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INTRODUCTION

CASE VIGNETTE 32.1

A 35-year-old woman with a history of migraine presents to the office complaining of worsening headaches. She recently underwent an unexpected change in her job. She seems tearful and depressed. The clinician asks about her mood and she says, “Of course I am depressed. These headaches are preventing me from doing things I enjoy and are limiting my abilities at work. If you can stop them, my mood should improve.” The health provider wonders: Is there a connection between depression and headaches? Which came first—the migraines or the depression? Does it even matter?

Headaches are one of the most common disorders of the central nervous system (CNS). The International Classification of Headache Disorders (ICHD-3)1 classifies headache disorders into two categories: (1) primary headache disorder and (2) secondary headache disorders. Secondary headache disorders only comprise about 10% of headache disorders2 and result from known CNS pathology such as brain tumors, aneurysms, trauma, etc.1 Table 32-1 illustrates many of the major causes of headache disorders. Taking a comprehensive history (Table 32-2) helps determine red flags, that is, whether there is significant concern for investigating a secondary headache. Table 32-3 demonstrates the red flags, potential differential diagnoses, and possible workups for some of these headache disorders. Of note, the Choosing Wisely Campaign specifically says, “Don’t do imaging for uncomplicated headache. Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.”3 Also, it is important to note that computerized tomography is good for looking for a bleed or a fracture, but it is not good for viewing the brain itself. Thus, in many cases of headache medicine, especially when there is not concern for a bleed, fracture, or herniation, magnetic resonance imaging is clearly preferred as it better visualizes the brain parenchyma and is without radiation (Figure 32-1).

FIGURE 32-1

Central and peripheral nervous system sites proposed to be involved in migraine pathogenesis. (Reproduced with permission from Simon RP, Aminoff MJ, Greenberg DA. Clinical Neurology, 10e. http://accessmedicine.mhmedical.com. Copyright © McGraw Hill LLC. All rights reserved.)

Despite both patient and physician concern for having a secondary headache, the vast majority of headaches are primary headaches. The most common primary headache disorders are tension type headache and migraine. Migraine is the most common headache for which patients present for medical care.4 Another primary headache is cluster headache (CH), and this is another extremely disabling headache disorder. In this chapter we focus on primary headache disorders such as migraine ...

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