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Résidence - FM Learner > 45. Headache (43%) > Flashcards

45. Headache (43%) Flashcards

1
Q

Nommez des pathologies graves : Cépahlés

A
  • méningite
  • tumeur
  • artérite temporale
  • hémorragie sous-arachnoïdienne
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2
Q

Chez un patient dont les antécédents laissent soupçonner une hémorragie sous-arachnoïdienne malgré une TDM cérébrale négative, quoi faire ?

A

procédez à une ponction lombaire.

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3
Q

Describe : Ottawa Subarachnoid Hemorrhage (SAH)

A

CT head if :
* Age >= 40
* Neck pain, stiff OR limited flexion on exam
* Thunderclap
* Witnessed loss of consciousness
* Exertional onset

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4
Q

When to use and not to use : Ottawa Subarachnoid Hemorrhage (SAH)

A

Only use if :
* Alert
* >= 15
* >NEW severe atraumatic headache
* Max intensity in 1hr
DO NOT use if :
* New neuro deficits
* Prior aneurysm
* Prior SAH
* Known brain tumor
* chronic recurrent headache

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5
Q

Décrire : Thrombose veineuse cérébrale

A
  • Céphalées chez 89 % des patients, convulsions, déficits neurologiques focaux, perte de la vision
  • TDM ou IRM (imagerie cérébrale sans contraste et phlébographie)
  • D-dimères, ponction lombaire non utiles
  • Orienter vers un service d’urgences vasculaires cérébraux pour héparine, possibilité d’hémicrainectomie
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6
Q

Décrire : Artérite à cellules géantes

A
  • Échographie de l’artère temporale possible si faible risque
  • La biopsie est le gold standarc
  • VS ou CRP
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7
Q

Décrire tx : Artérite à cellules géantes

A
  • Corticoïdes à forte dose quotidiennement. IV en cas de symptômes visuels au moment du diagnostic.
  • Envisager l’ajout de méthotrexate.
  • Ajouter du tocilizumab (anticorps anti-récepteur de l’IL-6).
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8
Q

Décrire tx : Migraine

A
  • AINS
  • Acétaminophène
  • Triptans (p. ex. rizatriptan)
  • Antiémétiques/antagonistes des récepteurs de la dopamine (p. ex. métoclopramide, dompéridone)
  • Stéroïdes (p. ex. dexaméthasone pour prévenir les récidives)
  • Blocage du ganglion sphénopalatin
  • Antagonistes du CGRP, gépants (p. ex. rimégépant)
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9
Q

Name lifestyle changes to prevent migraines

A
  • Journal des maux de tête
  • Réduction de la caféine
  • Exercice
  • Programme: sommeil, repas, exercice
  • Relaxation, TCC, biofeedback, yoga
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10
Q

Name MEDICATION to prevent migraines

A
  • Antihypertenseurs: BB (métoprolol), ARA (condésartan)
  • Antidépresseurs: venlafaxine, amitriptyline
  • Anticonvulsivants: valproate, topiramate
  • Mini ou continus si associés aux œstrogènes: AINS/triptans avant les règles, contraceptifs
  • Antagonistes du CGRP: anticorps monoclonaux (érénumab)
  • Botox
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11
Q

Décrire prophylaxis migraine chez les adolescents

A
  • Aucun médicament efficace
  • Utiliser des traitements non médicamenteux
  • Biofeedback
  • TCC
  • Techniques de relaxation
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12
Q

Name red flags of headaches

A

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

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13
Q

Name DDX of headaches (categories) (4)

A
  • Primary
  • Secondary
  • Intracranial
  • Extracranial
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14
Q

Name PRIMARY headaches

A
  • Migraine
  • Tension
  • Cluster

If ≥15d/mo for ≥3mo
* Chronic migraine
* Chronic tension
* Medication overuse headache
* Hemicrania continua
* New daily persistent headache

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15
Q

Describe Migraines

A
  • 4-72h (untreated)
  • 2 of unilateral, pulsatile, moderate-severe pain, worse with or avoid routine physical activity
  • 1 of nausea/vomiting, photo/phonophobia
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16
Q

Describe : Tension headaches

A

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

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17
Q

Describe : Cluster headaches (4)

A
  • 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
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18
Q

Describe : Medication overuse headache (3)

A
  • usually present on wakening
  • ≥15d/mo simple analgesics (acetaminophen, aspirin, NSAID)
  • ≥10d/mo ergotamine, triptan, opioids
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19
Q

Describe : Hemicrania continua (5)

A
  • Strictly unilateral
  • persistent with exacerbations
  • cranial autonomic symptoms
  • restlessness
  • responsive to indomethacin
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20
Q

Describe : New daily persistent headache (4)

A
  • Abrupt onset
  • daily
  • unremitting from onset (or within 3d of onset)
  • typically in patients without history of headache
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21
Q

