIDs (naproxen, ibuprofen, ASA, ketorolac) - Acetaminophen - Combination (ASA + acetaminophen + caffeine)

Moderate-severe: - Triptans (5HT-1B/1D agonists): sumatriptan, zolmitriptan, rizatriptan, eletriptan, almotriptan, naratriptan, frovatriptan - Different formulations (oral, SC, nasal) - Contraindicated in CAD, uncontrolled HTN, stroke, hemiplegic/basilar migraine - Gepants (CGRP receptor antagonists): - Ubrogepant (Ubrelvy) - Rimegepant (Nurtec ODT) — also for prevention - Zavegepant (Zavzpret) — intranasal, FDA 2023 - Lasmiditan (Reyvow) — ditan (5HT-1F agonist); no vasoconstriction, can use in CV disease

Rescue/severe (ED): - IV metoclopramide - IV prochlorperazine - IV ketorolac - IV DHE (dihydroergotamine) - IV magnesium - IV valproate

364.1.8 Preventive Treatment

Indications: - ≥ 4 headache days/month, OR - Severe attacks, OR - Failure of acute treatment, OR - Medication overuse risk

Traditional: - Topiramate (50-200 mg/d) - Propranolol, metoprolol (β-blockers) - Amitriptyline, nortriptyline - Venlafaxine - Valproate - Candesartan, lisinopril (less established) - OnabotulinumtoxinA (chronic migraine, ≥ 15 days/mo)

CGRP-Targeted Preventives (2018-2024): - Anti-CGRP monoclonal antibodies: - Erenumab (Aimovig) — anti-CGRP receptor; SC monthly - Fremanezumab (Ajovy) — anti-CGRP; SC monthly or quarterly - Galcanezumab (Emgality) — anti-CGRP; SC monthly (also cluster) - Eptinezumab (Vyepti) — anti-CGRP; IV quarterly - Oral gepants for prevention: - Atogepant (Qulipta) — daily oral - Rimegepant (Nurtec) — every other day oral

364.1.9 Chronic Migraine

  • ≥ 15 headache days/month for > 3 months, of which ≥ 8 have migraine features
  • Often associated with medication overuse
  • OnabotulinumtoxinA (PREEMPT trials)
  • Anti-CGRP mAbs
  • Topiramate
  • Withdrawal of overused medication

364.1.10 Special Populations

364.1.10.1 Pregnancy

  • Avoid: triptans (some safe), valproate, ergot
  • Safe: acetaminophen, metoclopramide
  • Preventive: avoid most; magnesium, riboflavin

364.1.10.2 Menstrual Migraine

  • Frovatriptan or naratriptan around menses
  • Magnesium
364.1.10.2.1 Tension-Type Headache (TTH)

364.1.11 Features

  • Bilateral
  • Pressing/tightening (not pulsating)
  • Mild-moderate intensity
  • Not aggravated by activity
  • No nausea (or mild only)
  • No photophobia + phonophobia (or only one)
  • 30 min - 7 days

364.1.12 Classification

  • Episodic infrequent (< 1 day/month)
  • Episodic frequent (1-14 days/month)
  • Chronic (≥ 15 days/month)

364.1.13 Treatment

  • Acute: NSAIDs, acetaminophen
  • Preventive (chronic): amitriptyline
364.1.13.0.1 Cluster Headache + TAC

364.1.14 Cluster Headache

364.1.14.1 Features

  • Severe unilateral pain, periorbital/temporal
  • Brief (15-180 min)
  • Cluster periods (weeks-months), then remission
  • Circadian + circannual pattern (often nocturnal, seasonal)
  • Restless/agitated (vs migraine — wants to lie still)
  • Cranial autonomic features: ipsilateral lacrimation, conjunctival injection, ptosis, miosis, rhinorrhea, nasal congestion, sweating, eyelid edema
  • Trigger: alcohol during cluster period

364.1.14.2 Treatment

Acute: - High-flow O2 (12-15 L/min via NRM for 15-20 min) - SC sumatriptan (6 mg) — fast onset - Nasal sumatriptan or zolmitriptan - Lidocaine intranasal

Preventive (Bridge): - Prednisone - Greater occipital nerve block

Preventive (Maintenance): - Verapamil (high doses 240-720 mg/d) — first-line - Galcanezumab (FDA approved cluster 2019) - Lithium - Topiramate - Civamide

364.1.14.3 Refractory Cluster

  • Sphenopalatine ganglion stimulation
  • Occipital nerve stimulation
  • Deep brain stimulation (posterior hypothalamus)

364.1.15 Other TACs

364.1.15.1 Paroxysmal Hemicrania

  • Shorter attacks (2-30 min)
  • More frequent (> 5/day)
  • Absolute response to indomethacin (diagnostic)

364.1.15.2 SUNCT/SUNA

  • Short-lasting unilateral neuralgiform headache with conjunctival injection + tearing (SUNCT) or autonomic (SUNA)
  • Very brief (5-240 sec)
  • Many per day
  • Lamotrigine, topiramate

364.1.15.3 Hemicrania Continua

  • Continuous unilateral
  • Absolute response to indomethacin
364.1.15.3.1 Other Important Headaches

364.1.16 Idiopathic Intracranial HTN (IIH)

  • “Pseudotumor cerebri”
  • Young, obese women
  • Daily headache, papilledema, vision loss, pulsatile tinnitus
  • LP: ↑ opening pressure (> 25 cm H2O) with normal CSF composition
  • Imaging: empty sella, slit-like ventricles, optic nerve sheath enlargement
  • Treatment: weight loss, acetazolamide, topiramate, LP, optic nerve sheath fenestration, VP shunt

364.1.17 Low Pressure Headache

  • After LP, dural tear, or spontaneous CSF leak
  • Postural (worse upright, better recumbent)
  • Treatment: bed rest, hydration, caffeine, epidural blood patch

364.1.18 Medication Overuse Headache (MOH)

  • Daily/near-daily headache + overuse of acute medications
  • Triptans ≥ 10 days/mo, simple analgesics ≥ 15 days/mo, opioids/combinations ≥ 10 days/mo
  • Treatment: withdraw offending agent + bridge therapy + initiate preventive

364.1.19 Giant Cell Arteritis (GCA)

  • Age > 50
  • New headache, scalp tenderness, jaw claudication, polymyalgia rheumatica
  • ↑ ESR (> 50), CRP
  • Temporal artery biopsy gold standard
  • Urgent high-dose steroids (vision loss risk!)
  • Tocilizumab for refractory/relapsing

364.1.20 Trigeminal Neuralgia

  • Brief electric-shock pain in V2/V3
  • Triggers (touch, eating, talking)
  • Carbamazepine first-line
  • Oxcarbazepine, gabapentin, lamotrigine
  • Microvascular decompression (Janetta)

364.1.20.1 🩺 床邊速查

  • SNOOP10 red flags for secondary
  • Migraine acute: NSAIDs/triptans/gepants/lasmiditan
  • Migraine preventive: topiramate/β-blockers/TCAs/CGRP mAbs (erenumab/fremanezumab/galcanezumab/eptinezumab)/atogepant/rimegepant
  • Cluster: high-flow O2 + SC sumatriptan; verapamil + galcanezumab prevention
  • Hemicrania response to indomethacin = paroxysmal hemicrania or hemicrania continua
  • GCA: ↑ ESR/CRP + temporal artery biopsy + urgent steroids
  • IIH: young obese woman + papilledema + ↑ LP pressure + acetazolamide