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Neurology 2 > Clin Med - Headache > Flashcards

Clin Med - Headache Flashcards

1
Q

What 7 factors must you determine for each type of HA

A
  1. frequency
  2. duration
  3. intensity
  4. type of pain (throbbing, sharp, etc.)
  5. Presence of GI sx
  6. Visual sx (aura)
  7. other neuro sx
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2
Q

what is one of the most important diagnostic tools for HA

A

History

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3
Q

Other neuro sx common associated with HA

A
  • tinnitus
  • hearing loss
  • dysarthria *
  • dysphagia *
  • weakness *
  • sensory loss *
  • LOC *
  • aphasia/dysphasia *

*could be signs of emergent condition (stroke, aneurysm)

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4
Q

Headache intensity classification

A
  • disabling: can’t get out of bed
  • severe: limits activity 50-90%
  • moderate: limits activity 25-50%
  • mild: does not limit activity at all
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5
Q

6 types of HA

A
  • 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
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6
Q

Two types of HA classified by cause

A
  1. primary - idiopathic

2. secondary - organic, related to other disease state

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7
Q

Two types of secondary/organic HA

A
  • intracranial

- extracranial

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8
Q

Three types of primary HA

A
  • migraine
  • cluster
  • tension
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9
Q

Common causes of secondary HA

A
  • toxic (CO poisoning)
  • metabolic
  • vascular
  • infectious
  • tumor/mass lesion
  • trauma
  • heredo-degenerative
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10
Q

What is very important in diagnosis toxic exposure HA

A

HISTORY

  • exposure
  • profession (exposure)
  • etc.
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11
Q

Examples of toxic causes for HA

A
  • organic compounds: solvents, drugs
  • inorganic compounds: lead, arsenic, cadmium, etc.
  • gases and fumes: H2S, CH4, CO, H2O, formaldehyde
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12
Q

Drugs that cause HA

A
  • oral contraceptives
  • nitro
  • fluoxetine
  • opioid pain meds
    MANY others
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13
Q

Causes of metabolic HA

A
  • renal failure
  • hepatic failure
  • acidosis
  • alkalosis
  • CO2 retention
  • anemia
  • hypo- and hyperthyroid
  • cushing
  • hyperparathyroid
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14
Q

Vitamin deficiency cause of HA

A
  • Niacin - pellagra
  • Thiamin - beri beri
  • vitamin C - scurvy
  • B12 - combined system disease
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15
Q

One common cause of infectious HA

A

meningitis

- history and PE important to look for other sx of meningitis

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16
Q

Parenchymal infectious causes of HA

A
  • bacterial
  • brain abscess
  • spirochete: syphilis
  • viral
  • HIV
  • fungal
    etc etc
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17
Q

Extracranial mass lesions that can cause HA

A
  • sinus carcinoma
  • mastoid tumor - cholesteatoma
  • head and neck carcinoma
  • carotid body tumor
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18
Q

Migraine epidemiology

A
  • F>M
  • onset generally 2nd or 3rd decade of life
  • fam history common
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19
Q

Migraine pathophys

A
  • exact mechanism unknown
  • maybe dt genetic abnormality that makes neuromuscular system hyperexcitable
  • a trigger is usually involved
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20
Q

What happens when a trigger activates a migraine?

A
  • cortical spreading depression which may or may not lead to aura
  • release of neuropeptides (serotonin, cytokines, etc.) which bind to intracranial blood receptors = vasodilation
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21
Q

Common migraine triggers

A
  • red wine
  • skipping meals
  • excessive afferent stimuli (flights, odors)
  • weather changes
  • sleep deprivation
  • stress
  • hormonal factors
  • certain foods
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22
Q

Two types of migraine

A
  • migraine with aura (25%)

- migraine without aura

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23
Q

When does aura occur during migraine phase?

A
  • can proceed migraine

- during migraine

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24
Q

characteristics of a aura headache

  • development
  • how long last
A
  • gradual development

- last less than one hour

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25
Q

Positive migraine aura symptoms

A
  • visual (bright lines, shapes, objects) MC
  • auditory (tinnitus, noises, music)
  • somatosensory (burning, pain, paresthesia)
  • motor (jerking, repetitive rhythmic movements)
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26
Q

Negative migraine aura symptoms

A
  • absences or loss of function

- loss of vision, hearing, feeling, ability to move part of body

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27
Q

Most common sx of migraine

A
  • pain
  • photophobia
  • phonophobia
  • nausea
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28
Q

Visual sx of migraine

A
  • scintillating scotoma (MC)
  • blurred vision
  • visual loss
  • diplopia
    • and many less common features
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29
Q

Mood/behavior changes due to migraine

A
  • mood changes
  • irritability
  • depression
  • euphoria

*before, during, after migraine

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30
Q

Things to consider when dx-ing migraine

A
  • TIA
  • CVA
  • intracranial hemorrhage
  • hypoglycemia
    MANY MORE
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31
Q

Diagnostic criteria for migraine without aura

A

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
32
Q

Diagnostic criteria for migraine with aura

A

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
33
Q

Is imaging necessary to dx migraine?

A

Nope!

34
Q

When is imaging necessary necessary when pt presents with non-acute HA

A
  • unexplained abnormal finding on neuro exam

- atypical HA features

35
Q

What HA sx warrant imaging?

A
  • 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
36
Q

What imaging to order for HA?

