Cephalgia Flashcards
0
Q
unilateral headache location
A
migraine
trigeminal neuralgia
1
Q
What are the types of headaches?
A
Migraine
Tension
Cluster
Post traumatic headaches
2
Q
temporal headache location
A
temporal arteritis
3
Q
occipital location headache
A
tension headache
4
Q
headache location - eye
A
acute glaucoma
temporal arteritis
sinusitis
migraine
5
Q
gradual headache onset indicates
A
usually benign
6
Q
sudden onset headache indicates…
A
may be more serious
7
Q
What would be an important item to ask about headache onset?
A
head injury
8
Q
pounding/pulsatile pain indicates…
A
migraine
9
Q
sharp/stabbing headache indicates…
A
trigeminal neuralgia
cluster headaches
10
Q
pressure/squeezing headache indicates…
A
tension headache
11
Q
Headache associated symptoms - anxiety indicates
A
tension headaches
12
Q
associated symptom - aura
A
migraine
13
Q
associated symptoms - vision change
A
temporal arteritis
glaucoma
14
Q
associated symptoms - nausea/vomiting
A
increased ICP
migraines
15
Q
associated symptoms - lacrimation/rhinorrhea
A
cluster headaches
16
Q
associated symptom - photophobia
A
meningitis
migraine
17
Q
What is important to document about headache timing?
A
Time of day/ interrupt sleep?
Frequency?
Duration of pain?
In relation to menstrual periods?
18
Q
What are headache modifying factors?
A
Environment?
Behavioral triggers?
Food triggers?
OTC analgesics
19
Q
What is important to ask about the severity of a headache?
A
Worst headache? THE headache of a lifetime?
How does this compare with previous headaches?
Documentation important to monitor effectiveness of treatment.
20
Q
prevalence of migraines
A
25% US population
18% women
6% men
21
Q
onset of migraine headaches
A
age 10-40
Usually disappear in 50s
22
Q
migraine risk factors
A
family history obesity sleep apnea head injury female analgesic overuse caffeine >100 mg/day
23
Q
migraine pathophysiology
A
depolarization theory
serotonin release
24
Depressed activity areas lead to platelet and mast cell activation.
Depolarization Theory
25
Fluctuations in chatecholamine levels cause alternating vasoconstriction/vasodilation.
Seratonin release
Vasodilation = wall stretching = pain
26
Migraine Triggers
```
Sleep deprivation/interruption
Histamine
MSG
Caffeine
Red wine/ other alcohol
Foods: Chocolate, cheeses, nitrates, soy, cold food, yeast extract
Gluten
Weather-barometric changes
Fragrances
Medications - oral contraceptives, nittroglycerin, Zantac
Physical exertion
```
27
What medications can cause migraines?
Oral contraceptives
Nitroglycerin
Zantac
28
What foods can trigger migraines?
```
Chocolate
Cheeses
Nitrates
Soy
Cold food
Yeast extract
```
29
What are the migraine types?
```
Common - without aura
Classic - with aura
Basilar
Hemiplegic
Opthalmoplegic
Menstrual - catemenial
Migrainous carotidynia
Abdominal
```
30
Characteristics of a Common Migraine
```
Pulsatile, throbbing (50%)
Unilateral (50%)
Lasts hours - days
Associated with nausea/vomiting
Pathophobia/phonophobia
Often debilitating
Cutaneous allodynia
```
31
How long does a common migraine last?
Hours to days
32
When does aura develop in classic migraine?
10-30 minutes prior to headache
33
Peripheral flashing lights - periphery
| Pale spot that enlarges
scintillating scotomas
34
zig-zagging lines
| Teichopsia
Fortification spectrum
35
What are the types of auras?
scintillating scotomas
| fortification spectrum
36
Where to the aura abnormalities develop?
Arise in the occipital cortex, not the eyes.
37
What is a prodrome?
Occurs before a classic migraine.
| Increased excitability/irritability; fatigue, depression, appetite increase or cravings
38
Sensory Auras associated with classic migraine
numbness, paresthesias, dysphasia
39
What is a migraine equivalent?
