Headache. Anna Morenkova, MD, PhD Assistant Professor Department of Neurology UC Irvine

Transcription

1 Headache Anna Morenkova, MD, PhD Assistant Professor Department of Neurology UC Irvine

2 SOURCE OF HEAD PAIN (NOCICEPTIVE STRUCTURES) Intracranial Extracranial arteries of circle of Willis dura, dural arteries large veins and dural venous sinuses pain-sensitive fibers of CN V, IX, X ECA and branches scalp/neck muscles facial skin/nerves mucosa of sinuses and teeth upper C-spine segments STRUCTURES INNERVATED BY TRIGEMINAL NERVE AND UPPER CERVICAL ROOTS

3 Headache Disorders: Classification I. Primary headaches - Migraine - Tension-type headache - Trigeminal autonomic cephalalgias (TAC): cluster headache, paroxysmal hemicrania, SUNCT/SUNA - Other primary headaches II. Secondary headaches - Vascular disorders - Intracranial nonvascular disorders - Head and/or neck trauma - Infection - Disorders of homeostasis (metabolic derangements) - Substance or its withdrawal - Cranium, ENT, teeth and mouth, other facial structures - Psychiatric disorder III. Cranial neuralgias, central or primary facial pain, and other headaches

4 A 39-year old man presents to your office with the abrupt onset severe diffuse headache, nausea and blurred vision. Headache began about 6 hours ago. He tried high dose ibuprofen combined with acetaminophen twice since headache onset with no relief. He has a history of migraine with 2-3 headaches per month that would respond to ibuprofen within 2 hours of use. His blood pressure is 145/70. His examination is normal.

5 Headache High prevalence Presentation to medical attention is either due to headache severity, failure to respond to analgesics, or due to concern of underlying pathology Headache is a frequent presenting symptom in the emergency room Physical examination is often normal >90% of patients have PRIMARY HEADACHE DISORDER History is most important

6 First objective: istinguish primary from secondary headaches Second objective: Establish correct diagnosis of primary headache disorder Third objective: Initiate appropriate abortive and preventive treatment

7 Headaches: Diagnostic Algorithm History and Examination Preliminary diagnosis? Red Flags? NO Primary headache? YES Secondary headache? YES Atypical features? Diagnostic testing

8 Headache features History/Review of systems Diagnostic Criteria Red Flags

9 Headache features Location Quality Severity Time to peak Duration Constant or episodic Frequency Periodicity Onset Associated neurologic symptoms Preceding transient neurologic symptoms (aura) Aggravating and alleviating factors

10 Pertinent Questions History of prior illness Constitutional symptoms Transient neurologic symptoms preceding, associated, or following the headache Medications/supplements (new medications or changes in medication regimen) nitrates hydralazine cialis/viagra beta-agonists stimulants dopamine agonists estrogen

11 SNOOP4 secondary causes (Red Flags) Systemic symptoms/signs: fever, chills, night sweats, myalgia, weight loss (GCA, meningoencephalitis/abscess, malignancy, systemic infection) Neurologic symptoms/signs (focal or global, including changes in behavior or personality; diplopia; transient visual obscurations; pulsatile tinnitus, numbness or weakness in face/limbs, vertigo, loss of balance) Onset after age 50 Onset recent Pattern change (if previous history of headache) 1. Progressive headache with loss of headache-free periods 2. Precipitated by Valsalva: Chiari malformation, structural lesions that obstruct CSF flow, dural CSF leak. Most headaches are worsened by Valsalva. Certain primary headaches may be precipitated by Valsalva (primary cough headache). All headaches that are provoked by Valsalva require imaging to rule out secondary cause. 3. Postural aggravation (worse standing or lying): intracranial hypotension (CSF leak), Chiari, intracranial hypertension (CSF flow obstruction), worse with certain neck movements/position (cervicogenic). 4. Papilledema. Indicates intracranial hypertension. Ask about transient visual obscurations, diplopia, and visual field defects.

12 A 39-year old man presents to your office with the abrupt onset extremely severe diffuse headache, nausea and blurred vision. Headache began about 6 hours ago. When asked, he admits that this is the worst headache he has ever had. He also reports some neck pain and says it feels stiff. He has a history of migraine. What would be the next course of action? 1. Ketorolac i/m injection and antiemetic 2. Sumatriptan s/c injection 3. Arrange for an urgent lumbar puncture 4. Obtain an urgent CT of the head without contrast 5. Start IV hydration with NS * CT of the head is normal. Next step? LP does not show xanthochromia. Next step? CTA h/n is normal. Next step?