Name SECONDARY headaches (3)

A
  • Infection: Meningitis, sinus, mastoid, dental
  • Hypertension: Preeclampsia
  • Systemic illness, Carbon monoxide
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22
Q

Name types of intracranial headaches (2)

A

Vascular and nonvascular

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23
Q

Name examples of intracranial vascular headaches (5)

A
  • 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)
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24
Q

Name examples of intracranial non-vascular headaches (3)

A
  • Eye disorder (refractory errors, glaucoma)
  • Carotid dissection
  • Articulation temporo-mandibulaire
25
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
26
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)
27
Name symptoms suggestive of secondary cause of headaches (3)
* Valsalva/exercise * systemic illness (fever/rash/neck stiffness/meningismus) * neuro sign (papilledema/seizure)
28
How to r/o increased ICP?
Fundoscopy
29
What exam to do if symptoms of secondary cause of headache ? (1)
Lumbar puncture
30
What exam to do if suspect of arthérite temporale ?
ESR/CRP
31
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)
32
Name criterias of Ottawa SAH rule (6)
* Age≥40 * Neck Pain/Stiffness * LOC * Onset during Exertion * Thunderclap * Limited Neck Flexion on exam
33
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)
34
Describe general tx of headaches (5)
* Keep headache diary, record frequency, intensity, triggers, medication * Lifestyle changes * Stress management * Acupuncture * Stimulation nerveuse électrique transcutanée
35
Name lifstyle changes for headaches tx (5)
* Reduce caffeine * Regular aerobic exercise * Avoid irregular/inadequate sleep or meals * Avoid triggers * Fluids
36
Name stress management for headaches tx (4)
* Entraînement à la relaxation * TCC * Activité de stimulation * Thérapie par biofeedback
37
Name 1st line tx : Migraine (4)
* Ibuprofen 400mg * ASA 1000mg * Naproxen 500mg * Acetaminophen 1000mg
38
Name 2nd line tx : Migraine (2)
* Second Line: Triptans (eg. Sumatriptan 100mg PO) * Sumatriptan 6mg subcutaneous if vomiting or resistant to oral triptans.
39
Name C-I of triptans (3)
* CV diseases * pregnancy * ergotamines
40
What to consider if triptans are C-I ?
Consider **Gepants** (Ubrogepant and Rimegepant) for patients with cardiovascular disease (for whom triptans are contraindicated)
41
When to consider prophylaxis in migraines ? (4)
* if 4+/month * >12h * increased in frequency * rebound
42
How long for prophylaxis migraine ?
trial of at least 2 months needed treat for 6-12 months then taper to reassess need
43
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
44
Describe ER cocktail of migraines
* 1L bolus NS * Prochlorperazine 10mg * Diphenhydramine 25mg * Ketorolac 30mg * Dexamethasone 10mg
45
Describe tx : Tension-type headaches (4)
* Ibuprofen 400mg * ASA 1000mg * Naproxen 500mg * Acetaminophen 1000mg
46
Describe prophylaxis: Tension-type headaches (4)
TCA (Amitriptyline, Nortriptyline)
47
Describe tx : Cluster headaches
* 100% **oxygen** 12L/min x 15 mins through non-rebreather mask * Suma**triptan** 6mg subcutaneous, Zolmitriptan 5mg intranasal * **Bridge with Corticosteroids (prednisone), Ergotamine, Occipital nerve block** * **Prophylactic** **Verapamil** 240-480mg/d or steroids * Early **specialist** referral
48
Describe tx : Medication overuse (2)
* Stop offending medication * Can bridge with NSAID (naproxen) or prednisone
49
Describe tx : Hemicrania Continua or Daily Persistent Headache (3)
* Indomethacin * Specialist referral * Consider MRI Brain
50
Migraine nécessite combien d'épisodes pour dx ?
Nécessite > ou = 5 épisodes (2 si avec aura)
51
Décrire fréquence Cluster/Horton
* Min Q2jours, max 8x/jour * 80% épisodes dure plusieurs sem/mois puis rémission
52
Le traitement PRN doit être utilisé combien de fois par mois ?
utiliser < 10 jours / mois
53
Quand débuter tx prophylaxique ?
Traitement prophylaxique si 6-14 jours/mois
54
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
55
Nommez : Facteurs de chronicisation des migraines (8)
* Femme * Hx trauma * Fréquence élevée * Apnée / obésité * Abus rx * Café * Stress * Sommeil
56
Décrire : Migraines associées avec menstruations (2)
* 2 cycles/3 * généralement 48h avant les menstruations ad 72h post
57
Nommez tx possible : Migraines associées avec menstruations
* COC en continu * AINS * Oestrogènes (estrodiol gel 1,5mg die) * Triptans périmenstruels
58
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
59
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

Résidence - FM Learner (95 decks)

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