Variant of classic migraine where aura occurs without the headache.
AKA- acephalic migraine
40
Migraine affects basilar artery, headache, vertigo, slurred speech, impaired coordination WITHOUT motor deficits. Occurs in younger patients.
basilar migraine
41
Familial migraines which occurs with paralysis on one side of the body. Can occur with or without a headache. Can persist for up to 24 hours.
Hemiplegic
42
Headache with eye pain, vomiting, and ptosis which can persist for weeks.
opthalmoplegic migraine
43
Face, jaw, neck; tenderness and swelling over carotid artery; older patients; normal carotid ultrasound
migrainous carotidynia
44
No headache; vomiting, GI pain. Typically in young patients and typically develop common/classic migraines as they grow.
Abdominal migraine
45
Only occur at menses; menopause-dissapear or become sporadic; usually disappear or become sporadic; usually disappear in pregnancy; occurs day -2 through day +3; more common to have "menstrual-related migraines"
catemenial migraines
46
When would you image a migraine?
```
First or worse ever migraine
New onset >5o yo
Sudden onset HA - thunderclap HA
Abnormal neuro exam
HA awakens from sleep
Rapid onset with strenuous activity
Meningeal signs: vomiting, altered mental status, personality changes
```
47
First line acute treatment for migraine:
```
Excedrin migraine (ASA, acetaminophen, caffeine)
NSAIDs - Naproxen
```
48
What is excedrin a combination of?
ASA
Acetaminophen
Caffeine
49
Second line acute migraine treatment:
Triptans
Dihydroergotamine (DHE-45)
-SC/IM/IV
-Intranasal (Migranal)
50
Migraine Triptans
Sumatriptan - Imitrex
Rizatriptan - Maxalt MLT
Zolmitriptan - Zomig
51
Sumatripten Imitrex Dosing
SC 6 mg (max 12 mg/day)
NS 5, 10,20 mg (Max 40 mg/day)
Oral 100 mg (Max 300 mg/day)
Treximet (Sumatriptan 85 mg/naproproxen 500 mg)
52
What is the benefit of adding naproxen to treximet?
migraine stays away for longer
53
How does Rizatriptan (Maxalt) come?
a dissolvable tablet
54
If one triptan does not work what should you do?
Try another one! One may work better than the other!
55
Which triptans are longer acting?Amerge
Naratriptan (Amerge)
| Frovatriptan (Frova)
56
What antimetics are given for migraines?
```
Metoclopramide (Reglan) - PO/IM/IV
Prochlorperazine (Compazine) - PO/IM/IV
Hydroxyzine (Atarax)
Promethazine (Phenergan) - PO/IM/Rectal
Other - Toradol, Dexamethasone
```
57
Why do rebound headaches occur from migraines?
Overuse of medications for migraines.
58
What is overuse of migraine medications?
>10 days out of the month
59
What drugs are likely to cause rebound headaches?
```
Acetaminophen - 45%
Narcotics - 31%
ASA - 24%
Ergot alkaloids - 6%
Triptans - 9%
```
60
When do you start migraine prophylaxis?
Greater than or equal to 2 headaches per week.
Severe
Prolonged duration - >2 days
61
What must the patient do if they are having rebound headaches?
Quit the offending medication "cold-turkey"
62
How much does prophylaxis decrease frequency of headaches?
50%
63
How long does prophylaxis for migraines occur?
Continue medications for at least 2-3 months before tapering of discontinuing.
64
What medications are used for migraine prophylaxis?
beta blockers
tricycling antidepressents
anti-seizure medications
65
Does migraine prophylaxis completely stop migraines?
No - decreases frequency by 50%
66
What beta blockers are used for prophylaxis?
Propranolol LA (Inderal LA)
Others: metaprolol, timolol
67
What is the prescription for propranalol for migraine prophylaxis?
80 mg daily to start
Increase over 3 weeks to 160 mg daily
Max: 240-320 mg
68
What types of tricyclic antidepressants are used for prophylaxis?
Amitriptyline (Elavil) 25 mg hs - normally 25-100
| Nortriptyline (Pamelor) 10 mg hs - normally 30 mg
69
What antiseizure medications are used for migraine prophylaxis?