13 Thunderclap Headache Severe headache of abrupt onset (peaks within seconds) No warning, as a clap of thunder MUST BE EVALUATED in the Emergency Room

14 Causes of Thunderclap Headache SAH due to cerebral aneurysm or AVM rupture Cervico-cerebral arterial dissection Cerebral venous sinus thrombosis Acute hypertensive crisis Illicit drug use with secondary intracranial hemorrhage or infarction Cerebral reversible vasoconstriction syndrome, posterior reversible encephalopathy syndrome (PRES) Pituitary apoplexy Third ventricle colloid cyst Spontaneous intracranial hypotension (CSF leak) Ischemic or hemorrhagic stroke Primary thunderclap headache (no underlying intracranial pathology after extensive workup)

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21 Primary Headaches

22 Primary Headaches 1. Migraine 2. Tension-type headache 3. Trigeminal autonomic cephalalgia (TAC) - Cluster headache - Paroxysmal hemicrania - SUNCT/SUNA 4. Other primary headaches - New Daily Persistent Headache - Hemicrania continua - Primary cough headache - Primary exertional headache - Headache associated with sexual activity - Primary stabbing headache - Hypnic headache

23 An overweight 36-year-old woman presents with 3-4 severe, debilitating headaches per month for the last 2 years. The headaches last 1 to 2 days. They are sometimes localized bifrontally, but more often localized to the right temple, right frontal region, and behind the right eye. There is often bilateral rhinorrhea and congestion associated with her headaches, and sense of pressure over the bridge the nose and sides of the nose. The pain is usually throbbing, but may be pressure-like when not very severe. She has to wear sunglasses and go to a quiet place and lay down because she can t function. She denies any prodrome or auras. What is the most likely diagnosis? 1. Cluster headache 2. Sinus headache 3. Tension-type headache 4. Episodic migraine * 5. Idiopathic intracranial hypertension (pseudotumor cerebri)

24 Migraine 95% of patients presenting in clinical practice with headache have migraine Clinical diagnosis Young age of onset: by age of 40 y.o. 90% of patients with migraine have had their first attack Positive family history (70% have first degree relative with migraine) Prevalence: 12% in general population Women:Men 3:1

25 Migraine: Diagnostic criteria 1. At least 5 attacks fulfilling the following criteria: 2. Attacks lasting 4 to 72 hours (untreated). 3. Any 2 of the following: - Unilateral (at least 40% of migraine sufferers will experience bilateral pain). - Pulsating/throbbing (50% of migraine sufferers will experience nonpulsating pain). - Moderate or severe intensity (mild headaches may still be migraine if other criteria are present). - Aggravated by or causing avoidance of routine physical activity 4. Any 1 of the following: - Photophobia AND phonophobia. - Nausea AND/OR vomiting 5. Not attributed to another disorder

26 probable migraine ( migrainous headache )

27 Migraine headache May switch sides and may become bilateral/diffuse Prodrome (up to 3 days prior to attack): mood changes, decreased energy, yawning, thirst, food craving Pain builds up over 30 min to 2 hrs to peak Cutaneous allodynia develops in most patients during migraine attack

28 Migraine with Aura Aura: transient visual, sensory, or language disturbance or other focal brainstem or cerebral symptoms that precede or accompany the headache Aura occurs in 25% of migraine patients Does not occur with each attack Duration of aura: 5 to 30 minutes Migraine equivalent = acephalgic migraine = migraine aura without headache

29 A 65-year-old woman went on a roller coaster ride. One day later, she began having left-sided retro-orbital daily intermittent throbbing headache lasting from several minutes to several hours. There was no associated sensitivity to light or sound, and no nausea or vomiting. The headache has continued for 3 weeks on-and-off, and today she had what sounds like amaurosis fugax in the left eye ( curtain going down for about 10 seconds). She had rare migraine headaches in her 30 s-40 s. She denies any other symptoms, such as general weakness/fatigue, fevers, chills, weight loss, joint pain, rash. Diagnosis? 1. Migraine with visual aura, status migrainosus 2. Temporal arteritis 3. Internal carotid artery dissection 4. Glaucoma *

