66. Headache

Question 1

What is the most common pain problem in family practices?

Which type of Primary HA occur more?

Answer 1

HA

1. Tension type (78%)
2. Migraine (12% - W>M 3:1)

Question 2

What signs/sx would prompt imaging? (Red flags)

Answer 2

Decreased mental status
Exertional HA
Nuchal Rigidity
Focal Neuro Deficits
Onset Age > 50
"First or Worst" WHOL

Question 3

What are 3 common causes of Secondary HA? How common are Secondary HA?

Answer 3

HA due to underlying pathology
Vascular: Aneurysms, AVMs, SAH
Meningitis
Stroke

0.18% of pts with HA and normal neuro exam have underlying pathology - RARE

Question 4

Migraine

• pt characteristics
• genetics?
• pathophysiology

Answer 4

• pt: beings at puberty and ages 35-45yo; lifelong attacks
• genes: 2/3 cases run in families (co-morbidities of anxiety, depression, bipolar disorder) - consider familial hemiplegic migraine/CADASIL single gene disorders

PP: Abnormal neuronal activity = release of vasoactive substances = VD = inflammatory response/tissue sensitization = activates trigeminovascular system = stim pain neurons in brainstem/upper SC = prolonged pain
Exacerbated by sterss/emotion

Question 5

Migraine

• features
• types of aura
• big 3 triggers

Answer 5

Features: HA moderate-severe intensity, NAUSEA, UNILATERAL PULSATING, aggravated by routine activity, for hours-days (can be bilateral/non-pulsating too)

Aura: focal neuro sx preceding HA
visual (scotoma, fortification spectra/scattered lines, scintillations/fireflies), motor (hemiparesis), sensory (numbness)
RED FLAG IF AURA > 60 min (STROKE/TIA)

Triggers: Hormones, Fasting, Alcohol

Question 6

List the medications used to tx migraines

Answer 6

1. Triptans (Sumatriptan)
2. Ergot Preparations (DHE)
3. Acetaminophen/Aspirin + Caffeine
4. Aspirin/Ibuprofen/Naproxen
5. Butorphanol Intranasally

Question 7

Triptans (Sumatriptan)

• mechanism
• site of action
• contraindications

Answer 7

CORNERSTONE OF MIGRAINE TX
M: 5HT 1b/1d receptor AGONISTS
SoA:
1. Central neuron in brainstem - inhibit NT release from activated trigeminal nerves
2. Peripheral neuron - reduce sensory nerve activation and inhibit VD neuropeptide release
3. Trigeminal blood vessels: VC

CI: conditions with VC (HTN, vascular disease, cardiac ischemia, CAD risk factors), use of other 5HT agonists (precaution with SSRI)

Question 8

Ergot Preparations (DHE)

• mechanism
• site of action
• when to use

Answer 8

Most effective EARLY in attack
M: 1. bind 5HT Receptors
2. affinity for alpha/beta DA receptors
3. inhibition of neurogenic inflammation

Question 9

Prophylactic Tx of Migraine

• indication
• types

Answer 9

Indication: disabling recurrent migraines despite acute tx, frequent attacks (>2/wk)

types:

• antihypertensives (BBlocker, CCB)
• antidepressants
• anticonvulsants
• BOTOX (if very frequent, no other meds work)

Question 10

Tension-Type HA

• features
• episodic v. chronic

Answer 10

• recurrent HA for 30min-7 days
• pain: pressure/tightening
• intensity: mild/moderate
• location: bilateral, not aggravated by routine physical activity
• photophobia/phonophobia (NO NAUSEA)

Episodic: <15x/mo. no underlying disease
Chronic: >15x/mo. for >6mo/year

Question 11

Tx of Tension-Type HA

Answer 11

-follow pain ladder - avoid overuse (rebound HA)
CORNERSTONE - non-pharm tx! (co-morbidities, stress, MSK problems, caffeine use)
Preventitive meds: tricyclic antidepressants, anticonvulsants, muscle relaxants

Question 12

Cluster HA

• location, frequency, onset
• features
• trigger
• tx: acute and preventative

Answer 12

MOST SEVERE RECURRENT HA
location: UNILATERAL (periorbital/temporal)
freq: once every other night thru 8x/day
onset: 20-40yo, M>F (5:1) - episodes in Spring/Fall
features: ipsilateral autonomic: facial sweating, tearing, miosis, ptosis, nasal congestion, rhinorrhea
Trigger: alcohol
tx: acute: 100% O2 (facemask), triptans
preventative: reduce triggers, CCB (Verapamil), lithium, prednisone, ergotamine