Recurrent and Chronic Headaches

00:00 - Intro
00:32 - Objectives
00:58 - Case
05:36 - Basic features of headache clinical history
06:36 - Fundoscopy
08:16 - Anatomy of pain: The headache network.
12:31 - Differential diagnosis of primary headache
14:15 - S.N.O.O.P. mnemonic
16:13 - IHS diagnostic criteria for migraine
17:45 - Migraine aura
18:25 - Cluster
21:19 - Treatments for primary headaches
30:14 - Differential diagnosis of secondary headache
30:43 - Idiopathic intracranial hypertension
32:37 - Tumor headache
37:53 - Cerebral venous thrombosis
39:01 - Cervical arterial dissection
40:41 - Giant cell (temporal) arteritis
43:07 - Trigeminal neuralgia
44:58- Case wrap-up
46:56 - Summary: Treatment algorithm
This video is intended for medical students to understand the clinical presentation, differential diagnosis and treatment of primary headaches and the wider differential diagnosis of secondary headaches.
Created by:
Igor Rybinnik, MD
Neurology Clerkship Director
Rutgers Robert Wood Johnson Medical School
Produced and narrated by:
Igor Rybinnik MD
Special appreciation to my wife, Jane Shmidt PhD, who is a migraine sufferer, for narrating the patient history.
Content review:
Pengfei Zhang, MD
Headache Neurologist
Assistant Professor
Rutgers Robert Wood Johnson Medical School
Images, video clip and audio adapted from:
- Vislisel J, Venckus T . EyeRounds.org, University of IOWA, 2014.
- Li J, et al. Experimental and Therapeutic Medicine, 12, 1119-1124
- Netter FH. The Netter Collection of Medical Illustrations. 2nd ed. 2013, Saunders.
- Goadsby PJ, Besbitt AD. BMJ 2012;344:e2407
- Pathophysiology of migraine, Springer Healthcare IME, 2020.
- Parameswaran A, et al. J Oral Maxillofac Surg 2018-76,1873-81
- "Let the Real Estate Games Begin." Selling Sunset, season 2, episode 1. Created by Adam DiVello. Netflix, 2019.
- “Parzival” by William Rosati
- Mazzucco S, et al. Neurology 2006; 66:E19.
- Schievink WI. NEJM 2001;344(12):898
- Kandel ER, et al. Principles of Neural Science 5th Edition. McGraw Hill, 2012.
- Nucleus Medical Media, Inc.
- Haouimi A, Radiopaedia.org, rID: 72159.
- T Hines, Mayfield Clinic
Disclaimer: Please note that this material was simplified for educational purposes. For patient management, please review your clinical society's guidelines and engage expert consultation where appropriate. Also, the opinions of the presenters do not necessarily reflect those of Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, or Rutgers University as a whole.

[@arminpalic7653]

Best medical lecture series on a field of medicine on YT by far.

[@theneurophile]

Wow! Thank you for that.

[@vxp999]

the life style changes part got me dead🤣🤣| your the coolest neurologist ever and my roll model no doubt!

[@theneurophile]

Oh wow. Thanks!

[@annazinishina5836]

Невероятные лекции с невероятным чувством юмора! Спасибо!

[@eduardohita6523]

Dude, this is pure gold! Thank you so much for these lectures!

[@thesnoringsleepapneacenter2200]

What a headache review! I'm studying for my Orofacial Pain boards and loved that you had a sample case and paused a bit so I could come up with my own answer before you told me.

[@hanakoaranilla1517]

I want to thank you sir and this channel for helping me get a 95 on my Neurology rotation. Whenever my classmates ask me where I learned what I knew during rotation, I always say “It’s Dr. Rybbinik, you should watch him on YT”. Your fresh take on teaching greatly helped. I’m graduating this July from Med school and hoping to take on Neurology/Psychiatry ỉn residency. Thank you so much!

[@theneurophile]

Wow. Good job on that grade!

[@user-qd2qv5wk1v]

Thank you so much for your work Dr. Rybinnik. Looking forward to your next video!

[@theneurophile]

It will be uploaded shortly. Almost done.

[@gagang5406]

What an amazing lecture!! This one's GOLD. Thank you so much Dr. Rybinnik.

[@pedroinarionovaisaraujo1859]

The best lecture ever! PURE GOLD. Thanks from Brazil.

[@raminvakili1038]

I am really appreciative for videos. As a neurologist I learned a lot and I recommended it to my friends. Thanks

[@Alfontanas]

Please keep going with the lectures, you're awesome!