30 Aura of migraine: diagnostic criteria At least 2 attacks Aura consisting of at least one of the following, but no motor weakness*: 1. Fully reversible VISUAL symptoms (including positive and/or negative features) 2. Fully reversible SENSORY symptoms (including positive and/or negative symptoms) 3. Fully reversible DYSPHASIC speech disturbance *Migraine with MOTOR deficit is classified as hemiplegic migraine *Migraine with BRAINSTEM SYMPTOMS is classified as basilar-type migraine Duration of typical aura: 5 to 30 minutes (<60 min)

31 Visual Aura

32 Sensory Aura Sensory auras may spread in min from where they started to maximal distribution Slower than sensory seizure spread Much slower than TIA sensory symptoms spread Latent period of few minutes between aura and headache development

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34 A 65-year-old woman went on a roller coaster ride. One day later, she began having left-sided retro-orbital daily intermittent throbbing headache lasting from several minutes to several hours. There was no associated sensitivity to light or sound, and no nausea or vomiting. The headache has continued for 3 weeks on-andoff, and today she had what sounds like amaurosis fugax in the left eye ( curtain going down for 10 seconds). She had rare migraine headaches in her 30 s-40 s. She feels weak all over, and states that her shoulders have been hurting for at least 6 months. On directed questioning, she endorses to getting tired of chewing, and her jaw hurts. On examination, left temporal scalp area is exquisitely sensitive to touch. Initial brain imaging and vascular imaging has been unremarkable. Diagnosis? 1. Migraine with aura, status migrainosus 2. Temporal arteritis * 3. Internal carotid artery dissection 4. Glaucoma

35 Migraine: Management Education and counseling: reduces anxiety and improves adherence to pharmacologic treatment Migraine diary Trigger avoidance (food, odors) and dietary changes (elimination diets should be avoided) Good hydration Sleep hygiene (weekend headaches) Regular meals and avoidance of fasting Reducing caffeine, alcohol, smoking cessation Medication review and changes Regular exercise nitrates hydralazine cialis/viagra Stress reduction and coping techniques: biofeedback, relaxation training, hypnosis, stimulants cognitive and behavioral training beta-agonists dopamine agonists estrogen

36 Potential Food Triggers Some association of certain food items with migraine Nitrites (hotdogs, preserved cold cuts) Monosodium glutamate (canned food, Chinese food) Aspartam (artificial sweetener) Aged cheeses, fermented food, red wine Chicken liver, pork Chocolate Sweets, nuts, dairy, citrus fruits

37 Pharmacologic treatment Abortive Prophylactic

38 A 34-year-old overweight woman present with a severe migraine headache that began 2 days ago, but is now nearly gone. She has not identified any triggers since these headaches began 2 years ago. She has tried to avoid stress and kept a headache diary prior to a visit with you today. She averages about 5 migraines per month, each lasting up to 1-2 days. What is the best choice of treatment at this time, assuming there are no contraindications? 1. Prescribe sumatriptan and a NSAID to take immediately today to stop her resolving headache 2. Prescribe preventive agent 3. Give IV dihydroergotamine (DHE) infusion today in the office 4. Follow her over the next couple of months before prescribing anything 5. Prescribe sumatriptan to use as needed, as well as preventive agent *

39 Abortive migraine treatment: as early as possible/at onset of aura Simple analgesics Aspirin NSAIDs Acetaminophen Analgesic combination with caffeine (avoid using > 2/week) Triptans Agonists at specific 5-HT receptors 5HT1B agonists: promote vasoconstriction 5HT1D agonists: block release of neuropeptides from perivascular trigeminal afferents Dihydroergotamine (DHE): for prolonged migraine attack/status migrainosus Triptans, DHE: contraindicated in CAD, cerebrovascular disease, peripheral vascular disease, caution in hypertension

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41 The patient depicted in previous case returns 1 week later. She is now in prolonged, severe headache phase that began 4 days ago. She has missed 2 days of work. Her last triptan dose was 1 day ago. As you examine her head, you find that her right temporal and right frontal regions are exquisitely sensitive to touch. What is the best choice of treatment at this point, assuming there are no contraindications? 1. Increase her preventive medication dose and have her take another triptan 2. Change her preventive agent because it does not appear to be working 3. Give IV dihydroergotamine (DHE) infusion * 4. Change her triptan and have her take one now 5. Proceed with CT of the head without contrast to investigate the dysesthesia found on examination

