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

45. Headache (43%) Flashcards

1
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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2
Q

Name DDX of headaches (categories) (4)

A
  • Primary
  • Secondary
  • Intracranial
  • Extracranial
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3
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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4
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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5
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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6
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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7
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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8
Q

Describe : Hemicrania continua (5)

A
  • Strictly unilateral
  • persistent with exacerbations
  • cranial autonomic symptoms
  • restlessness
  • responsive to indomethacin
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9
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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10
Q

Name SECONDARY headaches (3)

A
  • Infection: Meningitis, sinus, mastoid, dental
  • Hypertension: Preeclampsia
  • Systemic illness, Carbon monoxide
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11
Q

Name types of intracranial headaches (2)

A

Vascular and nonvascular

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12
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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13
Q

Name examples of intracranial non-vascular headaches (3)

A
  • Eye disorder (refractory errors, glaucoma)
  • Carotid dissection
  • Articulation temporo-mandibulaire
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14
Q

Describe physical exam : Headaches

A
  • 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
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15
Q

Describe investigations of headaches

A
  • 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)
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16
Q

Name symptoms suggestive of secondary cause of headaches (3)

A
  • Valsalva/exercise
  • systemic illness (fever/rash/neck stiffness/meningismus)
  • neuro sign (papilledema/seizure)
17
Q

How to r/o increased ICP?

A

Fundoscopy

18
Q

What exam to do if symptoms of secondary cause of headache ? (1)

A

Lumbar puncture

19
Q

What exam to do if suspect of arthérite temporale ?

A

ESR/CRP

20
Q

What exam to do if suspect of hémorragie sous-arachnoïdienne (HSA)? (3)

A

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)

21
Q

Name criterias of Ottawa SAH rule (6)

A
  • Age≥40
  • Neck Pain/Stiffness
  • LOC
  • Onset during Exertion
  • Thunderclap
  • Limited Neck Flexion on exam
22
Q

Name suggestive fundings on lumbar pucture for hémorragie sous-arachnoïdienne (HSA) (3)

A
  • Elevated opening pressure
  • Elevated RBC count that does not significantly diminish
  • Xanthochromia (hemoglobin degradation if blood in CSF >2h)
23
Q

Describe general tx of headaches (5)

A
  • Keep headache diary, record frequency, intensity, triggers, medication
  • Lifestyle changes
  • Stress management
  • Acupuncture
  • Stimulation nerveuse électrique transcutanée
24
Q

Name lifstyle changes for headaches tx (5)

A
  • Reduce caffeine
  • Regular aerobic exercise
  • Avoid irregular/inadequate sleep or meals
  • Avoid triggers
  • Fluids
25
Q

Name stress management for headaches tx (4)

A
  • Entraînement à la relaxation
  • TCC
  • Activité de stimulation
  • Thérapie par biofeedback
26
Q

Name 1st line tx : Migraine (4)

A
  • Ibuprofen 400mg
  • ASA 1000mg
  • Naproxen 500mg
  • Acetaminophen 1000mg
27
Q

Name 2nd line tx : Migraine (2)

A
  • Second Line: Triptans (eg. Sumatriptan 100mg PO)
  • Sumatriptan 6mg subcutaneous if vomiting or resistant to oral triptans.
28
Q

Name C-I of triptans (3)

A
  • CV diseases
  • pregnancy
  • ergotamines
29
Q

What to consider if triptans are C-I ?

A

Consider Gepants (Ubrogepant and Rimegepant) for patients with cardiovascular disease (for whom triptans are contraindicated)

30
Q

When to consider prophylaxis in migraines ? (4)

A
  • if 4+/month
  • > 12h
  • increased in frequency
  • rebound
31
Q

How long for prophylaxis migraine ?

A

trial of at least 2 months needed
treat for 6-12 months then taper to reassess need

32
Q

Name prophylaxis possible for migraines

A
  • 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
33
Q

Describe ER cocktail of migraines

A
  • 1L bolus NS
  • Prochlorperazine 10mg
  • Diphenhydramine 25mg
  • Ketorolac 30mg
  • Dexamethasone 10mg
34
Q

Describe tx : Tension-type headaches (4)

A
  • Ibuprofen 400mg
  • ASA 1000mg
  • Naproxen 500mg
  • Acetaminophen 1000mg
35
Q

Describe prophylaxis: Tension-type headaches (4)

A

TCA (Amitriptyline, Nortriptyline)

36
Q

Describe tx : Cluster headaches

A
  • 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
37
Q

Describe tx : Medication overuse (2)

A
  • Stop offending medication
  • Can bridge with NSAID (naproxen) or prednisone
38
Q

Describe tx : Hemicrania Continua or Daily Persistent Headache (3)

A
  • Indomethacin
  • Specialist referral
  • Consider MRI Brain

Résidence - FM Learner (27 decks)

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