[@asimzafar5015]

one of the few productive things on you tube.thanks sir

[@kyaw03]

So I don't usually leave comments on KZbin often, but wow....i had to for this one! Very very very helpful!!! Very clear and concise! All of your videos are so helpful! PLEASE make more videos! PLEASE!

[@damiensegers3555]

Final year med student applying neurology. Amazing youtube channel

[@johnbolger5955]

Incredible, thank you so much. I am a MS1 and this was so helpful

[@gentleman7951]

Thank you dr rybinnik Greatest lectures 🌷❤

[@ahmedthamir9531]

Sir , it is a great gift for me to have stumbled upon your channel . best greetings for you sir !♥️♥️♥️

[@rashadomar7330]

just excellent lecture as always, I am addicted to your videos,,,,, Thanks

[@ahmed086]

I just love your videos

[@cheemDr]

Good job!

[@goodvibesnerd3228]

This is awesome

[@SharafEl-Dein]

Amazing ❤

[@tomriddel2302]

Thanks guys!

[@fatgezimbela7272]

Thank you!

[@bekirsamiozturk8365]

Spontaneous intracranial hypotension:)) thank you so much for great videos👍

[@theneurophile]

Correct!

[@ilqar887]

The treatment?

[@bekirsamiozturk8365]

@@ilqar887 epidural blood patch

[@sarahbamford2633]

Yes! I was right too :)

[@edgarivanpalominomendoza2713]

What a lecture, thank you for sharing this amazing content.

[@theneurophile]

We are currently working on the prequel: Thunderclap headache. Stay tuned.

[@designmaster5074]

you are the best!

[@tomriddel2302]

Very informativ :)

[@sneakpeek9790]

Million and Billion of Thanks♥♥❤ and appreciations♥♥♥for covering this wonderful neurological topic,I really enjoyed the whole lectures learning about different kinds of headaches. 👍👍👍🥳🥳🥳

[@simple25124]

Complex topics explained simply. So far the best tutorials on various neurological topics. This is how good medicine and teaching are made. Do you plan to post something about neurological infectious diseases as well? An of course: BIG THANKS :)

[@theneurophile]

Thank you. I would love to put out many more of these videos, but my dayjob as a Stroke neurologist keeps me busy. I will try to post as soon as I can.

[@pixie89]

Thank you

[@termostat363]

Best!

[@frogprincessss]

Hi Dr Rybinnik, my suggested topic includes: Aphasias, Optic nerve anatomy and clinical correlates, and basics of localization. I am bingewatching your videos... really love your lectures. I admire your passion for medical education. Very inspiring!

[@theneurophile]

Thank you. A massive localization talk is in the works.

[@Lesgrandslivres]

@@theneurophile when will it be available, I have exams next month 🥺

[@theneurophile]

@@Lesgrandslivres I wish I could work that fast. Unfortunately for now I am a team of one, and I have clinical responsibilities :(

[@Lesgrandslivres]

@@theneurophile understandable... Thank you for your work though, really the best neuro lectures :)

[@caiyu538]

Great

[@SirBenniMilesOne]

Hi Dr Rybinnik, really impressed with your helpful and well presented videos! Would it be possible for you to make the algorithms available? Many thanks for your great work!

[@theneurophile]

Yes, I will start making them available with subsequent videos.

[@beu2426]

Thank you so much for this lecture! Is it possible to talk about cervical vertebral trauma? And thank you so much!!!

[@stevevet3652]

I'll second the need for cervical vertebra trauma that includes arachnoid cyst at the top of the spine.

[@baveshsiva7393]

Please make videos on these topics doc :) 📌 Surgical Management of Strokes (Bleeds, Infarcts, Aneurysms, AVMs) 📌 Management of Increased Intracranial Pressure 📌 Neurorehabilitation 📌 Management of Seizures & epilepsy 📌 Hyperkinetic Movement Disorders 📌 Management of Parkinson’s Disease & other Extrapyramidal syndromes And this video was amazing 😇🫂

[@theneurophile]

Excellent suggestions. Management of increased intracranial pressure is part of the "Coma" talk on this channel. I am slowly making the videos on all these other topics.

[@baveshsiva7393]

Thank you doc :)

[@hairballjones8451]

Hi Dr R- I live in the heart of another Big10 country- but if I lived in New Jersey I would be honored to have you for my instructor at Rutgers. Right now my neurologist seems to be flipping a coin between Migraine, IIH and Nornal Pressure Hydrocephalus- a few more tests Including an MRI, already had a Lumbar Puncture, CT, EEGs, tra tra la- maybe when I cross paths in July I will hear they have also consulted with a Witch Doctor. Anything fine with me; at 76- this perpetual headache gets me very worn out. Have A Happy and Successful Day, Doctor

[@theneurophile]

I am sorry to hear about your troubles. I hope you feel better soon.