42 During the office visit, a 46-year-old man with a longstanding history of recurrent headaches is diagnosed for the first time with migraine. He has a history of anxiety, hypertension, hyperlipidemia, smoking, and is noncompliant with medications. Family history is significant for his mother having migraine and his father dying from a heart attack in his mid fifties. If this patient presented to the emergency department at the very onset of a migraine, what would be the least optimal choice of treatment? 1. Sumatriptan 2. Ketorolac * 3. Valproic acid 4. Prochrolperazine 5. IV magnesium

43 Preventive/prophylactic treatment Consider prophylactic treatment if: frequency of headaches > 2 per month frequency and duration of migraines interfere with life style headache duration > 24 hours severe prolonged headaches not responsive to abortive medications, intolerance of abortive medications, contraindications to abortive medications

44 Preventive Treatment Medication selection based on patient s characteristics, comorbidities, and side effect profile of the medications Medications do not exert their effect for at least 2 weeks, most of the time - not sooner than 2 months Doses known to be therapeutic should be reached before failure is considered Ongoing frequent use of analgesics impedes onset of benefit from preventive medication Multiple agents may be necessary

45 Preventive Treatment Beta-blockers: propranolol mg/day Tricyclic antidepressants: amitriptyline (75 mg qhs), nortriptyline, desipramine, imipramine Selective serotonin reuptake inhibitors: Not consistently proven beneficial May cause headaches Anticonvulsants: topiramate, valproate CCB: verapamil mg tid or ER qd Useful in migraine with aura

46 Prophylactic medication selection Comorbid Condition Medication Hypertension Angina Beta blockers, CCB, ACE inhibitor, ARB (candesartan) Beta blockers Stress, anxiety Beta blockers Depression Tricyclic antidepressants, SSRIs Overweight Topiramate Underweight Tricyclic antidepressants Epilepsy Valproic acid, topiramate Bipolar disorder/mania Valproic acid

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48 A 22-year-old mildly overweight woman presents to the emergency department with increasing frequency of previously diagnosed migraine. Other medical history is unremarkable with exception of mild asthma and recurrent constipation. The attacks are occurring 4 days per week and are lasting the entire day. What would be the best preventive medication to start in this patient? 1. Amitriptyline 2. Propranolol 3. Sumatriptan 4. Topiramate 5. Verapamil *

49 Botulinum toxin type A Proven efficacy in chronic migraine Reduces proinflammatory and vasodilating neuropeptides from nociceptive terminals Reduces or inhibits development of peripheral and central trigeminal sensitization 5 Units in forehead, temporalis, splenius capitis, trapezius muscles into 31 injection sites Effect starts after 7-10 days and lasts 3 months

50 Butterbur extract (Petadolex) DO NOT use parts of plant use only commercially available preparation (Petadolex) Monitoring liver enzymes is recommended

51 A 38-year-old woman complains of frequent headaches for the past 2-3 years. The pain is located in bilateral fronto-temporal areas, described as pressure-like, band-like, tightness. There is no associated sensitivity to light or sound. No associated nausea or vomiting. Headache is not positional. The pain is not aggravated by routine physical activity and she is able to continue with her daily routine with these headaches. Headaches last from several hours to several days and respond fairly well to over-the-counter analgesics. She has had up to 10 headache-days per month for the past several months. She denies any other symptoms, such as vision changes, double vision, tinnitus, vertigo. Her general and neurologic examination is normal, except tenderness of pericranial muscles to palpation. Diagnosis? Treatment? 1. Migraine 2. Sinus headache 3. Pseudotumor cerebri 4. Tension-type headache 5. Psychogenic headache *

52 Tension Type Headache Prevalence: 30-78% Can begin at any age Bilateral, generalized or band-like pressure around the head Frequency: episodic or chronic (> 15 days a month for more than 3 months) With and without pericranial muscle involvement Persistent contraction of the scalp, neck, jaw muscles related to central mechanism Cranio-cervical muscle tenderness

53 Tension type headache: Diagnostic criteria NOT A MIGRAINE : Not unilateral Not throbbing or pulsating Not severe, but mild to moderate Not aggravated/provoked by routine physical activity No photo- AND phonophobia No nausea or vomiting + No other explanation

