Clinical Approach to Headache Flashcards
What is needed for headache history?
- Good general health history
- Headache history –> Types, frequency
- Pain –> intensity/quality, location, duration, impact of exertion
- Prodrome
- Associated symptoms
- Behavior –> retreats to dark, quiet room, paces, rocks
- Triggers
- Current or previous medications tried
What are some prodromes that may be seen in headaches?
- Change in energy levels, mood, appetite
- Fatigue
- Muscle aches
- Aura
What is needed in the medical or surgical history when looking into headaches?
- Comorbidities –> sleep disturbances and mood disturbances
- Other medications
- Head trauma
- Previous LOC
- Seizure disorders
- Allergies
What is needed about family/social history when looking into headaches?
- Family illnesses, including headaches
- Habits –> smoking, alcohol, other drugs
- Occupation
What should be part of the physical exam when looking into headaches?
- Vital signs –> particularly BP/pulse
- Cardiac status
- Extracranial structures
- ROM and presence of pain in C-spine
What should be included in the neurological exam for headaches?
- Neck flexion
- Presence of bruits over the head and neck
- Optic fundi, pupils, visual fields
- Thorough cranial nerve exam
- Motor power in limbs
- Muscle reflexes
- Plantar responses
- Sensory exam
- Coordination
- Gait
What are some worrisome signs in a headache?
- Worst headache
- Onset of headaches after age 50
- Atypical headache for patient
- Headache with fever
- Abrupt onset
- Subacute headache with progressive worsening over time
- Drowsiness, confusion, memory impairment
- Weakness, ataxia, loss of coordination
- Paresthesias/sensory loss/paralysis
What is meningitis?
- Inflammation of the meninges surrounding brain and spinal cord, sometimes with associated encephalitis
What is the most common cause of meningitis in adults, infants, and young children?
- Strep pneumoniae
What is the most highly contagious cause of meningitis?
- N. meningitidis
- Seen in young adults and teenagers
What are some complications of bacterial meningitis?
- Hearing loss
- Memory difficulty
- Learning disabilities
- Brain damage
- Gait problems
- Seizures
- Kidney failure
- Shock or death
What are the symptoms of meningitis in people over 2 years old?
- Sudden high fever
- Stiff neck
- Severe headache that seems different than normal
- Headache with N/V
- Confusion or difficulty concentrating
- Seizures
What are the signs of meningitis in newborns?
- High fever
- Constant crying
- Excessive sleepiness or irritability
- Inactivity or sluggishness
- Poor feeding
- Bulge in the soft spot on top of baby’s head
- Stiffness in a baby’s body and neck
What should be given to infants and children with bacterial meningitis?
- Empirical antibiotics and steroids which helps prevent from long term complications
What does CSF look like in bacterial meningitis?
- Opening pressure –> elevated
- WBC –> ≥1000 per mm3
- Cell differential –> PMNs
- Protein –> mild to moderate elevation
- Glucose –> normal to marked decrease
What does CSF look like in viral meningitis?
- Opening pressure –> normal
- WBC –> <100 per mm3
- Cell differential –> Lymphocytes
- Protein –> normal to elevated
- Glucose –> normal
What does CSF look like in fungal meningitis?
- Opening pressure –> variable
- WBC –> variable
- Cell differential –> lymphocytes
- Protein –> elevated
- Glucose –> low
What are some common causes of infectious encephalitis?
- HSV 1 or HSV 2
- West Nile
- Varicella Zoster
- Treponema pallidum
What are some causes of infectious encephalitis in neonates?
- HSV2
- CMV
- Rubella
- Listeria
- Treponema
- Toxoplasma
How does HSV 1 encephalitis present?
- Rapidly progressive neurologically devastating illness with combination of fever, headache, impaired consciousness, seizures, and focal neurologic symptoms
What do MRI and EEG show in HSV1 encephalitis?
- Focal abnormalities in temporal lobes
What is the treatment for HSV1 encephalitis?
- Acyclovir
What can happen do people who recover from HSV 1 encephalitis?
- Could develop recurrent neuropsychiatric symptoms sometimes associated autoantibodies with secondary autoimmune encephalitis
What are some treatment options for autoimmune encephalitis?
- High dose steroids
- IVIG
- Plasma exchange
- Rituximab
- Cyclophosphamide
Who is affected by NMDA encephalitis?
- Young or middle aged women
How does NMDA encephalitis present?
- Abnormal psychiatric behavior or cognitive dysfunction
- Speech dysfunction
- Seizures
- Movement disorders, dyskinesias, or rigidity/abnormal postures
- Decreased LOC
- Autonomic dysfunction or central hypoventilation
What is seen on laboratory study in NMDA encephalitis?
- Abnormal EEG –> extreme delta brush (diagnostic)
- CSF with pleocytosis or oligoclonal bands and/or NMDA receptor antibodies
What is associated with NMDA encephalitis?
- Presence of teratoma
What can happen with treatment in NDMA encephalitis?
- Many will improve with aggressive treatment
Who is affected most by LGI1 encephalitis?
- Men
How does LGI1 encephalitis present?
- Faciobrachial dystonic seizures –> brief seizures involving one side of the face and arm of same side that occur frequently
- Sleep disturbances
- Temporal lobe (hippocampus) abnormality present
What is the intensity of common migraine?
