Clin Med - Headache Flashcards
What 7 factors must you determine for each type of HA
- frequency
- duration
- intensity
- type of pain (throbbing, sharp, etc.)
- Presence of GI sx
- Visual sx (aura)
- other neuro sx
what is one of the most important diagnostic tools for HA
History
Other neuro sx common associated with HA
- tinnitus
- hearing loss
- dysarthria *
- dysphagia *
- weakness *
- sensory loss *
- LOC *
- aphasia/dysphasia *
*could be signs of emergent condition (stroke, aneurysm)
Headache intensity classification
- disabling: can’t get out of bed
- severe: limits activity 50-90%
- moderate: limits activity 25-50%
- mild: does not limit activity at all
6 types of HA
- migraine
- tension
- cluster
- HA with head trauma
- HA with vascular disorders
- HA with nonvascular intracranial issue
- HA with substance abuse/withdrawal
- HA with infection (meningitis)
- metabolic HA
- HA from cranial structure
- cranial neuralgia
- other facial pain
- psychogenic HA
- HA: not otherwise classified
Two types of HA classified by cause
- primary - idiopathic
2. secondary - organic, related to other disease state
Two types of secondary/organic HA
- intracranial
- extracranial
Three types of primary HA
- migraine
- cluster
- tension
Common causes of secondary HA
- toxic (CO poisoning)
- metabolic
- vascular
- infectious
- tumor/mass lesion
- trauma
- heredo-degenerative
What is very important in diagnosis toxic exposure HA
HISTORY
- exposure
- profession (exposure)
- etc.
Examples of toxic causes for HA
- organic compounds: solvents, drugs
- inorganic compounds: lead, arsenic, cadmium, etc.
- gases and fumes: H2S, CH4, CO, H2O, formaldehyde
Drugs that cause HA
- oral contraceptives
- nitro
- fluoxetine
- opioid pain meds
MANY others
Causes of metabolic HA
- renal failure
- hepatic failure
- acidosis
- alkalosis
- CO2 retention
- anemia
- hypo- and hyperthyroid
- cushing
- hyperparathyroid
Vitamin deficiency cause of HA
- Niacin - pellagra
- Thiamin - beri beri
- vitamin C - scurvy
- B12 - combined system disease
One common cause of infectious HA
meningitis
- history and PE important to look for other sx of meningitis
Parenchymal infectious causes of HA
- bacterial
- brain abscess
- spirochete: syphilis
- viral
- HIV
- fungal
etc etc
Extracranial mass lesions that can cause HA
- sinus carcinoma
- mastoid tumor - cholesteatoma
- head and neck carcinoma
- carotid body tumor
Migraine epidemiology
- F>M
- onset generally 2nd or 3rd decade of life
- fam history common
Migraine pathophys
- exact mechanism unknown
- maybe dt genetic abnormality that makes neuromuscular system hyperexcitable
- a trigger is usually involved
What happens when a trigger activates a migraine?
- cortical spreading depression which may or may not lead to aura
- release of neuropeptides (serotonin, cytokines, etc.) which bind to intracranial blood receptors = vasodilation
Common migraine triggers
- red wine
- skipping meals
- excessive afferent stimuli (flights, odors)
- weather changes
- sleep deprivation
- stress
- hormonal factors
- certain foods
Two types of migraine
- migraine with aura (25%)
- migraine without aura
When does aura occur during migraine phase?
- can proceed migraine
- during migraine
characteristics of a aura headache
- development
- how long last
- gradual development
- last less than one hour
Positive migraine aura symptoms
- visual (bright lines, shapes, objects) MC
- auditory (tinnitus, noises, music)
- somatosensory (burning, pain, paresthesia)
- motor (jerking, repetitive rhythmic movements)
Negative migraine aura symptoms
- absences or loss of function
- loss of vision, hearing, feeling, ability to move part of body
Most common sx of migraine
- pain
- photophobia
- phonophobia
- nausea
Visual sx of migraine
- scintillating scotoma (MC)
- blurred vision
- visual loss
- diplopia
- and many less common features
Mood/behavior changes due to migraine
- mood changes
- irritability
- depression
- euphoria
*before, during, after migraine
Things to consider when dx-ing migraine
- TIA
- CVA
- intracranial hemorrhage
- hypoglycemia
MANY MORE
Diagnostic criteria for migraine without aura
5 attacks of the following:
- untreated HA lasts 4-72 hours
Plus two of the following:
- Unilateral
- pulsating
- moderate/severe pain
- exacerbated by physical activity
Plus at least one during HA:
- n/v
- photo- or phonophobia
Diagnostic criteria for migraine with aura
Two attacks of the following:
- One or more reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, retinal)
- Two of the following characteristics:
- one aura sx >5 minutes or 2 or more sx in succession
- at least one aura sx is unilateral
- ea aura sx lasts 5-60 min
- aura is accompanied by or followed by HA within 60 min
Is imaging necessary to dx migraine?
Nope!
When is imaging necessary necessary when pt presents with non-acute HA
- unexplained abnormal finding on neuro exam
- atypical HA features
What HA sx warrant imaging?
- sudden and severe
- “first or worst”
- recent significant change in pattern, frequency, severity
- new or unexplained neuro sx or signs
- HA always on same side
- HA not responding to tx
- new onset HA after age 50
- new onset w/ HIV or cancer
- sx: fever, stiff neck, papilledema, cog impairment, personality change
What imaging to order for HA?
