3- Headaches Flashcards
What are the most common types of benign HAs?
Migraine- most common dx
Cluster- most debilitating
Tension- most frequent
Migraine and cluster are what types of HA?
Vascular
A tension HA is what type of HA?
Muscle contraction
Organic diseases of the head such as an IC mass lead to what type of HA?
Traction
Meningitis of giant cell arteritis lead to what type of HAs?
Inflammatory
What is the most important factor in establishing a HA dx?
HA hx
What are common HA triggers? (6)
Diet, hormones, sensory stimuli, stress, environment, change in habits
Pt presents with a throbbing and pulsating HA on only one side of their head. Associated sxs include photophobia, phonophobia, incapacity, N/V. Movement worsens sxs. What type of HA are you concerned about?
Migraine
Pt presents with a throbbing, pulsatile, unilateral HA that lasts 4-72 hours and began without warning. What type of HA are you concerned for?
Migraine without aura (“common”)
(more frequent form)
What are the 4 phases of a migraine with aura (“classic”)?
Prodrome, aura, HA, postdrome
In a pt with “classic” migraines (with aura), when does the prodrome phase occur?
(food cravings, mood change, uncontrollable yawning, fluid retention, constipation, neck stiffness)
24-48 hrs prior to HA
Positive and negative sxs (vision, sensory, language) are a/w with phase/ type of migraine?
positive: visual/ auditory/ sensory/ motor
negative: loss of function/ vision/ hearing/ sensation/ motor
Aura phase of “classic” migraine (w/ aura)
(usually occusr 10-60 prior to HA)
How might a pt present if they are in the postdrome phase of a “classic” (w/ aura) migraine HA?
Confused, exhausted
Pt presents with abn pain response from normal ADL (combing hair, wearing glasses, etc). What condition are you concerned about?
Cutaneous allodynia
(can be a/w migraine)
Although not typically necessary for migraine dx, what is the recommended imaging study and when is it indicated? (6 indications)
CT
- “Worst HA of my life”
- Changes in presentation
- Neuro sxs
- Refractory to tx
- New onset > 50 yo
- Hx of CA or HIV
Pt presents with rapid onset HA with max intensity w/i a few minutes and lasting up to 24 hours. On PE you note additional/ multiple neuro deficits. What are you concerned for?
TIA
(vs aura = gradual onset, duration no longer than 1 hr)
Acute migraines should be treated early. What is first line pharmacologic tx (if indicated) for mild- mod?
Oral NSAIDS +/- antiemetic
Acute migraines should be treated early. What is first line pharmacologic tx (if indicated) for mod- severe?
Triptans and ergots
Pt treated for a migraine experiences chest pressure/ heaviness, flushing, weakness, drowsiness, dizziness, malaise, feeling of warmth, and paresthesia. What were they likely treated with and what pt edu should you provide?
Triptans (“tripton sensation”)
Resolves in 30 min
What are the c/i’s to triptans and ergots in the tx of HAs?
Uncontrolled HTN, pregnancy, hx of vascular disease
(pregnancy = NO ERGOTS = absolute c/i)
What meds are recommended for preventative migraine management? (4)
Propranolol
Amitriptyline
Topiramate
CGRP antagonists (migraine clinics, newly approved)
Pt presents with non-throbbing, mild-mod intensity HA with bilateral pressure and band-like. Pt states is lasts 30 min- 7 days. They DENY phonophobia, photophobia, aura, or N/V. What type of HA are you concerned for?
Tension-type HAs (TTH)- most common type of HA
Stress, jaw clenching, missed meals, depression, too little sleep, or head/ neck strain are all possible triggers for what type of HA?
Tension-type HAs (TTH)
How do you differentiate between an episodic infrequent vs episodic frequent tension-type HA (TTH)?
Infrequent: < 12 days/ yr + lasting < 1 day/month
Frequent: 1-14 days/ month + lasting 30 min- several days
Neither type is disabling
How do you define a chronic tension-type HA (TTH)?
> 15 days/ month, lasts hours to days, +/- unremitting
What is included in the (acute) management for a tension-type HA (TTH) aside from treating the underlying cause?
NSAIDS
Chronic management of TTHs may include antidepressants or other alternative therapies to tx comorbidies (stress, anxiety, depression). What meds should be avoided and why?
