Migraine Headache
Unilateral, pulsating, 4–72 hours, photophobia, phonophobia, nausea; abortive: Triptans (5-HT1B/1D agonists); preventive: Topiramate, Propranolol, CGRP antagonists.
Cluster Headache
Severe unilateral periorbital pain occurring in cyclical bouts; ipsilateral autonomic symptoms (lacrimation, rhinorrhea, Horner syndrome); acute Rx: 100% O2.
Pseudotumor Cerebri
Idiopathic intracranial HTN in young obese females; papilledema, headache, pulsatile tinnitus, transient visual obscurations; LP opening pressure > 250 mm H2O.
Bell's Palsy (CN VII)
LMN facial nerve lesion: paralysis of ENTIRE ipsilateral hemiface (cannot wrinkle forehead); UMN stroke lesion SPARS forehead due to bilateral cortical innervation.
Primary Headache Syndromes Differential
| Headache Type | Pain Location & Characteristics | Associated Manifestations | Acute Abortive & Prophylactic Therapy |
|---|---|---|---|
| Migraine Headache | Unilateral (60%), throbbing/pulsatile; aggravated by routine physical activity; lasts 4–72 hours | Nausea, vomiting, photophobia, phonophobia; visual or sensory aura (scintillating scotoma) in 25% | Abortive: Sumatriptan (contraindicated in CAD/Prinzmetal angina), NSAIDs; Prophylaxis: Propranolol, Topiramate, Amitriptyline, Erenumab (CGRP inhibitor) |
| Cluster Headache | Strictly unilateral, excruciating, piercing, stabbing periorbital / retro-orbital pain; lasts 15–180 min; occurs at same time daily (wakes from sleep) | Ipsilateral autonomic signs: Conjunctival injection, lacrimation, rhinorrhea, nasal congestion, partial Horner syndrome (ptosis/miosis) | Acute: 100% high-flow oxygen (12 L/min via non-rebreather) + Subcutaneous Sumatriptan; Prophylaxis: Verapamil (first-line) |
| Tension Headache | Bilateral, non-pulsatile, dull, aching, 'band-like' constricting pain around head; NOT aggravated by exertion | Pericranial muscle tenderness; NO nausea, vomiting, or focal neurologic signs | Acute: Acetaminophen, NSAIDs; Prophylaxis: Amitriptyline, stress reduction, physical therapy/OMT |
Cranial Neuropathies: CN V vs. CN VII
| Neuropathy | Anatomical Mechanism | Clinical Presentation | First-Line Management |
|---|---|---|---|
| Trigeminal Neuralgia (Tic Douloureux) | Vascular compression of the CN V root entry zone (superior cerebellar artery) | Repetitive, lightning-like, stabbing electric shocks in V2/V3 dermatomes triggered by chewing, brushing teeth, light breeze | Carbamazepine (voltage-gated sodium channel blocker; monitor for agranulocytosis/hyponatremia); microvascular decompression |
| Bell's Palsy | Idiopathic inflammation/edema of CN VII in facial canal (frequently post-HSV reactivation) | Unilateral upper AND lower facial paralysis (inability to close eye, flatten nasolabial fold, cannot furrow forehead), loss of taste anterior 2/3 tongue, hyperacusis | Oral Prednisone within 72 hours of onset + artificial tears / eye taping at night to prevent corneal abrasion |
| Central (UMN) Facial Palsy | Cerebral cortex or internal capsule infarction (contralateral MCA stroke) | Paralysis of contralateral lower face ONLY; forehead wrinkling is preserved (bilateral cortical projection to upper facial nucleus) | Acute stroke code activation; non-contrast head CT -> IV thrombolysis / endovascular thrombectomy |
OMM Board Correlate: Sphenopalatine Ganglion & Suboccipital Tension
- Sphenopalatine (Pterygopalatine) Ganglion: Situated in the pterygopalatine fossa deep to the maxilla. Intraoral sphenopalatine ganglion stimulation relieves acute trigeminal pain, cluster headache autonomic congestion, and vasomotor rhinitis.
- Cervicogenic Headache Mechanics: Myofascial trigger points in the suboccipital triangle (rectus capitis posterior, obliquus capitis) impinge upon the greater occipital nerve (C2), producing ram's horn radiating pain over the scalp.
Board Traps & Common Distractors
- Any patient > 50 years old presenting with new-onset temporal headache, scalp tenderness, and jaw claudication must be evaluated for Giant Cell (Temporal) Arteritis; obtain immediate ESR/CRP and begin high-dose oral Prednisone immediately to avert irreversible ischemic optic neuropathy (blindness).
- Triptans and Ergotamines are potent vasoconstrictors and are strictly CONTRAINDICATED in patients with coronary artery disease, peripheral vascular disease, uncontrolled hypertension, or hemiplegic migraine.
- Papilledema with elevated opening pressure on lumbar puncture in the absence of a space-occupying lesion confirms Idiopathic Intracranial Hypertension (Pseudotumor Cerebri); managed with weight reduction and Acetazolamide (carbonic anhydrase inhibitor) to prevent permanent optic nerve atrophy.