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Neurology Module > Cephalgia > Flashcards

Cephalgia Flashcards

0
Q

unilateral headache location

A

migraine

trigeminal neuralgia

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1
Q

What are the types of headaches?

A

Migraine
Tension
Cluster
Post traumatic headaches

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2
Q

temporal headache location

A

temporal arteritis

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3
Q

occipital location headache

A

tension headache

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4
Q

headache location - eye

A

acute glaucoma
temporal arteritis
sinusitis
migraine

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5
Q

gradual headache onset indicates

A

usually benign

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6
Q

sudden onset headache indicates…

A

may be more serious

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7
Q

What would be an important item to ask about headache onset?

A

head injury

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8
Q

pounding/pulsatile pain indicates…

A

migraine

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9
Q

sharp/stabbing headache indicates…

A

trigeminal neuralgia

cluster headaches

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10
Q

pressure/squeezing headache indicates…

A

tension headache

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11
Q

Headache associated symptoms - anxiety indicates

A

tension headaches

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12
Q

associated symptom - aura

A

migraine

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13
Q

associated symptoms - vision change

A

temporal arteritis

glaucoma

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14
Q

associated symptoms - nausea/vomiting

A

increased ICP

migraines

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15
Q

associated symptoms - lacrimation/rhinorrhea

A

cluster headaches

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16
Q

associated symptom - photophobia

A

meningitis

migraine

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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?

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18
Q

What are headache modifying factors?

A

Environment?
Behavioral triggers?
Food triggers?
OTC analgesics

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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.

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20
Q

prevalence of migraines

A

25% US population
18% women
6% men

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21
Q

onset of migraine headaches

A

age 10-40

Usually disappear in 50s

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22
Q

migraine risk factors

A 
family history
obesity
sleep apnea
head injury
female
analgesic overuse
caffeine >100 mg/day
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23
Q

migraine pathophysiology

A

depolarization theory

serotonin release

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24
Q

Depressed activity areas lead to platelet and mast cell activation.

A

Depolarization Theory

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25
Q

Fluctuations in chatecholamine levels cause alternating vasoconstriction/vasodilation.

A

Seratonin release

Vasodilation = wall stretching = pain

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26
Q

Migraine Triggers

A 
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
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27
Q

What medications can cause migraines?

A

Oral contraceptives
Nitroglycerin
Zantac

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28
Q

What foods can trigger migraines?

A 
Chocolate
Cheeses
Nitrates
Soy
Cold food
Yeast extract
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29
Q

What are the migraine types?

A 
Common - without aura
Classic - with aura
Basilar
Hemiplegic
Opthalmoplegic
Menstrual - catemenial
Migrainous carotidynia
Abdominal
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30
Q

Characteristics of a Common Migraine

A 
Pulsatile, throbbing (50%)
Unilateral (50%)
Lasts hours - days
Associated with nausea/vomiting
Pathophobia/phonophobia
Often debilitating
Cutaneous allodynia
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31
Q

How long does a common migraine last?

A

Hours to days

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32
Q

When does aura develop in classic migraine?

A

10-30 minutes prior to headache

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33
Q

Peripheral flashing lights - periphery

Pale spot that enlarges

A

scintillating scotomas

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34
Q

zig-zagging lines

Teichopsia

A

Fortification spectrum

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35
Q

What are the types of auras?

A

scintillating scotomas

fortification spectrum

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36
Q

Where to the aura abnormalities develop?

A

Arise in the occipital cortex, not the eyes.

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37
Q

What is a prodrome?

A

Occurs before a classic migraine.

Increased excitability/irritability; fatigue, depression, appetite increase or cravings

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38
Q

Sensory Auras associated with classic migraine

A

numbness, paresthesias, dysphasia

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39
Q

What is a migraine equivalent?

A

Variant of classic migraine where aura occurs without the headache.

AKA- acephalic migraine

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40
Q

Migraine affects basilar artery, headache, vertigo, slurred speech, impaired coordination WITHOUT motor deficits. Occurs in younger patients.

A

basilar migraine

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41
Q

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.

A

Hemiplegic

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42
Q

Headache with eye pain, vomiting, and ptosis which can persist for weeks.

A

opthalmoplegic migraine

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43
Q

Face, jaw, neck; tenderness and swelling over carotid artery; older patients; normal carotid ultrasound

A

migrainous carotidynia

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44
Q

No headache; vomiting, GI pain. Typically in young patients and typically develop common/classic migraines as they grow.

A

Abdominal migraine

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45
Q

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”

A

catemenial migraines

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46
Q

When would you image a migraine?

A 
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
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47
Q

First line acute treatment for migraine:

A 
Excedrin migraine (ASA, acetaminophen, caffeine)
NSAIDs - Naproxen
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48
Q

What is excedrin a combination of?

