Current Understanding and Treatment of Headache Disorders

Abstract

As general practitioners become increasingly adept at prescribing triptans and preventive treatment, neurologists are more likely to see patients who are refractory to standard therapies. The most pressing concern for physicians and patients is excluding secondary headache. Reversible cerebral vasoconstriction syndrome is increasingly recognized as an underdiagnosed cause of headache, and may present as a sudden-onset thunderclap headache. The past few years have brought exciting new advances in the understanding of migraine pathophysiology including new genes for migraine and discovery of a new pathway for light sensitivity. After almost 20 years since the introduction of triptans, calcitonin gene-related peptide antagonists now appear to be effective as acute migraine treatment for patients with poor response or contraindications to triptans. Finally, onabotulinumtoxin A has become only the 6th medication approved by the US Food and Drug Administration for migraine prevention and the first approved for chronic migraine. This article aims to highlight these exciting new topics in the treatment and understanding of headache disorders, which will help neurologists better treat and explain the disorders to their patients. Thunderclap headache is a neurologic emergency originally defined as a severe, sudden-onset headache; ruptured intracranial aneurysm had to be suspected and ruled out.1 In addition to subarachnoid hemorrhage, many other disorders, such as spontaneous CSF leak, cerebral venous thrombosis, pituitary apoplexy, sphenoid sinusitis, carotid or vertebral dissection, stroke, hypertensive emergency, third ventricle colloid cyst, and even an unruptured aneurysm, can present with thunderclap headache.2 Many patients with thunderclap headache have segmental cerebral vasoconstriction likely related to a disturbance in the control of vascular tone.3 Originally called Call-Fleming syndrome, it is now known as reversible cerebral vasoconstriction syndrome (RCVS).4 In almost all cases, cerebral vasoconstriction resolves within a few weeks. Angiography (conventional, MRI, or CT angiography) is crucial to make the diagnosis. …