45. Headache (43%) Flashcards
Name red flags of headaches
SNOOPPPPS
* Systemic - fever, weight loss, HTN, myalgias, scalp tenderness
* Neuro - confusion, decreased LOC, papilledema, visual field defect, CN asymmetry, extremity drift/weakness, reflex asymmetry, seizure
* Onset - Sudden
* Older - New onset or progressive >50yo
* Pattern change/progressive - Different or new
* Papilledema
* Postural aggravation
* Precipitated by valsalva (cough, sneeze)
* Secondary risk factors- HIV, malignancy, trauma, early morning/nocturnal
Name DDX of headaches (categories) (4)
- Primary
- Secondary
- Intracranial
- Extracranial
Name PRIMARY headaches
- Migraine
- Tension
- Cluster
If ≥15d/mo for ≥3mo
* Chronic migraine
* Chronic tension
* Medication overuse headache
* Hemicrania continua
* New daily persistent headache
Describe Migraines
- 4-72h (untreated)
- 2 of unilateral, pulsatile, moderate-severe pain, worse with or avoid routine physical activity
- 1 of nausea/vomiting, photo/phonophobia
Describe : Tension headaches
2 of Bilateral, non-pulsating (pressing), mild-moderate intensity, not worse with or avoid routine physical activity
No N/V, no more than one of photo/phonophobia
Describe : Cluster headaches (4)
- Severe unilateral orbital
- Supraorbital and/or temporal pain
- 15-180mins (untreated)
- One symptom/sign ipsilateral (Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, sweating, flushing, ear fullness, miosis, ptosis)
- Sense of restlessness or agitation
Describe : Medication overuse headache (3)
- usually present on wakening
- ≥15d/mo simple analgesics (acetaminophen, aspirin, NSAID)
- ≥10d/mo ergotamine, triptan, opioids
Describe : Hemicrania continua (5)
- Strictly unilateral
- persistent with exacerbations
- cranial autonomic symptoms
- restlessness
- responsive to indomethacin
Describe : New daily persistent headache (4)
- Abrupt onset
- daily
- unremitting from onset (or within 3d of onset)
- typically in patients without history of headache
Name SECONDARY headaches (3)
- Infection: Meningitis, sinus, mastoid, dental
- Hypertension: Preeclampsia
- Systemic illness, Carbon monoxide
Name types of intracranial headaches (2)
Vascular and nonvascular
Name examples of intracranial vascular headaches (5)
- Hémorragie sous-arachnoïdienne (coup de tonnerre)
- Artérite temporale
- Thrombose des sinus veineux,
- Hématome sous-dural (aggravation avec le temps)
- Dissection de l’artère cervicale (AIT/déficit neuro chez le jeune)
Name examples of intracranial non-vascular headaches (3)
- Eye disorder (refractory errors, glaucoma)
- Carotid dissection
- Articulation temporo-mandibulaire
Describe physical exam : Headaches
- Vitals including BP
Neurological exam - Mental status
- Cranial nerve (including fundoscopy)
- Unilateral limb weakness, reflex asymmetry, coordination in arms
- Gait, heel-toe walking
- Consider neck and oropharynx exam
Describe investigations of headaches
- Neuro exam
- Fundoscopy r/o increased increased intracranial pressure
- CT if red flags or risk of intracranial pathology
- Lumbar puncture if symptoms of secondary cause
- Consider Taux de sédimentation des érythrocytes (ESR)/CRP if suspect artérite temporale
- Consider CT/LP to rule out hémorragie sous-arachnoïdienne (HSA)
Name symptoms suggestive of secondary cause of headaches (3)
- Valsalva/exercise
- systemic illness (fever/rash/neck stiffness/meningismus)
- neuro sign (papilledema/seizure)
How to r/o increased ICP?
Fundoscopy
What exam to do if symptoms of secondary cause of headache ? (1)
Lumbar puncture
What exam to do if suspect of arthérite temporale ?