54 Tension type headache: Treatment Techniques of relaxation (biofeedback), neck massage Medications: 1. Abortive: acetaminophen+isometheptene+dichloralphenazone avoid codeine, propoxyphene, butalbital with caffeine (high potential to cause medication overuse headache) 2. Preventive: amitriptyline is the best choice other TCAs, gabapentin, mirtazapine, topiramate

55 A 46-year-old man presents with episodic headaches. His headaches are described as severe attacks of unilateral pain lasting minutes and associated with ipsilateral droopy eyelid, tearing, redness of the eye, and nasal congestion. He has 1-3 attacks daily or every other day. Some attacks occur during the night, waking him up from sleep typically at 2 a.m. He is agitated and restless during the headache and cannot stay still. The attacks occur in bouts lasting for several weeks up to 4 months, then remit for several months, then return. He has had these headaches for 2 years. Neurologic examination is normal. He was told that during the attacks, his pupil on the side of the headache is smaller compared to the other pupil. Diagnosis? 1. Migraine 2. Hemicrania continua 3. Pseudutumor cerebri 4. Cluster headache 5. Glaucoma *

56 Trigeminal Autonomic Cephalalgias (TACs) 1.Cluster headache 2.Paroxysmal hemicrania 3.SUNCT/SUNA Common features: pain location in the distribution of trigeminal nerve V1 strictly unilateral unilateral ipsilateral cranial autonomic associated symptoms periodicity need to rule out secondary causes: pituitary, hypothalamic, cavernous sinus, trigeminal nerve pathologic process Distinguishing features: attack duration (longest in cluster headache, shortest in SUNCT) and number of attacks a day (highest in SUNCT/SUNA) unique response to medications (abortive and preventive)

57 Cluster Headache Prevalence 1/2000 Men >> women (4.3:1) Onset in 3rd decade of life Most painful recurrent headache ( suicide headache") Unilateral orbital/temporal/supraorbital Throbbing, hot poker in the eye, eye being pushed out Rapid buildup of pain over 5-10 min Attack duration: 15 min-3 hrs Restless patient and prefers to pace 1-8 attacks a day; onset during night or few hours after falling asleep ( alarm headache) Daily or eod attacks in clusters lasting 6-12 weeks followed by remissions for months or years

58 Diagnostic criteria: Cluster Headache A. At least 5 attacks fulfilling B - D B. Severe unilateral orbital, supraorbital and/or temporal pain lasting min untreated C. Headache is associated with at least 1 of the following signs that have to be present on the pain side: 1.Conjunctival injection. 2.Lacrimation. 3.Nasal congestion. 4.Rhinorrhea. 5.Forehead and facial sweating. 6.Miosis. 7.Ptosis. 8.Eyelid edema. D. Frequency of attacks: from 1 every other day to 8 a day.

59 Cluster headache: Management Abortive: High flow O2 (12 L/min 100% O2 via NRM, seated) Sumatriptan: s/c superior to intranasal, s/c and intranasal are superior to oral DHE: intranasal (2 mg) is superior to oral, i/m and s/c Zolmitriptan: intranasal, oral Lidocaine spray or nasal drops (only moderate reduction of pain in less than 30% of patients) Transitional ( bridge ) Course of steroids: 60 mg oral prednisone with rapid taper by 10 mg every 2-3 days over days Ergotamine tartrate orally/rectally to prevent nocturnal attacks DHE: few doses every 6-8 hrs Occipital nerve block Maintenance prophylaxis: Calcium channel blockers (verapamil) mg a day as tid or ER Lithium carbonate 300 mg tid or 450 ER qd Valproic acid mg

60 Paroxysmal Hemicrania(PH) Onset in third decade of life Women >> Men (5:1) Severe unilateral orbital/retroorbital/temporal pain Attack duration: 2-30 minutes Attack frequency > 5 a day Ipsilateral cranial autonomic symptoms Episodic PH: attacks for 4-24 weeks followed by remission periods Chronic PH: daily with multiple discrete attacks without remissions Indomethacin in TID dose (total up to 225 mg/day), diagnosis-defining treatment! May be difficult to distinguish from cluster HA > trial of indomethacin (diagnosis-defining treatment)