Valproic acid (Depakote) - 250 - 500 mg BID, prenatal vitamin/folate, weight gain
Topiramate - Topamax - 25 mg BID x 1 week, etc. Titrate to 100-200 mg daily. Weight loss/anorexia. Difficulty concentrating "Dopamax"
70
Can you give Valproic acid (Depakote) or Topiramate (Topamax) to pregnant women?
NO!!!!
71
What should you also give with Depakote?
Prenatal vitamins - Depakote depletes folic acid and causes hair to fall out.
72
What is the most common side effect of Depakote?
Weight Gain
73
What are "other" migraine prophylaxis medications?
Lisinopril - ACEI
Candesartan - ARB
Inadequate evidence - calcium channel blockers, SSRIs, carbamazepine (Tegretol)
Other - butterbur (petasites, Petadolex), Vit B12, magnesium oxide, coenzyme Q
Very refractory headaches: Lidocaine, Caffeine protocols, propofol infusion, Botox
74
What are cluster headaches?
Migraine variant
75
cluster headache prevalence
Men 4-1
Men 20-40 yo
Familial association
76
Risk factors for cluster headaches
family history
tobacco
head injury
shift work
77
What are cluster headaches often triggered by?
alcohol ingestion
78
What is HIGHLY associated with cluster headaches?
Smoking!! Pt must quit smoking.
79
Cluster headache pathophysiology
vascular dilation
trigeminal nerve stimulation
circadian rhythms - patients may awake from sleep with these headaches
80
characteristics of cluster headaches
Excruciating, stabbing pain - "suicide HA"
Unilateral - behind the eye, jaw, teeth
Duration: 15 min - 3 hours
Timing:
-multiple attaches may occur in the same day
-may occur daily at the same time
-May spontaneously regress and have months without symptoms
-May awaken from sleep
81
To diagnose a cluster headache you must have at LEAST one of the following:
Lacrimation
Ipsilateral flushing/sweating
Ipsilateral nasal DC
Conjunctival redness - maybe ipsilateral?
Horners syndrome - ipsilateral ptosis, ipsilateral miosis (pupillary constriction)
82
Acute treatment for cluster headaches
Triptans (sumatriptan, zolmitriptan)
| ***Oxygen - 100% NRB mask: 12-15 L x 20 min. Complete relief in 78% of patients
83
prophylaxis for cluster headaches
Verapamil - 80 mg TID ( may increase up to 160 mg TID)
| +/- corticosteroids as a "bridging therapy" to BREAK THE CYCLE
84
Why to tension headaches occur?
myofascial origin
85
symptoms of tension headaches
vice-like, gripping HA "band"
Forehead- occiput bilaterally
Radiates into posterior neck and trapezius
Duration: 30 min - 7 days
86
How do you differentiate a tension headache from a migraine?
NO n/v, photo/phonophobia, pulsatile; not worse with activity
87
Risk factors for tension headaches:
```
Stress/anxiety
Depression
Overwork
Lack of sleep
Posture
Marital/family dysfunction
Conversion
Malingering - people believe they have an issue but really don't.
```
88
Non-pharmacologic treatments of tension headaches:
```
Exercise
Relaxation therapy/counseling
Yoga
PT
Accupuncture
```
89
Pharmacologic treatments for headaches:
NSAIDs
Tylenol
Myofascial trigger point injections
TCAs or SSRI
90
What should you stay away from when treating migraine headaches?
Narcotics
91
TCA
Tricyclinc antidepressants
92
Why would you use a TCA or SSRI for tension headache treatment?
To treat underlying stress/anxiety.
93
onset of post traumatic ha
Occurs within first seven days of injury
94
acute post traumatic headache
< 2 months after injury
95
chronic post traumatic headache
>2 months after injury.
| At higher risk of becoming "daily" headache
96
characteristics of post traumatic headache
Mixed:
Migraine-tension
Frequently develop rebound headache.
97
treatment for post traumatic HA
VERY DIFFICULT!
