B7.001 Big Case: Headache Flashcards
3 components of neuro conditions
syndrome (symptoms and signs)
lesion (where in the nervous system?)
etiology
characteristics of migraine without aura
attacks lasting 4-72 hours 2 of the 4: 1. unilateral 2. pulsating 3. moderate or severe 4. aggravation by or causing avoidance of routine physical activity at least one of the following during the attack: 1. nausea / vomiting 2. photophobia and phonophobia NO identifiable cause
what constitutes severe pain
have to stop activity as a result
4 common headache syndromes
migraine
chronic migraine
episodic tension-type
chronic tension type
difference between tension type and migraine headaches
severity
tension type mild/mod where a person may carry on activity
characteristics of migraine with aura
migraine headache features
preceded or accompanied by visual, sensory, or other focal neuro symptoms
2 most common neuro symptoms associated with migraine with aura
visual hallucinations of bright shimmering lights (fortification spectra)
tingling / numbness
status migrainosus
migraine lasting greater than 72 hours
what are episodic tension type headaches
recurrent headaches not fulfilling criteria for migraine
characteristics of episodic tension type headaches
last from 30 min to 7 days 2 of the 4: 1. bilateral 2. pressing or tightening 3. mild to moderate 4. not aggravated by routine physical activity such as walking or climbing stairs both of the following: 1. no nausea / vomiting 2. no more than one photophobia or phonophobia
most common headache type to present to physician
migraine
most common headache type overall
episodic tension type
what constitutes a chronic headache
daily or nearly daily
>15 days per month
transformed migraine
recurrent migraines become more frequent until they become a constant tension type headache with superimposed migraines
classified as chronic migraine due to history of migraine
reasons for chronic migraine
spontaneous medication overuse (rebound headache)
epidemiology of headaches
migraine prevalence 10%
tension : migraine = 5:1
women : men = 2: 1 for migraine with aura
what is the etiology of most headaches
cryptogenic / unknown
cranial pain sensitive structures
skin periosteum orbits paranasal sinuses teeth dural sinuses blood vessels
common findings that usually DO NOT cause headaches
DJD of the neck sinus disease refractive eye problems TMJ psych problems
does the brain itself feel pain?
no
neurogenic migraine hypothesis
hypothesized when it was discovered that during migraine with aura, there was depressed cerebral activity during hallucinations
thought that part of the brain shuts down and then reactivation causes increased blood flow and headache
vascular migraine hypothesis
blood vessel constriction > aura
blood vessel dilation > head pain
trigeminal vascular migraine hypothesis
most current theory
synapse of neuron with blood vessel causes additional vasodilation and neurogenic inflammation
mediated by CGRP and serotonin which are now targets of drugs
non specific headache abortive treatment
don't target hypothesized migraine pathophysiology analgesics : NSAIDs, opioids caffeine (vasoconstrictor) sedatives: butalbital antiemetics
specific headache abortive treatments
ergotamine (5HT1 receptor affinity) - not used much due to side effects
triptans: 5HT1 agonist
- most effective, based on trigeminal vascular theory
medication overuse induced chronic headache
most common cause of chronic migraine is overuse of symptomatic migraine drugs and/or analgesics
diagnosis is important because patients rarely respond to preventative medications until withdrawn from the offending medication
treatment for rebound headaches and transformed migraine
prophylactics
types of headache prophylaxis
antiepileptics B-blockers antidepressants: amitriptyline, venlafaxine (low doses) NSAIDs herbal therapies / vits / minerals botulinum toxin injection CGRP inhibitors: erenumab
when are NSAIDs used in headache prophylaxis
usually only for menstruation related headaches because they are predictable
don’t want people on NSAIDs long term
what is a cluster headache
less common primary headache syndrome
trigeminal autonomic cephalgia
characteristics of cluster headache
severe, unilateral, peri-orbital, 15-180 minutes untreated
associated with 1 of the following on painful side:
conjunctival injection, lacrimation, rhinorrhea, miosis, ptosis, eyelid edema
frequency: qod to 8/day
red flags in chronic headache
new onset > 35 yo
neuro findings including altered mental status
evidence of elevated intracranial pressure (optic nerve exam)
inflammation, fever, neck stiffness
steps in localization of headache lesion
- determine subsystem involved
- determine likely localization based on pattern and nature of deficits
- confirm and refine localization with other subsystems
components of CNS
cerebrum
brain stem
spinal cord
components of PNS
cranial nerves (from brain stem) peripheral nerves (from spinal cord)
upper motor neuron
motor neurons in the cerebrum that synapse in the brain stem / spinal cord with lower motor neurons to create an action in the face, arms, legs
lower motor neurons
effector neurons that originate in the brain stem / spinal cord that act on the face, arms, legs
what is the rule of thumb when looking at the position of UMN and LMN
UMN and LMN on contralateral sides of the brain/body
what helps distinguish UMN from LMN lesions
reflexes
0-1 = low
2 = normal
3-4 = hyperreflexia
what type of lesions presents with unilateral, asymmetric patterns of effects (hemiparesis)
focal
contralateral cerebral hemisphere to rostral brainstem
focal lesions
pattern: unilateral, asymmetric
etiology: structural
pattern explained by: anatomy
diffuse lesions
pattern: bilateral, symmetric
etiology: toxic or metabolic
pattern explained by: physiology
modality to look at suspected focal lesion
MRI
focal causes of acute headaches
vascular
trauma
focal causes of chronic headaches
tumor
entrapment
diffuse causes of acute headaches
toxins
drugs
electrolytes
organ failure
diffuse causes of chronic headaches
nutritional
hereditary
degenerative
diagnostics / treatment of focal lesions
imaging
surgical
diagnostics / treatment of diffuse lesions
blood work
pharmacological
