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M2 Neuron Brain Behavior > 9/29 Headache - Bhise > Flashcards

9/29 Headache - Bhise Flashcards

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1
Q

primary headache disorders

A
  1. migraine
  2. tension-type headache
  3. trigeminal autonomic cephalalgias
  4. others

represent 80-90% of headaches

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2
Q

migraine headaches

A
  • unilateral but not side-locked
  • pouding or throbing
  • photophobia, phonophobia, osmophobia
  • nausea w/wout vomiting
  • typically 4-24 hours
  • aura that begins 5-30 min before headache
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3
Q

aura

A

seen with classic migraines

begins 5-30 mins before

  • last 15-30min
  • scotomata (flashing lights, bars)
  • sometimes somatosensory
  • maybe independent (acephalgic migraine)
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4
Q

history, prov/pall, and complications with migraines

A

history

  • v common to have family history
  • history of motion sickness
  • comorbid anxiety, depression

provocation/palliation

  • worsen with activity
  • better when sleeping off in dark, quiet room

complications

  • opthalmoplegia
  • homonymous hemianopsia
  • hemianesthesia
  • hemiplegia
  • word-finding difficulty
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5
Q

headache triggers

A

low threshold for external stressors like:

  • stress, weather, lack of sleep
  • skipping meals
  • dehydration
  • certain foods
  • hormonal changes (menses, birth control, preg)
  • medication (ex. nitroglycerin)
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6
Q

neurobiology of migraines

A

cortical spreading depression

  • behind zone of activation, there is a zone of depression (depol) which correlates with onset of headache
  • headache usually starts while flow is diminished
  • activates trigeminovascular neurons → pain!!!

*oligemia isnt severe enough to cause ischemia

**reactive vasodilation (vascular theory) is not supported

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7
Q

trigeminovascular system involvement in migraines

A

CN V

  • mediates pain from cerebrovasculature and craniofacial region
  • handles reflex control of cerebral blood flow
  • activated by neurogenic inflammation

major peptide: CGRP (calcitonin gene-related peptide)

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8
Q

neurovascular theory

A

complex neurovasc/neurochem process activates trigeminal pain pathways

brainstem nuclei (locus ceruleus and dorsal raphe nucleus)

→ superior salivary nucleus

→ pterygopalatine ganglia

→ pia, dura, and blood vessels, and trigeminal nucleus

→ release of CGRP (potent vasodilator)

  • stimulates MMP (matrix metalloproteinase) → release of polypeptide “soup” to blood vessels
    • serotonin, bradykinin, substance P, neurokinin P&Y, prostaglandins

→→→ perivascular inflammation and pain!

prodrome: suggestive of hypothalmis and/or brainstem origin

headache phase: indicative of trigeminovascular system

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9
Q

treatment of migraine

A

abortive treatment

  1. NSAIDs
  2. anti-emetics
  3. triptans/ergots
  4. combo

preventive tx

  1. pharmaco
  2. non-pharmaco
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10
Q

lifestyle modification examples

A
  • headache log
  • keeping on the lookout for: hunger, dehydration, lack of sleep
  • limiting/stopping NSAID use
    • rebound headaches when you stop taking a med
  • avoiding junk food, caff drinks
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11
Q

high severity migraines

A

status migrainosus

  • migraine lasting over 72hr
  • abortive tx: ketorolac, meoclopramide, IV fluid
  • secondary option: sumatriptan, DHE, methylprednisolone, valproic acid, MgSO4

transformed migraines

  • moved into chronic daily headache
  • vulnerable to long term conseqs of headaches!
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12
Q

tension headaches

A

most common headache type

usually episodic, but can be chronic (chronic? F>M)

typically bilateral

pressing or tightening, squeezing

incr pericranial tenderness on palpation

minutes-days

lacks migraine features:

  • pain doesn’t worsen with routine phys activity
  • not assoc with nausea
  • either photophobia or phonophobia
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13
Q

tension headache pathophysiology

A

pain mechanisms

  • peripheral pain mechs in episodic TH
  • central pain mechanisms (sensitization) in chronic TH
    • prob sensitized at supraspinal level and spinal dorsal horn/trigeminal nucleus in CTTH
    • mood disorders may aggravate central sensitization
  • low vitD, elevated IL-1beta levels?
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14
Q

trigeminal autonomic cephalalgias

A
  1. cluster headaches
  2. hemicrania: episodic, chronic, continua
  3. SUNCT (short-lasting unilateral neuralgiform headache attachs with conjunctival injection and tearing)
  4. SUNA (short-lasting unilateral neuralgiform headache attacks with cranial autonomic sx)
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15
Q

trigeminal autonomic cephalalgias:

autonomic features

A

autonomic features ipsilateral to headache:

  • conjuctival injection or lacrimation
  • nasal congestion and/or rhinorrhea
  • eyelid edema
  • forehead and facial sweating
  • forehead and facial flushing
  • sensation of fullness in ear
  • miosis and/or ptosis
  • Horner syndrome
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16
Q

cluster headaches

A
  • 1-8 attacks per day
    • attacks in series for weeks-months, separated by remission periods for months-yrs
  • max effect: orbitally, supraorbitally, temporally
    • excruciating boring pain, unable to lie down, pacing
  • sense of restlessness or agitation