ESR/CRP
What exam to do if suspect of hémorragie sous-arachnoïdienne (HSA)? (3)
Consider CT/LP
* Ottawa SAH Rule (100% sensitive, 15% specific - if negative helpful to rule out, excluded neuro deficits, brain tumors, chronic recurrent headache)
* CT (diagnosis 90% SAH within 24h)
* Lumbar Puncture (If negative CT)
Name criterias of Ottawa SAH rule (6)
- Age≥40
- Neck Pain/Stiffness
- LOC
- Onset during Exertion
- Thunderclap
- Limited Neck Flexion on exam
Name suggestive fundings on lumbar pucture for hémorragie sous-arachnoïdienne (HSA) (3)
- Elevated opening pressure
- Elevated RBC count that does not significantly diminish
- Xanthochromia (hemoglobin degradation if blood in CSF >2h)
Describe general tx of headaches (5)
- Keep headache diary, record frequency, intensity, triggers, medication
- Lifestyle changes
- Stress management
- Acupuncture
- Stimulation nerveuse électrique transcutanée
Name lifstyle changes for headaches tx (5)
- Reduce caffeine
- Regular aerobic exercise
- Avoid irregular/inadequate sleep or meals
- Avoid triggers
- Fluids
Name stress management for headaches tx (4)
- Entraînement à la relaxation
- TCC
- Activité de stimulation
- Thérapie par biofeedback
Name 1st line tx : Migraine (4)
- Ibuprofen 400mg
- ASA 1000mg
- Naproxen 500mg
- Acetaminophen 1000mg
Name 2nd line tx : Migraine (2)
- Second Line: Triptans (eg. Sumatriptan 100mg PO)
- Sumatriptan 6mg subcutaneous if vomiting or resistant to oral triptans.
Name C-I of triptans (3)
- CV diseases
- pregnancy
- ergotamines
What to consider if triptans are C-I ?
Consider Gepants (Ubrogepant and Rimegepant) for patients with cardiovascular disease (for whom triptans are contraindicated)
When to consider prophylaxis in migraines ? (4)
- if 4+/month
- > 12h
- increased in frequency
- rebound
How long for prophylaxis migraine ?
trial of at least 2 months needed
treat for 6-12 months then taper to reassess need
Name prophylaxis possible for migraines
- Betablocker (Propranolol, Metoprolol, Timolol)
- Antidepressants (Amitriptyline, Venlafaxine),
- Anticonvulsants (Valproate, Topiramate)
Less evidence:
- Calcium channel blockers (Verapamil)
- Melatonin 3mg (as effective as amitriptyline in one RCT)
- Riboflavin (Vit B2) 400mg/d after three months
Describe ER cocktail of migraines
- 1L bolus NS
- Prochlorperazine 10mg
- Diphenhydramine 25mg
- Ketorolac 30mg
- Dexamethasone 10mg
Describe tx : Tension-type headaches (4)
- Ibuprofen 400mg
- ASA 1000mg
- Naproxen 500mg
- Acetaminophen 1000mg
Describe prophylaxis: Tension-type headaches (4)
TCA (Amitriptyline, Nortriptyline)
Describe tx : Cluster headaches
- 100% oxygen 12L/min x 15 mins through non-rebreather mask
- Sumatriptan 6mg subcutaneous, Zolmitriptan 5mg intranasal
- Bridge with Corticosteroids (prednisone), Ergotamine, Occipital nerve block
- Prophylactic Verapamil 240-480mg/d or steroids
- Early specialist referral
Describe tx : Medication overuse (2)
- Stop offending medication
- Can bridge with NSAID (naproxen) or prednisone
Describe tx : Hemicrania Continua or Daily Persistent Headache (3)
- Indomethacin
- Specialist referral
- Consider MRI Brain
Migraine nécessite combien d’épisodes pour dx ?
Nécessite > ou = 5 épisodes (2 si avec aura)
Décrire fréquence Cluster/Horton
- Min Q2jours, max 8x/jour
- 80% épisodes dure plusieurs sem/mois puis rémission
Le traitement PRN doit être utilisé combien de fois par mois ?
utiliser < 10 jours / mois
Quand débuter tx prophylaxique ?
Traitement prophylaxique si 6-14 jours/mois
C’est quoi le lien entre migraine et dépression ?
Relation bidirectionnelle entre migraine et dépression; traiter les deux conditions, rechercher la dépression surtout si fréquen/chronique
Nommez : Facteurs de chronicisation des migraines (8)
- Femme
- Hx trauma
- Fréquence élevée
- Apnée / obésité
- Abus rx
- Café
- Stress
- Sommeil
Décrire : Migraines associées avec menstruations (2)
- 2 cycles/3
- généralement 48h avant les menstruations ad 72h post
Nommez tx possible : Migraines associées avec menstruations
- COC en continu
- AINS
- Oestrogènes (estrodiol gel 1,5mg die)
- Triptans périmenstruels
Décrire migraine et grossesse (5)
- 60% diminue en grossesse
- cesser prophylaxie
- triptan pas étudier en grossesse
- dérivés de l’ergotamine contre-indiqué
- éviter AINS en T1-T3
Quand référer en neuro ? (6)
- Échec à 2 traitements prophylaxies (efficaces si diminution de 50%, pas E2, diminution des tx PRN, sevrage possible)
- Crises violentes/status migraineux
- Aura hémiplégiques
- Cluster/horton
- Céphalée invalidante sans dx
- Suspicion de HTIC