A
  • CT w/o contrast (1st to ro bleeding)
  • MRI
  • MRA (vascular issues)
37
Q

First line tx for mild/moderate attacks

A
  • simple analgesics (NSAIDs or acetaminophen)

- antiemetic for n/v

38
Q

First line tx for moderate to severe attacks without n/v

A
  • oral migraine specific meds (triptans)
39
Q

First line tx for mod to severe attacks with n/v

A

non-oral migraine specific meds

  • sub q sumatriptan
  • nasal sumatriptan

non-oral antiemetics

  • topical or rectal phenergan
  • parental dihydroergotamine (DHE)
40
Q

Meds to consider when treating migraine in the ER

A

(usually severe by time reach ER)

  • sumatriptan subq
  • dihydroergotamine (DHE)
  • antiemetics (metoclopramide, prochlorperazine, chlorpromazine)
  • ketorolac
41
Q

what type of meds should be avoided in migraine tx

A
  • opioids

- barbituates

42
Q

Rebound headache/medication overuse HA (MOH)

  • which meds possible
  • which meds most likely?
  • which meds lowest risk
A
  • all acute symptomatic meds have potential
  • risk highest in opioids, butalbital containing analgesics, aspirin/acetaminophen/caffeine combos
  • triptans moderate risk
  • NSAIDS lowest risk
43
Q

how to prevent MOH

A
  • acute meds limited to < 10 days per month or <15 days for NSAIDs
44
Q

simple analgesics

A
  • NSAIDs
  • aspirin
  • ibuprofen
  • naproxen
  • diclofenac
  • ketorolac
  • acetaminophen
45
Q

HA dt temporal arteritis

A
  • severe HA

- recurrent/persistent over weeks to months

46
Q

Temporal arteritis

  • dx
  • tx
A
  • elevated ESR and CRP and temporal artery biopsy

- high dose steroids and NSAIDs

47
Q

Presentation of cluster HA

A
  • brief, severe, constant
  • non throbbing
  • 10 min to < 2 hours
  • unilateral, return to same side
  • begins as burning behind eye
48
Q

What HEENOT sx do cluster HA present with?

A
  • conjunctival injection
  • tearing
  • nasal stuffiness
  • ipsilateral Horner’s syndrome
49
Q

what can precipitate cluster HA

A
  • alcohol

- vasodilation drugs

50
Q

Dx of cluster HA

A
  • hx and PE to r/o other causes of HA
51
Q

Cluster HA tx

A
  • 100% O2 via nonrebreather
  • sumatriptan IM or nasal spray
  • dihydroergotamine
52
Q

Tension HA

  • how common?
  • pathophys
  • men vs. women
A
  • most common benign HA disorder
  • no pathophysiologic mechanism
  • W > M
53
Q

Tension HA location

- often associated with what?

A
  • neck, back of neck, top of head

- often assoc. with neck pathology (degenerative disk dz, etc.)

54
Q

What is very important in dx of tension HA?

A
  • history of PE

- necessary to r/o more ominous dx and/or to determine underlying condition causing HA

55
Q

What is common cause of tension HA that can be found in history?

A
  • often secondary to analgesic overuse

- thoroughly address efforts at medical management!

56
Q

Tension HA presentation

A
  • steady, nonthrobbing
  • bilateral
  • global head pain
  • not associated with prodrome, neuro signs/sx or n/v
57
Q

What are CT findings fro tension HA?

A

usually normal CT :)

58
Q

Tension HA tx

A
  • similar tx to other HA (triptans, anti-inflammatories) with possible addition of a muscle relaxer
59
Q

Non pharm tx for tension HA

A
  • psychotherapy
  • PT
  • muscle relaxants
  • relaxation techniques
60
Q

GCS

A

memorize if you wish

61
Q

Concussion

- overview

A
  • head injury due to contact and/or acceleration or deceleration forces
  • cortical contusion
  • can be coup contrecoup
62
Q

Hallmark sx of concussion

A
  • confusion
  • amnesia
  • +/- LOC

** assess duration to assess severity of injury (and risk of complications)

63
Q

Early sx of concussion

A

(minutes to hours)

  • HA
  • dizziness
  • lack of awareness of surroundings
  • n/v
64
Q

late sx of concussion

A

(hours to days)

  • mood or cognitive disturbances
  • sensitivity to light and noise
  • sleep disturbances
65
Q

Other sx of concussion

A
  • 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!

66
Q

Concussion Dx

A
  • Head CT w/o contrast
67
Q

Concussion: when to order a CT

A
  • 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
68
Q

Concussion tx

A
  • monitored at home X 24 hours
69
Q

When to return to ER after concussion

A
  • inability to awaken pt
  • severe/worsening HA
  • confusion/somnolence
  • restlessness/unsteadiness
  • seizure
  • vision change
  • vomiting, fever, stiff neck
  • urinary or bowel incontinence
  • numbness/weakness
70
Q

Post concussion syndrome sx

A
  • seizures (MC)
  • HA
  • dizziness
  • neuropsychiatric sx
  • cognitive impairment
  • depression
  • anxiety
  • PTSD

*does not require LOC

71
Q

Post concussion syndrome Dx

A
  • neuropyschological testing

- neuroimaging (CT, MRI, EEG)

72
Q

Post concussion syndrome CT

A
  • 10% show abnormal bleed, mild subarachnoid hemorrhage, subdural hemorrhage, contusion
73
Q

Post concussion syndrome MRI

A
  • more sensitive than CT

- shows abnl in 30% pts with normal CT

74
Q

Post concussion syndrome Tx

A
  • migraine meds
  • analgesics
  • psych counseling
  • psychotropic meds
75
Q

Post concussion syndrome recovery

A
  • most recover quickly within several weeks

- minority have prolonged disability

Neurology 2 (21 decks)

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