A

ASA
Acetaminophen
Caffeine

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49
Q

Second line acute migraine treatment:

A

Triptans
Dihydroergotamine (DHE-45)
-SC/IM/IV
-Intranasal (Migranal)

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50
Q

Migraine Triptans

A

Sumatriptan - Imitrex
Rizatriptan - Maxalt MLT
Zolmitriptan - Zomig

51
Q

Sumatripten Imitrex Dosing

A

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
Q

What is the benefit of adding naproxen to treximet?

A

migraine stays away for longer

53
Q

How does Rizatriptan (Maxalt) come?

A

a dissolvable tablet

54
Q

If one triptan does not work what should you do?

A

Try another one! One may work better than the other!

55
Q

Which triptans are longer acting?Amerge

A

Naratriptan (Amerge)

Frovatriptan (Frova)

56
Q

What antimetics are given for migraines?

A 
Metoclopramide (Reglan) - PO/IM/IV
Prochlorperazine (Compazine) - PO/IM/IV
Hydroxyzine (Atarax)
Promethazine (Phenergan) - PO/IM/Rectal
Other - Toradol, Dexamethasone
57
Q

Why do rebound headaches occur from migraines?

A

Overuse of medications for migraines.

58
Q

What is overuse of migraine medications?

A

> 10 days out of the month

59
Q

What drugs are likely to cause rebound headaches?

A 
Acetaminophen - 45%
Narcotics - 31%
ASA - 24%
Ergot alkaloids - 6%
Triptans - 9%
60
Q

When do you start migraine prophylaxis?

A

Greater than or equal to 2 headaches per week.
Severe
Prolonged duration - >2 days

61
Q

What must the patient do if they are having rebound headaches?

A

Quit the offending medication “cold-turkey”

62
Q

How much does prophylaxis decrease frequency of headaches?

A

50%

63
Q

How long does prophylaxis for migraines occur?

A

Continue medications for at least 2-3 months before tapering of discontinuing.

64
Q

What medications are used for migraine prophylaxis?

A

beta blockers
tricycling antidepressents
anti-seizure medications

65
Q

Does migraine prophylaxis completely stop migraines?

A

No - decreases frequency by 50%

66
Q

What beta blockers are used for prophylaxis?

A

Propranolol LA (Inderal LA)

Others: metaprolol, timolol

67
Q

What is the prescription for propranalol for migraine prophylaxis?

A

80 mg daily to start
Increase over 3 weeks to 160 mg daily
Max: 240-320 mg

68
Q

What types of tricyclic antidepressants are used for prophylaxis?

A

Amitriptyline (Elavil) 25 mg hs - normally 25-100

Nortriptyline (Pamelor) 10 mg hs - normally 30 mg

69
Q

What antiseizure medications are used for migraine prophylaxis?

A

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
Q

Can you give Valproic acid (Depakote) or Topiramate (Topamax) to pregnant women?

A

NO!!!!

71
Q

What should you also give with Depakote?

A

Prenatal vitamins - Depakote depletes folic acid and causes hair to fall out.

72
Q

What is the most common side effect of Depakote?

A

Weight Gain

73
Q

What are “other” migraine prophylaxis medications?

A

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
Q

What are cluster headaches?

A

Migraine variant

75
Q

cluster headache prevalence

A

Men 4-1
Men 20-40 yo
Familial association

76
Q

Risk factors for cluster headaches

A

family history
tobacco
head injury
shift work

77
Q

What are cluster headaches often triggered by?

A

alcohol ingestion

78
Q

What is HIGHLY associated with cluster headaches?

A

Smoking!! Pt must quit smoking.

79
Q

Cluster headache pathophysiology

A

vascular dilation
trigeminal nerve stimulation
circadian rhythms - patients may awake from sleep with these headaches

80
Q

characteristics of cluster headaches

A

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
Q

To diagnose a cluster headache you must have at LEAST one of the following:

A

Lacrimation
Ipsilateral flushing/sweating
Ipsilateral nasal DC
Conjunctival redness - maybe ipsilateral?
Horners syndrome - ipsilateral ptosis, ipsilateral miosis (pupillary constriction)

82
Q

Acute treatment for cluster headaches

A

Triptans (sumatriptan, zolmitriptan)

***Oxygen - 100% NRB mask: 12-15 L x 20 min. Complete relief in 78% of patients

83
Q

prophylaxis for cluster headaches

A

Verapamil - 80 mg TID ( may increase up to 160 mg TID)

+/- corticosteroids as a “bridging therapy” to BREAK THE CYCLE

84
Q

Why to tension headaches occur?

