Ch 7 Headache Flashcards
Primary headache and examples
not from other diseases but likely from complex interplay of genetics, developmental, and environmental
ex: migraine, tension type, cluster
primary headache’s neuro exam is…
normal!
can see photophobia but otherwise normal neuro exam
secondary headache and examples
associated with or caused by other conditions and will NOT resolve until specific cause is addressed
ex: intracranial bleeding, IICP, meningitis, accelerated HTN, giant cell arteritis, tumor, etc
secondary headache’s neuro exam is…
have abnormalities that point to differential diagnosis’s
ie: viremic (influenza, COVID), acute sinusitis headache most common = usu self resolving, self limiting, normal neuro exam
Red flags for secondary headaches
SNOOP
Systemic symptoms (fever, unintended weight loss, etc)
-meningitis, encephalitis, inflammation
Secondary h/a risk factors: HIV, malignancy, pregnancy, anticoag, >180/>120 BP, etc
Neuro signs/sx’s: new neuro findings: confusing, impaired alertness, nuchal rigidity, papilledema, cranial nerve dysfunction, abnormal motor function
Onset: sudden onset or split second “thunder clap” headache
Onset with exertion, sex, cough/sneeze from clearing throat and not sick= IICP
Onset: age of onset; > 50 yrs or < 5 yrs
-giant cell arteritis, mass lesion
P: prior headache history: change in quality, frequency (medication overuse, mass lesion, subdural hematoma)
Positional: change upright vs laying down, neck position
Papilla-edema: swelling of optic disk; vision problems
Primary headache: Tension type headache: clinical presentation, last how long & diagnosis
lasts 30 mins - 1 week and 2 or more:
- pressing, non pulsatile pain
-mild to mod intensity
-usu bilateral
-NO nausea, photophobia, or phonophobia
Primary headache: Migraine without aura clinical presentation & diagnosis
lasts 4-72 hrs with 2 or more of:
-unilateral but can be bilateral
-pulsating, mod - severe
- worsen with normal activity (walking, or causes avoidance of activities)
during headache, have 1 or more of:
- nausea and/or vomiting, photophobia, photophobia
females > male; strong family hx
Primary headache: Migraine with aura clinical presentation & diagnosis
Repeated attacks of headache lasting 4-72 hours with normal exam
At least 2 of following:
-Unilateral pain 60% of time
-throbbing/pulsating pain
-Aggravating of movement or activity
-Moderate to severe intensity
Plus at least 1 of :
Nausea + vomiting
Photophobia or phonophobia
strong family hx
Primary headache: cluster headache clinical presentation & diagnosis
occurs daily in groups or clusters
-lasts weeks-months, then disappears months to years
- usu at diff times of year, vernal and autumn with 1-8 episodes same time of day
-common 1 hr into sleep aka “alarm clock” headache
-located behind 1 eye, steady, intense “hot poker eye”, severe pain in crescendo pattern 15 min to 3 hrs (most 30-45 min)
- may have lacrimation, conjunctival injection, ptosis, nasal puffiness
which type of headache is more seen in males and in 30’s yrs?
cluster
primary headache treatment: analgesics as acute therapy and limits
NSAIDs, acetaminophen etc
BEST TO TAKE AT ONSET OF H/A
limit to 2 days per week (analgesic rebound headache)
-use with triptan, divan, gepant to enhance relief
what acute therapy meds for migraine?
triptans (sumatriptan, almotriptan, rizatriptan)
ergot derivatives (migranal as nasal spray or inj)
diltans
gepants (ubrelvy)
BEST TO TAKE AT ONSET OF H/A
triptans, ergots, detains cautions/precautions
NO in pregnancy, CVD, poorly controlled HTN (d/t vascular effect)
prophylactic/prevention primary h/a treatment meds
Migraine prophylaxis takes 4-6 weeks to have effect
-BB (metoprolol, propranolol)
-TCA (amitriptyline)
-antiepiletic drugs (AED): divalproex sodium, sodium valproate, topiramate
-supplements (butterbur, feverfew, coenzyme Q10, mg, riboflavin
- lithium (only for cluster h/a)
-calcitonin gene rated peptide (CGRP) antagonists (Amovig, Ajovy, Ubrelvy, etc) but $$$
rescue therapy for primary headaches
only when other tx ineffective or severe or specific sx’s…
antiemetics, short course systemic corticosteroids,
NO opioids
triptans are good for
migraines with photophobia and photophobia (not really for pain. give with NSAID for pain)
when is neuroimaging usually warranted?
in most secondary headaches not primary
if have acute, severe headache with new onset abnormality on neurological exam…
order CT without contrast
-can show acute/chronic hemorrhage blood, stroke
CT with contrast of head shows
tumor, abscess
MRI of head shows
tumor
older adult using long term systemic corticosteroid has a risk of..
gastric ulcer while on a systemic corticosteroid than a younger person!
what is giant cell arteritis? common in what age groups?
autoimmune vasculitis that affects medium and large sized vessels (temporal artery) = inflamed/swelling = decreased blood flow = sx’s
50-85 years, females
often seen with polymyalgia rheumatica
which meds are used to treat headache symptoms, and best taken at headache ONSET?
NSAID
acetaminophen
triptans
ergot derivatives
oral CGRP antagonist (gepants, ubrogepant (Ubrelvy)
5-HT1F receptor agonist (ditans, lasmiditan Revow)
Which meds are used to minimize risk of developing headaches and need WEEKS of prior use to have clinical effect?
Beta blocker
TCA
topiramate
injectible/oral CGRP antagonist (erenumab (Aimovig), ubrogepant Ubrelvy), vitamin, minerals, herbal
giant cell arteritis clinical presentation
-tender or nodular pulseless temporal artery WITH severe unilateral headache
50% have visual impairment (blurring, diplopia, eye pain, sudden loss of vision)
CRP/ESR very elevated
Dx with temporal artery biopsy or duplex US
giant arteritis intervention
goal: reduce pain and minimize risk of blindness
-give high dose systemic corticosteroids (1-2 mg/kg/day prednisone until stabilized) then reduce dose and continue for 6 mo- 2 yrs
-aspirin (reduce stroke risk)
-PPI or misoprostol (GI protection from steroids)
-bisphosphonate (bone protection)
diet triggers for migraines/primary headaches
avoid:
sour cream
ripe cheese (cheddar, brie, camembert)
preserved meat (sausage, salami, pepperoni, hot dogs)
pizza
chicken liver, pate
herring
pickled, fermented, marinated foods
MSG
yeast sour dough bread
chocolate
nuts, peanut butter
beans
onions
figs, papayas, avoacods
citrus fruits
bananas
caffeinated (tea, energy drinks, coffee)
alcohol
aspartame, phenylalanine foods/bev
when do you consider using preventative meds for headaches?
Freq long lasting h/a a/s with significant disability
Contraindication to abortive tx
Frequent use of abortive tx
Uncommon migraine (hemiplegic, basilar, migraine with prolonged aura, migrainous infarction)