- Moderate to severe
What disability is seen in common migraines?
- Inhibits or prohibits daily activities
- Pain aggravated by activity
Who is most commonly affected by common migraines? What age?
- Females in their late teens to early 20s
- Prevalence peaks between 35-40 years old
What is the frequency and duration of common migraines?
- 1-4 attacks per month
- 4 to 72 hour duration –> usually 12 to 24 hours
Where are common migraines located? How are they described?
- Unilateral or bilateral
- Described as throbbing/sharp/pressure
What is the prodrome seen in common migraines?
- Mood changes
- Myalgias
- Food cravings
- Sluggishness
- Excessive yawning
What is the postdrome seen in common migraines?
- Fatigue
- Irritability
- “Fog”q
Is there an aura with common migraines?
- NO
What are the most common associated symptoms of common migraines?
- N/V
- Photophobia
- Phonophobia
How does classic migraine differ from common migraine?
- Classic migraines have an aura
What is an aura?
- Usually lasts 15-30 min
- Commonly visual symptoms (scintillations, scotoma - often hemianopic) but can be anything neurological
What are chronic migraines?
- Headaches consistent with migraine, now with headache 15 or more days per month, headache lasting 4 hours or longer, for a period of at least 3 months
What causes migraines?
- Not really for sure
- One theory is that they could be caused by neurogenic inflammation
What is the intensity and disability of a tension type headache?
- Intensity: mild to moderate
- Disability: May inhibit, but does not prohibit daily activities
Who is most affected by tension type headaches?
- Variable age, generally peak incidence at 20-40 years old
- More in females
What is the frequency of tension type headaches?
- Episodic type –> <15 days
- Chronic type –> >15 days
What is the duration of tension type headaches?
- Episodic type –> several hours
- Chronic type –> all day, waxing and waning
What is the location and description of tension type headaches?
- Bifrontal, bioccipital, neck, shoulders, band like
- Described as a dull, aching, squeezing pressure
Do tension type headaches have an aura?
- NO
What is the intensity and disability of cluster headaches?
- Severe and excruciating
- Prohibits daily activities
Who is most affected by cluster headaches?
- More in males in their 20s-50s
What is a big association of cluster headaches?
- Obstructive sleep apnea
What is the monthly frequency of cluster headaches?
- Episodic type –> 1 or more attacks a day for 6-8 weeks
- Chronic type –> several attacks per week without remission
What is the duration and location of cluster headaches?
- 30 min to 2 hours
- 100% unilateral –> generally orbitotemporal
What is the description and prodrome of cluster headaches?
- Non Throbbing, excruciating, shapr, boring, penetrating
- Prodrome may include brief mild burning in ipsilateral inner canthus or internal nares
What is the behavior of someone with cluster headaches?
- Frenetic
- Pacing
- Rocking
What are some associated symptoms of cluster headaches?
- Ipsilateral ptosis
- Miosis
- Conjunctival injection
- Lacrimation
- Stuffed or runny nose
What are some headache triggers?
- Hormones –> menses, ovulation, HRT, OCPs
- Diet –> alcohol, chocolate, aged cheeses, MSG, aspartame, caffeine, nuts,
- Changes in weather, altitude, seasons, travel
- Stress
- Sensory stimuli –> bright or flickering lights, odors
What are some treatment options for migraines?
- OTC analgesics
- NSAIDs
- Isometheptene
- Butalbital
- Opioids
- DHE nasal spray
- Triptans
What is a contraindication to triptan use?
- Ischemic heart disease
- Cerebrovascular or peripheral vascular disease
- Raynaud’s
- Uncontrolled HTN
- Hemiplegic or basilar migraine
- Severe renal or hepatic impairment
- Use within 24 hr of treatment with ergotamines, MAOIs or other 5HT1 agonists
What could be given to people with insomnia as well as migraines?
- Sedative/hypnotic like diazepam
- Major tranquilizer like thorazine
What should be done if someone has multiple headaches per week?
- Consider preventative meds
What are some preventative measures for headaches?
- Antidepressants –> TCAs, SSRIs, SNRIs, MAOIs
- B-blockers
- CCBs
- Anticonvulsants
- Ergot alkaloids
- NSAIDs
- Muscle relaxants
- Methysergide
- BOTOX injection has been shown to treat chronic migraine
What are some nonprescription treatment options of migraine?
- Exercise
- Stop smoking
- HA education
- Riboflavin
- Magnesium
- Stress management
What is used for the acute treatment of tension headaches?
- OTC analgesics
- NSAIDs
- Opioids
- Midrin
What is the treatment for cluster headaches?
- DHE 1 mg IM or ergotamine 2mg SL
- Lidocaine 4%
- Narcotics
- Oxygen 100% 8L/min by mask
- Sumatriptan 6mg SQ
- Zolmitriptan nasal spray
What can be used for preventative treatment for cluster headaches?
- CCBs
- Anticonvulsant
- Lithium
- Indomethacin
- Prednisone
- Ergotamine tartrate
What is trigeminal neuralgia?
- Excruciating sharp, shooting, electrical quality pain occurring in paroxysm
What is the treatment for trigeminal neuralgia?
- Carbamazepine
- Oxcarbazepine
