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Martin L. Kutscher, MD, Departments of Pediatrics and Neurology
New York Medical College, Valhalla, NY.
I. Muscle Contraction
Episodic tension headache
Chronic tension headache
II. Raised Intracranial Pressure & Other Structural Pathology
Symptoms of Raised ICP (Not all intracranial disease has raised ICP)
Worse with supine position
Night awakening or morning prominence
Assoc. nauseau, vomiting
6th N. palsy (esotropia); head tilt
Change in personality
Subdural, abscess, etc.
Arnold Chiari Malformation
Vascular Theory: Aura is vasoconstriction; Headache is vasodilitation. Convenient theory; probably not true.
Spreading Depression Theory: Stimulation of the trigeminal ganglia => release of vasoactive substances such as VIP, substance P, etc. => combination of hyperperfusion and spreading oligemia (independent of vascular patterns) related to neuronal cytoarchitecture. However, in migraine without aura, there are no consistent blood flow changes.
Seratonin Theory: Seratonin can cause either vasodilitation or vasoconstriction of intracranial vasculature.
Clinical Symptoms of Migraines
Family history of migraines in 50-70% of patients.
1/5 patients have first attack before age 5.
Boys affected twice as often as girls.
Often history of motion sickness, recurrent abdominal pain, head banging, sudden personality changes.
Often unilateral. Concern if always on the same side.
Better with sleep.
Classic Migraines have aura: Nauseau, vomiting, abdominal pain, abnormal vision (scotoma, amaurosis fugax). May also have any neurological symptom such as sensory, motor, or speech findings.
Common Migraine: No aura
Complicated Migraine: The aura continues into the headache phase.
Ophthalmoplegic Migraine: Unilateral ptosis or complete 3rd N. palsy with forehead headache. Can persist. Rule out vascular and pressure abnormalities.
Basilar Migraine: Vertigo, tinnitus, ataxia, dysarthria, and diplopia.
Acute Confusional Migraine
Alice and Wonderland Migraine
Migraine RX: Symptomatic
sumatriptan (5-HT1 agonist)
Migraine RX: Prophylactic (for severe or weekly headaches)
stress and diet alterations
cyproheptidine (Periactin): esp. if prominent GI symptoms. Watch for weight gain.
valproic acid (Depakote)
See also headache links.
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