[@sarahbamford2633]

Loved this! So informative but also engaging. A hard balancing act for my ADHD brain.

[@ramazantemel6405]

I am really astonished by how beautifully designed this PowerPoint presentation and your skills of making easy to understand. I wonder which website or application that you are using for your slight

[@theneurophile]

Thank you. I am just using Powerpoint

[@mercypower8002]

amazing 👏....thank you .....can you please make a video about neurolocalization ( resident level ) thanks

[@theneurophile]

Yep. It’s in the works.

[@kapiladahanayake2096]

Thank you very much. Keep it up

[@enkidu001]

what about one year of headaches , getting worse now in the last 2 months. Severe fatigue, sometimes i really want to sleep 1 hour after i woke up. I try without success to fall asleep, sadly. Low energy. Location: if i feel this correct its exactly in the centre of my head. Geometrical centre. Level of pain?... around 3...or 4 out of ten. History?... i went vegetarian in my 20s for ethical reasons. Had big health issues because i was naive, had no idea i have to add a few things, not just throw away so many :) and after 10 years started eating fish again. Rare, but i did. Now i am 46 and try fasting, low carb diet, experiment, but no success. My doc sent me to a set of analysis because i had very high B12 levels. When i told him the level is actually very low, he masked his lack of interest and said a bluffing and amazing: we are doing the same set anyway. Really. Anyway. Can't get help from him, he seems to be non human. Anyone ?:)Thanks. Another few facts: i did sports in my youth, started again last year (because of the fatigue), , 1.86 m height , 77 kg, little bellyfat, my vision is weakening slowly in the last months. And maybe an important element: i lost something 3 years ago. And all that kept me alive was gaming. I threw myself totally into an extremely stressing game, where i reached top levels. I do that around 12 -14hours/day wihtout pause, day after day (i don't need an income, survive from old savings. When they' ll be over...well... we'll see.) Last 2 monthis i kinda stopped. Some days i do not play at all, other days a few hours...but nothing changes. Sorry for the long story. Really. But i am lost :) I am in a country where docs don't give a flying fuck. Thanks again

[@theneurophile]

I’m sorry that you are feeling badly. It is very challenging to diagnose people based on an internet post. I suggest you continue working with your doctor to find a solution.

[@enkidu001]

Thanks for being nice:) Peace (And sorry again for the long comment)

[@drchalo7170]

So good lecture Dr. Rybinnik. How could I email you?

Please Dr., some talk about fMRI and differents types of paradigms and it's implementation in mental disorders. Greets and thanks.

[@theneurophile]

There is an MRI video on this channel.

[@josemoreira50]

You HAVE to make this stuff for other specialties (cardiology). Its pure gold

[@theneurophile]

I would love to, but I am a Neurologist. So, unfortunately I am not qualified to comment on other specialties.

[@pavolskacik5064]

Could you make a talk about antitrombotic therapy and Its indications/contraindications in vascular neurology?

[@theneurophile]

Sure, will try.

[@pvermehren]

Pathophysiology of dissection has more recently been shown to be rupture of vasa vasorum in intimal layers causing intramural hämatoma in most cases, not intimal tear and flap formation

[@theneurophile]

Thank you. Please include a reference for that statement.

[@Neurologi]

Thank you for a very nice review on this topic! Just wondering - why is tension-type headache not mentioned?

[@theneurophile]

Although tension headache is a defined entity in the IHS, the existence of muscle tension has never been proven, and some headache neurologists (at least the ones that trained me) believe that it is on the continuum with migraine. So for the purposes of this talk, consider tension as part of migraine.

[@Neurologi]

@@theneurophile Very interesting! I agree that the pathophysiology of tension type headache is still not well understood and it is true that migraine and tension type headache often do co-exist. However, the treatment (at least here in Denmark where I work) is rather different! In cases with primary tension type headache, we tend to recommend physiotherapy, avoiding medication overuse and prophylactic amitriptylin (70mg), mirtazapin (30mg) or venlafaxin (150mg).

[@Neurologi]

@@theneurophile By the way: thank you for your awesome videos!

[@theneurophile]

@@Neurologi Thank you for that insight. I generally find headache difficult to treat given the vast number of disorders and paucity of data. I'm hoping these videos will give medical students an overview of the topic, so that they can be inspired to dig deeper.