61 Onset in fourth decade of life SUNCT/SUNA Men:Women is 3:2 Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing/Autonomic symptoms Orbital/retroorbital/temporal pain with ipsilateral autonomic symptoms attack duration less than 2 min attack frequency a day Daily or almost daily for weeks/months w/w/o remissions Lamotrigine has best evidence of benefit Rule out pituitary, cavernous sinus pathology, neurovascular conflict (trigeminal neuralgia) Surgical procedures for refractory cases

62 Other Primary Headaches Primary cough headache Primary stabbing headache Primary exertional headache Primary headache associated with F sexual activity Primary thunderclap headache Hypnic headache Hemicrania continua New daily persistent headache

63 Secondary Headaches

64 A 26-year-old obese woman with borderline hypertension presents with worsening headache, which she describes as a bifrontal and bioccipital band-like pressure and pain, variable in intensity - from mild to severe, fluctuating throughout the day. Occasionally, she experiences brief visual loss or graying, especially with straining, which lasts only seconds. On directed questioning, she endorses to occasional mild double vision. Occasionally, she is sensitive to light and sound. She sometimes gets nauseated and vomits when the pain is severe and she feels her vision is becoming increasingly blurred. What do you suspect may be a diagnosis? Diagnostic tests? Treatment? 1. Migraine 2. Psychogenic headache 3. Pseudotumor cerebri 4. Tension-type headache 5. Posterior fossa tumor * CTH > Lumbar puncture + fundoscopic examination > acetazlamide/topiramate > furosemide > CSF diversion procedures (VP shunt, LP shunt, VA shunt), optic nerve sheath fenestration

65 Medication Overuse Headache (MOH) Old term: rebound headache Headache related to overuse of abortive medication for patients with frequent headaches Diagnostic criteria

66 Medication Overuse Headache Opioids, butalbital-based medications, aspirin/acetaminophen/caffeine: highest risk Triptans: moderate risk NSAIDs: lowest risk Treatment

67 Secondary headaches Vascular disorders Intracranial nonvascular disorders Head and/or neck trauma Infection Disorders of homeostasis (metabolic derangements) Substance or its withdrawal Pathology of cranium, ENT, teeth and mouth, other facial structures Psychiatric disorder

68 Headache: classification I. Primary headaches - Migraine - Tension-type headache - Trigeminal autonomic cephalalgias (TAC): cluster headache, paroxysmal hemicrania, SUNCT/SUNA - other primary headaches II. Secondary headaches - Vascular disorders - Intracranial nonvascular disorder - Head and/or neck trauma - Infection - Disorders of homeostasis (metabolic derangements) - Substance or its withdrawal - Cranium, ENT, teeth and mouth, other facial structures - Psychiatric disorder III. Cranial neuralgias, central or primary facial pain, and other headaches

69 Headaches: Diagnostic Algorithm History and Examination Preliminary diagnosis? Red Flag? YES NO Primary headache? Secondary headache Atypical features Diagnostic testing

70 Most headaches are primary Red Flags (SNOOP4) Take home points History and semiology are the most important Diagnostic criteria should be met, otherwise diagnosis is probable migraine, probable cluster headache, etc. Aura: positive and negative symptoms for 5-30 minutes Preventive treatment is critical part of treatment Preventive medication choice is based on comorbidities and side effect profile of the medication Elimination diets are counterproductive Analgesic overuse leads to development of secondary headache - Medication Overuse Headache Brain +/- vascular imaging should be pursued if underlying pathology is suspected Sinus headaches are almost nonexistent Cervicogenic headache can be diagnosed only if pathology is at or above C2-C3 level

71 Thunderclap headache DO NOT IGNORE New onset headache in an adult Change in headache pattern (intensity, frequency, new features, decreased response to analgesics) Nocturnal occurrence or early morning awakening Worsening/precipitation by changes in posture or Valsalva Presence of focal neurologic signs

72 HEADACHE MYTHS Most headaches are secondary Headache is a common initial symptom of stroke Hypertension causes headache Sinus headaches are common Occipital neuralgia is common Cervicogenic headache is due to C4-C7 disc disease Atypical migraine Secondary headache in a patient with underlying primary headache disorder always presents with headache of new pattern Positive Valsalva means secondary headache Medication side effect is a rare cause of headache

73 Questions?

74 Thank you

75 Complications of Migraine 1. Status migrainosus 2. Chronic migraine 3. Persistent aura without infarction 4. Migrainous infarction 5. Migralepsy