Opioid/ barbiturates; high potential for medication overuse HA
Pt presents with hx of sharp, boring, unilateral, periorbital HA with autonomic sxs. They state the pain is excruciating and they are restless, pacing, or sitting/ rocking back and forth. HAs are brief, lasting 15-180 minutes. What type of HA are you concerned for?
Cluster HA
In what time frames do cluster HAs typically occur?
(attacks, clusters, remission, chronic)
Attacks: every other day- 8x/ day
Clusters: 6-12 weeks
Remission: up to 12+ mos
Chronic: clusters > 1 yr or remission < 1 month
PE of a pt with HA reveals conjunctival injection, lacrimation, eyelid edema, nasal congestion, rhinorrhea, facial sweating, miosis, and ptosis on the side ipsilateral to pain. You also note parasympathetic hyperactivity and sympathetic impairment. What are you concerned for?
Cluster HA
What imaging is used for diagnosis of a cluster HA?
MRI with and without contrast
(eval brain and pituitary)
What is the treatment for a cluster HA?
100% O2 x 15 min
Triptan (subcutaneous sumatriptan)
What is a c/i to use of O2 in the tx of a cluster HA due to risk of hypercapnia and CO2 narcosis?
COPD
What is the preventative tx for a cluster HA?
Verapamil- start at onset of cluster episode
Pt with hx of HAs that occur ≥ 15 days/ month during 3+ mos with mod pain on sides or top of head is concerning for what?
Chronic daily HA
Pt presents with continuous, fluctuating pain on the same side of face/ head that lasts minutes to days. Associated sxs include tearing, irritated eyes, rhinorrhea, and swollen eyelids. What type of chronic daily HA are you concerned for and what is the tx?
Hemicrania continua
Dx and tx with Indomethacin
Pt presents with abrupt onset HA that does not remit and described as throbbing/ tightening on both side of head. Associated sxs include light and sound sensitivity. What type of chronic daily HA are you concerned for and what is the tx?
New daily persistent HA (NDPH)
Tx with muscle relaxants, antidepressants, anticonvulsants
What type of chronic daily HA may occur following infection, medication use, trauma, or other condition with no previous hx of HA?
New daily persistent HA (NDPH)
Pt with HA lasting 1-10 seconds and occuring anywhere along the trigeminal nerve (usually around eye) is indicative of what type of primary HA and what is the treatment?
Primary stabbing HA
Tx: Indomethacin/ abortive meds
Pt with HA lasting minutes to days + N/V and triggered by coughing, sneezing, or intense activity is indicative of what type of primary HA?
Primary exertional
What imaging might be performed if suspicious for primary exertional HA and what is the tx?
MRI/ MRA to r/o vascular abns
Tx: NSAIDS, Indomethacin, warm-up exercises
Pt who is ≥ 50 yo presents with HA that develops during sleep and awakens them at night with mild-mod throbbing on both sides of the head. They typically experience ≥ 10 episodes/ month lasting 15 min- 3 hrs. Associated sxs include N and sensitivity to light/ sound. What type of primary HA are you concerned for?
Hypnic HA
If new presentation of hypnic HA, what imaging should be performed and what is the tx?
MRI
Tx: caffeine at night > Indomethacin > Lithium
When evaluating a pt with a secondary HA, what are considered red flags? (10)
- First HA > 50 yo
- Sudden, intense HA w/o previous hx
- Nuchal rigidity (+ Kernig/ Brudzinski signs)
- Diplopia
- Papilledema or retinal hemorrhage
- Neuro signs
- Fever
- Excessive BP elevation
- Hx of head trauma, malignancy, coagulopathy
- Change in previous HA presentation
SNOOP checklist
(systemic sx/ illness, neuro, onset sudden, older, previous HA hx)
Pt presents with hx of chronic opioid, barbiturate, aspirin/ acetaminophen combination, or triptan use. Previous visits have included management for episodic HA disorder. Pt states they now have new onset HAs upon awakening in the morning. What type of HA are you concerned about and what is the tx?
Medication overuse HA (MOH)
Tx: d/c meds + give NSAIDS for pain control, preventative med for underlying HA disorder