- CT w/o contrast (1st to ro bleeding)
- MRI
- MRA (vascular issues)
First line tx for mild/moderate attacks
- simple analgesics (NSAIDs or acetaminophen)
- antiemetic for n/v
First line tx for moderate to severe attacks without n/v
- oral migraine specific meds (triptans)
First line tx for mod to severe attacks with n/v
non-oral migraine specific meds
- sub q sumatriptan
- nasal sumatriptan
non-oral antiemetics
- topical or rectal phenergan
- parental dihydroergotamine (DHE)
Meds to consider when treating migraine in the ER
(usually severe by time reach ER)
- sumatriptan subq
- dihydroergotamine (DHE)
- antiemetics (metoclopramide, prochlorperazine, chlorpromazine)
- ketorolac
what type of meds should be avoided in migraine tx
- opioids
- barbituates
Rebound headache/medication overuse HA (MOH)
- which meds possible
- which meds most likely?
- which meds lowest risk
- all acute symptomatic meds have potential
- risk highest in opioids, butalbital containing analgesics, aspirin/acetaminophen/caffeine combos
- triptans moderate risk
- NSAIDS lowest risk
how to prevent MOH
- acute meds limited to < 10 days per month or <15 days for NSAIDs
simple analgesics
- NSAIDs
- aspirin
- ibuprofen
- naproxen
- diclofenac
- ketorolac
- acetaminophen
HA dt temporal arteritis
- severe HA
- recurrent/persistent over weeks to months
Temporal arteritis
- dx
- tx
- elevated ESR and CRP and temporal artery biopsy
- high dose steroids and NSAIDs
Presentation of cluster HA
- brief, severe, constant
- non throbbing
- 10 min to < 2 hours
- unilateral, return to same side
- begins as burning behind eye
What HEENOT sx do cluster HA present with?
- conjunctival injection
- tearing
- nasal stuffiness
- ipsilateral Horner’s syndrome
what can precipitate cluster HA
- alcohol
- vasodilation drugs
Dx of cluster HA
- hx and PE to r/o other causes of HA
Cluster HA tx
- 100% O2 via nonrebreather
- sumatriptan IM or nasal spray
- dihydroergotamine
Tension HA
- how common?
- pathophys
- men vs. women
- most common benign HA disorder
- no pathophysiologic mechanism
- W > M
Tension HA location
- often associated with what?
- neck, back of neck, top of head
- often assoc. with neck pathology (degenerative disk dz, etc.)
What is very important in dx of tension HA?
- history of PE
- necessary to r/o more ominous dx and/or to determine underlying condition causing HA
What is common cause of tension HA that can be found in history?
- often secondary to analgesic overuse
- thoroughly address efforts at medical management!
Tension HA presentation
- steady, nonthrobbing
- bilateral
- global head pain
- not associated with prodrome, neuro signs/sx or n/v
What are CT findings fro tension HA?
usually normal CT :)
Tension HA tx
- similar tx to other HA (triptans, anti-inflammatories) with possible addition of a muscle relaxer
Non pharm tx for tension HA
- psychotherapy
- PT
- muscle relaxants
- relaxation techniques
GCS
memorize if you wish
Concussion
- overview
- head injury due to contact and/or acceleration or deceleration forces
- cortical contusion
- can be coup contrecoup
Hallmark sx of concussion
- confusion
- amnesia
- +/- LOC
** assess duration to assess severity of injury (and risk of complications)
Early sx of concussion
(minutes to hours)
- HA
- dizziness
- lack of awareness of surroundings
- n/v
late sx of concussion
(hours to days)
- mood or cognitive disturbances
- sensitivity to light and noise
- sleep disturbances
Other sx of concussion
- vacant stare
- delayed verbal expression
- inability to focus
- disorientation
- slurred/incoherent speech
- gross incoordination
- emotions out of control
- memory deficits
- LOC
*can show up 2-3 days after injury, educate family!
Concussion Dx
- Head CT w/o contrast
Concussion: when to order a CT
- GCS < 15 two hours after injury
- suspected open/depressed skull fx
- signs of basilar skull fx
- > 2 vomit
- > 65 yo
- amnesia before impact > 30 min
- neuro deficit
- seizure
- use of anticoagulants
Concussion tx
- monitored at home X 24 hours
When to return to ER after concussion
- inability to awaken pt
- severe/worsening HA
- confusion/somnolence
- restlessness/unsteadiness
- seizure
- vision change
- vomiting, fever, stiff neck
- urinary or bowel incontinence
- numbness/weakness
Post concussion syndrome sx
- seizures (MC)
- HA
- dizziness
- neuropsychiatric sx
- cognitive impairment
- depression
- anxiety
- PTSD
*does not require LOC
Post concussion syndrome Dx
- neuropyschological testing
- neuroimaging (CT, MRI, EEG)
Post concussion syndrome CT
- 10% show abnormal bleed, mild subarachnoid hemorrhage, subdural hemorrhage, contusion
Post concussion syndrome MRI
- more sensitive than CT
- shows abnl in 30% pts with normal CT
Post concussion syndrome Tx
- migraine meds
- analgesics
- psych counseling
- psychotropic meds
Post concussion syndrome recovery
- most recover quickly within several weeks
- minority have prolonged disability
