Approach to patient with HA

Question 1

3 general HA presentations and their types

Answer 1

1. recurrent sterotyped attacks with well in between
   - migraines, tension, cluster
2. sudden onset severe isolated
   - subarachnoid, meningitis
   3 daily or almost daily
   - chronic migraine, over use of drugs

Question 2

8 danger signs in a headache

Answer 2

1. new onset at middle age or later
2. thunderclap headache
3. brought on be orgasm or excercise
4. changes from usual chars.
5. progressive worsening
6. features suggestive of increased ICP
7. other neuro Sx
8. abnormal physical findings

Question 3

6 associated medical states to be caustious about

Answer 3

1. malignancy
2. HIV
3. obesity - idiopathic HT
4. post-partum
5. prothrombotic states
6. drugs

Question 4

what to do if any danger signals

Answer 4

1. CT scan at minimum - possible conrast
2. LP
3. blood work

Question 5

what does response to analgesics mean

Answer 5

does NOT mean that the headache is benign

Question 6

what are 2 most common primary HA

Answer 6

1. tension - not severe so PTs don’t come in

2. migraine

Question 7

epi of migrain

Answer 7

3: 1 F:M
- high burden to society
- underdiagnosed and undertreated

Question 8

criteria for migraine

Answer 8

1. 5 or more attacks lasting 4-72 hours
2. 2 of
   - unilateral (can be bilateral)
   - pulsating
   - moderate to severe intensity
   - aggravated by routine activity
3. 1 of
   - N/V
   - photo/phonophobia

Question 9

what is typical visual aura in migraine

Answer 9

scotoma with aura around edges

Question 10

what is sensory aura in migraine

Answer 10

spreading movement around body

Question 11

what is cortical preading depression

Answer 11

• cause of visual aura

- slow propagating wave of neuronal depolarization followed by inhibition

Question 12

what is clincal sig. of aura (2)

Answer 12

1. migraine aura
   - pos +/- neg Sx
   - gradual onset
2. TIA or stroke
   - neg Sx
   - suddne onset

Question 13

what is key to good migraine treatment

Answer 13

• PT education

- good relationship

Question 14

5 common treatment pitfalls

Answer 14

1. PT misunderstands diff. of acute and prophylactic meds
2. meds taken too late
3. underdosing acute meds
4. unrealistic expectations of response
5. inadequate trial of prophylactics

Question 15

3 behvioral treatments

Answer 15

1. ID triggers and correct
2. maintain healthy balance lifestyle (fluids, meals, sleep)
3. keep HA diary

Question 16

3 classes of acute meds

Answer 16

1. NSAIDS - mild-mod
2. triptans - mod-severe
3. ergot based - NOT for regular use
   avoid use overe 2-3/wk

Question 17

what is MOA of triptan

Answer 17

agonist of 5-HT 1B/D receptors

- probably has effect on wall of blood vessels

Question 18

what is response rate for triptans

Answer 18

60% improve

30% no migraines

Question 19

4 contraindications to triptans

Answer 19

1. CHD, HT, PVD
2. basilar or hemoplegic migraine
3. conurrent other serotonin drugs
4. concurrent MAO

Question 20

SE of triptans

Answer 20

common

• chest and neck tightness
• tingling in chest and face
• sensation of warmth
• flush

Question 21

proper dosing of triptans

Answer 21

• takes ASAP

- can take again in 2-4 hours if suboptimal

Question 22

when to use prophlactics

Answer 22

• high freq
• high use of acute meds
• loss of QOL
• intolerable SEs

Question 23

3 classes of prophylactics

Answer 23

1. B-blockers - good (A)
2. tricyclics (B)
3. antiepileptics (A)

Question 24

3 vitamins

Answer 24

1. butterbur - good evidence to try
2. B2
3. magnesium

Question 25

what to avoid in preg

Answer 25

1. NSAIDS in T3
2. triptans
3. ergot based - def. bad
4. B-blockers
5. topiramate
6. butterbur

Question 26

what is risk of stroke in migraine

Answer 26

RR - 2.16

much higher in smoker in OCP