20s-40s: men > women

  • men peak in 30s
  • women peak in 20s, 60s
17
Q

diffs between cluster headaches and migraines

A

cluster headaches have…

  • no prodrome
  • no aura
  • worse with smoking/alcohol

timing

  • headaches lasting 15min-hours
  • awake pt in middle of night
  • recurrent
  • periodic: same time of day, same time of year
18
Q

cluster headaches

mechanism

A

theories: vascular dilation, autonomic system, circadian effects, histamine release, genetics, autonomic system

  1. activation in ipsilateral posterior hypothalmic gray matter
  • ant cingulate gyrus, bilateral insula
  • low testosterone
  1. pain mediated by trigeminal nerve → vasodilation and edema (histamine, CGRP, substance P, VIP)
  2. parasympathetic fibers activated (CN VII involved)

sleep association

  • often begins in sleep → disturbed circ rhythms suspected
  • associated with migraines and sleep apnea
  • suprachiasmatic nucleus [sleep pathologies] → parasympathetic pathway

genetic association

  • first degree relative → 14-39x incr risk
  • inherited auto dom in 5% of cases (HCRTR2 gene)
19
Q

treatment of cluster headaches

A
20
Q

hemicrania

A

1. paroxysmal: severe, unilat pain (orbital, supraorbital, temporal) lasting 2-30min, several times daily

2. continua: nonstop for over 3 months

  • incessant, sometimes severe, side-locked headache that ONLY RESPONDS TO INDOMETHACIN
    3. SUNCT: moderate or severe unilat head pain (orbital, supraorbital, temporal, other trigeminal distribution)
  • 1-600 seconds
  • single stabs, series of stabs, sawtooth pattern
  1. SUNA: attacks lasting 7 days - 1 year spearated by pain free periods lasting at least 1 month
  • 2s-10min duration
  • freq: daily or more
21
Q

indomethacin responsive headaches

A

indicated for

  • paroxysmal hemicrania
  • cough-induced
  • ice pick (stabbing)
  • SUNCT
22
Q

trigeminal autonomic cephalgias

summary table

A

lasting less than 30min → likely paroxysmal hemicrania

lasting more than 30min → likely cluster

23
Q

primary headaches

summary table

A
24
Q

new daily persistent headache

A

acute onset, chronic headache - daily and unremitting

bilateral tightening (non-pulsating), mild-moderate intensity

over 3 months

not aggravated by normal activity

distinguishing features from chronic tension-type headache:

  • chronic from onset
  • often occurs in patients without prior HA history
25
Q

primary stabbing headache

A
  • aka “icepick headache”
  • usually V1 region, 1-10s irregularly between one and many times per day
  • assoc with migraine or cluster
  • responsive to indomethacin
26
Q

thunderclap headache

A

sudden onset, severe

1hr-10days

may recur within first week

esp in young women with history of migraine

require imaging to rule out subarachnoid hemorrhae and RCVS in ant circulation (reversible cerebrovasoconst syndrome)

27
Q

secondary headaches

sinus headache

A

dull, deep throbbing in center of head

  • worse bending down, leaning over, in cold weather, sudden movement of head

tender to touch on face

yellow/green discharge from nose

postnasal drip

mild-mod fever

fatigue

28
Q

secondary headaches

med overuse headache

A

headache occuring on 15+ days per month in patient with preexisting headache disorder

  • taking meds more than twice weekly
  • regular overuse for > 3months of one or more drugs taken for acute/sx treatment of headache

ex. caffeine, excedring, fioricet, fiorinal, ergotamine, triptans

29
Q

idiopathic intracranial HTN

A

aka psudotumor cerebri

  • incr ICP
  • no structural CNS abnormality
  • no CSF outflow obstruction

need to rule out other causes of incr ICP

  • chronic headache (positional)
  • blurred vision (papilledema)
  • tinnitus
  • diplopia (CN VI palsy)
  • LP with high opening pressure
30
Q

low CSF pressure headache

A

“spinal headache” or “spinal leak” after LP

  • results from shift/traction on vessels from low intracranial tension
  • positional : only on sitting or standing
  • self-limiting

tx: IV fluid, IV caffeine, epidural blood patch

when spontaneous: rupturing of Tarlov cyst!

31
Q

Chiari I malformation

A

downward displacement of cerebellar tonsils at leas 3mm into upper cervical canal

  • commonly see syringomyelia (syrinx)

tx: suboccipital cranectomy, C1 ring laminectomy

occipital or upper cervical headache with valsalva [vending over, laughing, coughing, sneezing]

32
Q

cranial neuralgias

A

trigeminal neuralgia (tic douloureux)

  • older adults, women > men
  • anticonvulstants
  • MS

occipital neuralgia

glossopharyngeal neuralgia

33
Q

temporal arteritis

A

inflammatory arteritis of the temporal artery

clinical features:

  • headache
  • monocular visual loss (irrev)
  • jaw claudication
  • loss of temporal artery pulses
  • systemic sx

increased RBC sedimentation rate

dx: temporal artery biopsy
tx: steroids

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