[@rahulpramanik7889]

in that case can i tell this cvst problem

[@potatonail7463]

Great video!, I wonder though about tension type headache? Why is it excluded from this video?

[@theneurophile]

There is great debate among the headache specialists whether tension headache is a separate entity or really on a continuum with migraine. So to keep things simple, we didn't discuss it.

[@potatonail7463]

@@theneurophile I see. Thankyou 😊

[@gpetrolli]

In a case of cerebral venous thrombosis, should we just anticoagulate the patient or interrupt anticoagulation to perform relief punctures?

[@theneurophile]

Lumbar punctures do not really work to reduce intracranial pressure in venous sinus thrombosis. As of now, aggressive anticoagulation is the primary treatment. If cerebral edema progresses despite anticoagulation, then surgical decompression may be necessary.

[@gpetrolli]

@@theneurophile Thanks!

[@rupindergill94]

Answer Headache attributed to low cerebrospinal fluid (CSF) pressure

[@gabbiet9138]

I know another cause of headaches .. Botox prior auths! Haha 😅 We do see great response from patients though.

[@AnniePharm]

The woman in the case is literally me (even the blurry vision details), that's surprising.

[@theneurophile]

Migraines are unfortunately common. I hope yours are not too terrible.

[@AnniePharm]

@@theneurophile They are very mild, I never thought it was a case of migraine because I always believed migraines can only be really painful.

[@theneurophile]

@@AnniePharm Good to hear. Migraines can certainly occur without pain.

[@ilqar887]

How do you treat cervical headache?

[@theneurophile]

That’s a tough question to answer since it depends highly on the cause. Most cases are treated conservatively.

[@ericreece2639]

Last was csf leak.. Right?

[@theneurophile]

Yep

[@hairballjones8451]

What about normal pressure Hydrocephalus? You touch on IIH but not this? J- u- s-t wondering

[@theneurophile]

Normal pressure hydrocephalus typically does not present with headache (this is a headache talk). Please refer to the “Hydrocephalus” talk on this channel for that discussion.

[@zuhairyassin505]

high dose corticosteriods could you tell us how many mg/kg ??

[@theneurophile]

For prednisone, it would typically be 1mg/kg daily to start.

[@zuhairyassin505]

@@theneurophile thanks

[@ilqar887]

@@theneurophile is not Prednisone bad for you?

[@juancolores]

Cephalea related IgG4

[@theneurophile]

Are you referring to the thumbnail? That’s actually just intracranial hypotension.

[@konosmgr]

What about new persistent daily headaches?

[@theneurophile]

You may have to read about that one. It didn't fit into the talk.

[@konosmgr]

@@theneurophile Thanks for replying, perhaps you got any specific reading material to recommend?

[@user-ju7bs6me3c]

😅😅😅

[@lindafreudiger8022]

Good thing I went to medical school so I can understand this-NOT AT ALL😢

[@theneurophile]

Oh no! I hope you understood at least something.

[@danyelPitmon]

I really wish you would not have just briefly went past the possibility of CSF leaks because there are many people who have migraines as well as parts that also have CSF leaks many neurologist and doctors are just brushing that aside and not even considering that at all and your video you just did the same thing which is a disservice to many that have severe migraine problems and I am very dissatisfied with this video because you did not address that particular issue but yet you weren’t right word but all other neurologist and doctors have done is go right to tumors and didn’t even consider the Souter tumor which is a CSF leak which can be very debilitating to ask you to please review redo and put out a new video that encompasses this problem because I have severe migraines and I mean severe debilitating migraines but also seem to have a positional issue with fluid increase in the frontal lobe of my brain I see it being an impossibility that positions and neurologist are not asking in that direction one lady that I know and I follow on KZbin went for years without getting the right diagnosis and finally went to a clinic in Texas by video conferencing and found out her suspicion was correct that she had a suitor tumor her medication regimen and things have changed to take that into account with her migraines and her pots thank you for reading this comment especially are you students that are study in this area please take into account that some people may actually have increased or decreased cerebral fluid to the brain because of recent CAT scan that I had done when I went into the emergency room for a migraine showed that I do have a reduced fluid level and one section of my brain has reduced blood flow included as well I also have a history of Trumatic brain injury which could also cause weakening of the Durham around the brain and the brain stem leaking fluid thank you goodbye

[@theneurophile]

I’m sorry to hear that you are suffering. You are absolutely right that low pressure from CSF leaks is a very real problem. Unfortunately it is impossible to cover every disorder in one video (there are over 84 types of headaches). I will try to make a video about low pressure headaches when I have some time.