Headache — Last Minute Review
Rapid Review
A last-minute review of high-yield headache facts for the RITE and board exams. Tables, key associations, and must-know one-liners — designed for a quick pass the night before.
Migraine Diagnostic Criteria (ICHD-3)
Migraine Without Aura
| Criterion | Requirement |
|---|
| A | ≥5 attacks fulfilling B–D |
| B — Duration | 4–72 hours (untreated or unsuccessfully treated) |
| C — ≥2 of 4 pain features | Unilateral • Pulsating • Moderate-to-severe intensity • Aggravated by routine physical activity |
| D — ≥1 associated feature | Nausea and/or vomiting • Photophobia AND phonophobia |
| E | Not better accounted for by another ICHD-3 diagnosis |
Migraine With Aura
| Criterion | Requirement |
|---|
| A | ≥2 attacks fulfilling B–C |
| B — ≥1 fully reversible aura | Visual • Sensory • Speech/language • Motor • Brainstem • Retinal |
| C — ≥3 of 6 features | ≥1 aura symptom spreads gradually over ≥5 min • ≥2 symptoms occur in succession • Each non-motor symptom lasts 5–60 min (motor aura in hemiplegic migraine may last up to 72 h) • ≥1 symptom is unilateral • ≥1 symptom is positive (scintillations, pins/needles) • Aura accompanied or followed within 60 min by headache |
Chronic Migraine
| Feature | Criterion |
|---|
| Frequency | Headache ≥15 days/month for >3 months |
| Migraine features | ≥8 days/month with migraine features or treated/relieved by triptan or ergot |
| Key distinction | Must rule out medication overuse headache as contributing factor |
- 5-4-3-2-1 rule for migraine without aura: 5 attacks, 4–72 h, ≥3 months for chronic, 2 pain features, 1 associated feature
- Migraine with aura only needs 2 attacks (not 5)
- Typical aura is visual → sensory → speech; motor aura = hemiplegic migraine (separate category)
- Aura WITHOUT headache is common in older patients — must rule out TIA
Headache Pattern Recognition by Duration (Board Quick Reference)
| Diagnosis | Typical Attack Duration | Key Distinguisher |
|---|
| Trigeminal neuralgia | Seconds (paroxysmal lightning jabs) | V2/V3 distribution; cutaneous triggers; NO autonomic features |
| SUNCT / SUNA | Seconds (1–600 sec; typically <1 min) | V1 distribution; prominent ipsilateral autonomic features (conjunctival injection / tearing); cutaneous triggers; NOT indomethacin-responsive |
| Primary stabbing headache ("ice-pick") | Seconds (often <3 sec) | Random extratrigeminal locations; jab-and-jolt; partial indomethacin response |
| Paroxysmal hemicrania | 2–30 minutes | Strict unilateral; autonomic features; absolute response to indomethacin |
| Cluster headache | 15–180 minutes | Severe unilateral V1; agitation/pacing; autonomic features; circadian/seasonal pattern |
| Hypnic headache | 15 min – 4 hours | "Alarm clock" headache — nocturnal only; >50 yo; NO autonomic features; bedtime caffeine first-line |
| Migraine | 4–72 hours (treated or untreated) | Photophobia, phonophobia, nausea; aggravated by activity; pulsating |
| Tension-type headache | 30 min – 7 days | Bilateral, pressing, mild-moderate; NOT worsened by routine activity |
| Hemicrania continua | Continuous (with exacerbations) | Strict unilateral, daily; absolute response to indomethacin; autonomic features during exacerbations |
| NDPH (new daily persistent headache) | Continuous from a known exact start date | Patient knows the exact date of onset; treatment difficult |
Indomethacin-Responsive Headaches
| Response Category | Headache |
|---|
| Absolute response (diagnostic criterion) | Paroxysmal hemicrania (episodic and chronic); Hemicrania continua |
| Often responsive | Primary cough headache; primary exercise headache; primary stabbing headache; primary headache associated with sexual activity (pre-orgasmic and orgasmic) |
| NOT responsive | Cluster headache; migraine; SUNCT/SUNA; trigeminal neuralgia; tension-type headache |
Indomethacin response is a diagnostic criterion for paroxysmal hemicrania and hemicrania continua — a properly conducted indomethacin trial (e.g., escalating to 150–225 mg/day for at least 3 days, with GI/renal monitoring) that fails to resolve the headache excludes these diagnoses. Always prescribe with a PPI given chronic NSAID use.