A

myofascial origin

85
Q

symptoms of tension headaches

A

vice-like, gripping HA “band”
Forehead- occiput bilaterally
Radiates into posterior neck and trapezius
Duration: 30 min - 7 days

86
Q

How do you differentiate a tension headache from a migraine?

A

NO n/v, photo/phonophobia, pulsatile; not worse with activity

87
Q

Risk factors for tension headaches:

A 
Stress/anxiety
Depression
Overwork
Lack of sleep
Posture
Marital/family dysfunction
Conversion
Malingering - people believe they have an issue but really don't.
88
Q

Non-pharmacologic treatments of tension headaches:

A 
Exercise
Relaxation therapy/counseling
Yoga
PT
Accupuncture
89
Q

Pharmacologic treatments for headaches:

A

NSAIDs
Tylenol
Myofascial trigger point injections
TCAs or SSRI

90
Q

What should you stay away from when treating migraine headaches?

A

Narcotics

91
Q

TCA

A

Tricyclinc antidepressants

92
Q

Why would you use a TCA or SSRI for tension headache treatment?

A

To treat underlying stress/anxiety.

93
Q

onset of post traumatic ha

A

Occurs within first seven days of injury

94
Q

acute post traumatic headache

A

< 2 months after injury

95
Q

chronic post traumatic headache

A

> 2 months after injury.

At higher risk of becoming “daily” headache

96
Q

characteristics of post traumatic headache

A

Mixed:
Migraine-tension
Frequently develop rebound headache.

97
Q

treatment for post traumatic HA

A

VERY DIFFICULT!

98
Q

risk factor for idiopathic intracranial htn

A

women 15-44 (3.5/100,000)

obese women 20-44 (19.3/100,000)

99
Q

IIH

A

idiopathic intracranial htn

100
Q

other names of IIH

A

Pseudotumor cerebri

benign intracranial htn (BIH)

101
Q

Medications that cause IIH

A

Vit A derivatives (Accutane)
Tetracyclines
Oral contraceptives

102
Q

Symptoms of IIH

A 
retro-orbital pain
worse with eye movement
throbbing
worse in morning
nausea and vomiting
monocular/binocular vision loss
pulsatile tinnitus - 60%
\+/- neck pain
103
Q

What are the PE findings for IIH?

A

Papilledema - slightly elevated

104
Q

Diagnostic findings for IIH

A

LP - opening pressure >200 mmH20/>250 in obese (normal 70-180 mm H20)

105
Q

MRI for IIH

A

negative for masses/hydrocephalus

106
Q

Treatment for IIH

A

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
Q

Prevalence of trigeminal neuralgia

A

Women > Men

Age >40 (peak 60-70)

108
Q

Trigeminal Neuralgia AKA:

A

“Tic Deouloreux”

109
Q

Risk factors for trigeminal neuralgia

A

Multiple sclerosis

110
Q

Pathophysiology for trigeminal neuralgia

A

Demyelination of trigeminal nerve.
Light touch stimulates pain fibers.
Maxillary and mandibular branches most commonly affected.

111
Q

Symptoms of trigeminal neuralgia:

A

Right side more commonly affected.
Stabbing/lancinating/electric shock.
Associated with facial spasm.

112
Q

Trigeminal neuralgia timing

A

Attacks last <2 minutes
Multiple times daily or monthly
Become more frequent over time

113
Q

Trigeminal Neuralgia triggers:

A 
Trigger zones
Washing face
Brushing teeth
Chewing
Cold air
114
Q

Treatment of Trigeminal Neuralgia

A

Carbamazepine (Tegretol) - 200-800 mg in divided doses BID or TID
+/- other anti-seizure meds
+/- baclofen, capsaicin, gamma knife, microvascular decompression

115
Q

Temporal Arteritis AKA

A

“Giant Cell Arteritis”

116
Q

Risk factors for temporal arteritis

A

Average age 72

Associated with polymyalgia rheumatica (50%)

117
Q

Symptoms of temporal arteritis:

A

Temporal HA
+/- diplopia and/or visual field cuts
+/- systemic - fevers, malaise, weight loss
Jaw claudication

118
Q

PE findings for temporal arteritis

A

Tenderness over temporal artery

Diminished pulses

119
Q

How do you diagnosis temporal arteritis?

A

Temporal Artery Biopsy

Nonspecific labs: ESR, CRP (elevated)

120
Q

What should you always do if you suspect temporal cell arteritis?

A

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
Q

Treatment for temporal cell arteritis

A

Corticosteroids

122
Q

What do you prescribe for temporal arteritis with no vision change?

A

Prednisone - 40-60 mg daily x 4 months

123
Q

What do you prescribe for temporal arteritis with vision changes?

A

IV Solumedrol q 6h x 3-5 days then oral steroid

124
Q

Headache DDX

A 
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

Neurology Module (7 decks)

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