98
risk factor for idiopathic intracranial htn
women 15-44 (3.5/100,000)
| obese women 20-44 (19.3/100,000)
99
IIH
idiopathic intracranial htn
100
other names of IIH
Pseudotumor cerebri
| benign intracranial htn (BIH)
101
Medications that cause IIH
Vit A derivatives (Accutane)
Tetracyclines
Oral contraceptives
102
Symptoms of IIH
```
retro-orbital pain
worse with eye movement
throbbing
worse in morning
nausea and vomiting
monocular/binocular vision loss
pulsatile tinnitus - 60%
+/- neck pain
```
103
What are the PE findings for IIH?
Papilledema - slightly elevated
104
Diagnostic findings for IIH
LP - opening pressure >200 mmH20/>250 in obese (normal 70-180 mm H20)
105
MRI for IIH
negative for masses/hydrocephalus
106
Treatment for IIH
Weight loss
Low sodium diet
Avoid sulfa medications
Diuretics: acetazolamide (Diamox), Furosemide (Lasiz)
+/- steroids
HA Mgmt: NSAIDs, TCAs
Large volume lumbar puncture (>20 mL spinal fluid removed)
Surgery: Optic nerve sheath decompression, CSF fluid shunt.
107
Prevalence of trigeminal neuralgia
Women > Men
| Age >40 (peak 60-70)
108
Trigeminal Neuralgia AKA:
"Tic Deouloreux"
109
Risk factors for trigeminal neuralgia
Multiple sclerosis
110
Pathophysiology for trigeminal neuralgia
Demyelination of trigeminal nerve.
Light touch stimulates pain fibers.
Maxillary and mandibular branches most commonly affected.
111
Symptoms of trigeminal neuralgia:
Right side more commonly affected.
Stabbing/lancinating/electric shock.
Associated with facial spasm.
112
Trigeminal neuralgia timing
Attacks last <2 minutes
Multiple times daily or monthly
Become more frequent over time
113
Trigeminal Neuralgia triggers:
```
Trigger zones
Washing face
Brushing teeth
Chewing
Cold air
```
114
Treatment of Trigeminal Neuralgia
Carbamazepine (Tegretol) - 200-800 mg in divided doses BID or TID
+/- other anti-seizure meds
+/- baclofen, capsaicin, gamma knife, microvascular decompression
115
Temporal Arteritis AKA
"Giant Cell Arteritis"
116
Risk factors for temporal arteritis
Average age 72
| Associated with polymyalgia rheumatica (50%)
117
Symptoms of temporal arteritis:
Temporal HA
+/- diplopia and/or visual field cuts
+/- systemic - fevers, malaise, weight loss
Jaw claudication
118
PE findings for temporal arteritis
Tenderness over temporal artery
| Diminished pulses
119
How do you diagnosis temporal arteritis?
Temporal Artery Biopsy
| Nonspecific labs: ESR, CRP (elevated)
120
What should you always do if you suspect temporal cell arteritis?
START TREATMENT!!! Biopsy will be positive for 2 days starting treatment.
DO NOT WAIT FOR BIOPSY RESULTS, START STEROID IMMEDIATELY AND GET BIOPSY WITHIN 2 DAYS, if not treated CAN LEAD TO PERMANENT BLINDNESS.
121
Treatment for temporal cell arteritis
Corticosteroids
122
What do you prescribe for temporal arteritis with no vision change?
Prednisone - 40-60 mg daily x 4 months
123
What do you prescribe for temporal arteritis with vision changes?
IV Solumedrol q 6h x 3-5 days then oral steroid
124
Headache DDX
```
Temporal arteritis
Post traumatic HA
Tumor
Subarachnoid hemorrhage
Venous thrombosis
Meningitis
Spinal HA
Post seizure/post -ictal HA
Acute angle - closure glaucoma
Carbon manoxide poisoning
Pseudomotor celebri
Sinusitis
TMJ dysfunction
Cervicalgia
Preeclampsia (pregnancy)
Chiari malformation
Drug/caffeine withdrawal
Trigeminal neuralgia
Obstructive sleep apnea
Tension HA
Cluster HA
Migraines
```