Headache Imaging Findings (Board Quick Reference)
| Disease | Classic Imaging Finding(s) |
|---|
| IIH (idiopathic intracranial hypertension) | Empty sella, optic nerve sheath distension/tortuosity, posterior globe flattening, transverse sinus stenosis on MRV |
| SIH (spontaneous intracranial hypotension) | Diffuse pachymeningeal enhancement (NOT leptomeningeal), brain sagging / tonsillar descent, pituitary engorgement, subdural collections; CT/MR myelography to localize leak |
| RCVS (reversible cerebral vasoconstriction syndrome) | "String of beads" / sausage-on-a-string multifocal segmental cerebral artery narrowing on CTA/MRA/DSA; reversible by ~12 weeks |
| CVT (cerebral venous thrombosis) | MRV/CTV filling defect; "empty delta sign" on post-contrast CT; cord sign; venous infarction (often hemorrhagic, atypical territory) |
| GCA (giant cell arteritis) | "Halo sign" on temporal artery ultrasound (hypoechoic wall thickening); MRA may show vessel wall enhancement; PET-CT for large-vessel GCA |
| Pituitary apoplexy | Hemorrhagic sellar/suprasellar mass; pituitary enlargement with mixed-signal hemorrhage; mass effect on optic chiasm/cavernous sinus |
| Aneurysmal SAH | Basal cistern hyperdense blood on non-contrast CT; CTA shows aneurysm; LP xanthochromia if CT negative >6–12 h |
| Chiari I (relevant to cough headache) | Cerebellar tonsils ≥5 mm below foramen magnum; ± syrinx |
Trigeminal Autonomic Cephalalgias (TACs) Comparison
Master TAC Comparison Table
| Feature |
Cluster Headache |
Paroxysmal Hemicrania |
Hemicrania Continua |
SUNCT/SUNA |
| Duration | 15–180 min | 2–30 min | Continuous (with exacerbations) | 1–600 sec |
| Frequency | 1 q.o.d. to 8/day | >5/day (for more than half the time) — ICHD-3 criterion C | Continuous background | 3–200/day |
| Gender predominance | Male (3–4:1) | Female (2–3:1) | Female (2:1) | Male (1.5:1) |
| Pain location | Orbital/supraorbital/temporal | Orbital/temporal | Orbital/temporal | Orbital/periorbital/temporal |
| Pain quality | Stabbing/boring, excruciating | Throbbing/stabbing, severe | Dull ache with sharp exacerbations | Stabbing/burning, severe |
| Autonomic features | Prominent (lacrimation, rhinorrhea, ptosis, miosis) | Prominent (same as cluster) | Mild (may be subtle) | Prominent (conjunctival injection + lacrimation = defining) |
| Restlessness/agitation | Yes (pacing, rocking) | Yes (can occur) | No | Yes (can occur) |
| Circadian/circannual pattern | Yes (hallmark) | No | No | No |
| Indomethacin response | No | Absolute (diagnostic criterion) | Absolute (diagnostic criterion) | No |
| First-line acute Tx | High-flow O2 (12–15 L/min) + sumatriptan 6 mg SC | Indomethacin | Indomethacin | No effective abortive (attacks too brief); IV lidocaine as bridge for severe exacerbations |
| First-line preventive Tx | Verapamil (requires ECG) | Indomethacin | Indomethacin | Lamotrigine |
| Alternate preventive Tx | Lithium, galcanezumab, suboccipital steroid injection | Verapamil, topiramate | Topiramate, gabapentin, CGRP mAbs | Topiramate, gabapentin, carbamazepine |
| Key board association | Posterior hypothalamus activation; Horner can persist | "Indomethacin-responsive TAC" (female) | "Continuous side-locked headache + indomethacin" | Must exclude pituitary adenoma |
- Indomethacin-responsive TACs = paroxysmal hemicrania + hemicrania continua (NOT cluster, NOT SUNCT/SUNA)
- SUNCT = Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing; SUNA = only one or neither autonomic sign
- Cluster headache is the only primary headache where O2 is a first-line acute treatment
- Verapamil for cluster → ECG at baseline and ~10 days after each dose escalation (risk of heart block / PR prolongation)
Tension-Type Headache
Diagnostic Criteria (Episodic TTH)
| Criterion | Requirement |
|---|
| A | ≥10 episodes occurring <15 days/month (<180 days/year) for >3 months |
| B | Duration: 30 min to 7 days |
| C — ≥2 of 4 | Bilateral • Pressing/tightening (non-pulsating) • Mild-to-moderate • NOT aggravated by routine physical activity |
| D — Both of | No nausea or vomiting • No more than one of photophobia or phonophobia |
Episodic vs Chronic TTH
| Feature | Episodic | Chronic |
|---|
| Frequency | <15 days/month | ≥15 days/month for >3 months |
| Acute Tx | Simple analgesics (NSAIDs, acetaminophen) | Same, but watch for MOH |
| Preventive Tx | Usually not needed | Amitriptyline (first-line preventive) |
- TTH is the most common primary headache but rarely presents to neurology
- TTH is essentially the opposite of migraine on criteria: bilateral, non-pulsating, mild-moderate, not worsened by activity, no nausea/vomiting
- If both photo AND phonophobia are present → think migraine, not TTH
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