Clinical care: Headaches

Question 1

Sudden onset or “thunderclap” headache

Answer 1

subarachnoid hemorrhage (SAH)

Question 2

Absence of prior headache/s similar to present one

Answer 2

CNS infection

Question 3

Focal neurologic signs other than auras

Answer 3

Could be stroke or tumor

Question 4

Other physical symptoms like fevers

Answer 4

Could be meningitis

Question 5

Rapid onset with exercise

Answer 5

Could be intracranial hemorrhage associated with brain aneurysm

Question 6

Associated with nasal congestion

Answer 6

Could be sinusitis

Question 7

Associated with papilledema

Answer 7

Could be increased intracranial pressure

Question 8

(1) Recent change in pattern, frequency, or severity of headaches
(2) Progressive worsening despite therapy
(3) Focal neurological deficits or scalp tenderness
(4) Onset of headache with exertion, cough, or sexual activity
(5) Visual changes, auras, or orbital bruits
(6) Onset of headache after age 40
(7) History of trauma, hypertension, fever

Answer 8

Reasons to refer for imaging

Question 9

1) Most prevalent headache
2) Bilateral headaches
3) Often occurs daily
4) Characterized as “vice-like” band like
5) Often exacerbated by emotional stress, fatigue, noise, glare
6) May be associated with neck muscles.

Answer 9

Tension Headaches:
Overview and presentation

Question 10

Tension Headaches:
Diagnosis

Answer 10

No diagnostic tests are required

Question 11

Tension Headaches:
Treatment

Answer 11

NSAIDS (anti-inflammatory)
(1 Ibuprofen (Motrin) 400- 800 mg PO q 4- 6 hours, Max 2400mg/24 hours
(2 Naproxen (Naprosyn) 250- 500 mg PO q12 hours

Analgesics
(1 Dose: 325-1000 mg PO q 4-6 hours, max 4 grams/24 hours

Question 12

-Dull, aching px in larges areas of the head
-Tightness/ pressure across forehead and sides
-Tenderness on scalp neck and shoulder muscles

Answer 12

Physical Examination:
Tension Headaches

Question 13

1) Usually affects middle aged men also in women
2) Intense unilateral pain that starts around the temple or eye
3) Patients is often restless and agitated due to the pain
4) Episodes often occur 15 minutes to 3 hours
5) Usually occur seasonally and attacks are grouped together
7) After resolution of attacks there is a hiatus of several months

Answer 13

Overview and presentation:
Cluster Headache

Question 14

Other associated symptoms:
a) Ipsilateral congestion or rhinorrhea
b) Lacrimation and redness of the eye
c) Horner syndrome (Ptosis, miosis, anhidrosis)

Answer 14

Overview and presentation:
Cluster Headache

Question 15

Cluster Headache:
Treatment

Answer 15

1) Oral treatment during an attack is generally unsatisfactory
2) Inhaled 100% oxygen for 15 minutes is initial treatment of choice
3) Subcutaneous Sumatriptan (Imitrex) - Anti-migraine medication
4) Oral Zolmitirptan (Zomig) – Oral anti-migraine medication if they are able to
tolerate.

Question 16

Subcutaneous Sumatriptan (Imitrex) - Anti-migraine medication Dose and MOA

Answer 16

Dose: SubQ Initial: 6 mg; may repeat if needed .1 hour after initial dose (maximum: 6 mg per dose; two 6 mg injections per 24-hour period)

MOA: Selective agonist for serotonin (5-HT1B and 5- HT1D receptors) on intracranial blood vessels and sensory nerves of the trigeminal system; causes vasoconstriction and reduces neurogenic inflammation.

Question 17

Oral Zolmitriptans (Zomig) DOSE

Answer 17

Dose: Initial: 2.5 mg, may repeat if needed . 2 hour after initial dose
(maximum single dose: 10 mg per 24 hour period).

Question 18

1) Gradual build-up of a throbbing headache, that may be unilateral or bilateral

2) Duration of several hours

3) Aura may or may not be present
a) Visual disturbances such as visual field deficits or visual hallucinations (stars, light slashes, zigzags, etc)
b) Other focal disturbances such as aphasia or numbness, tingling,clumsiness, or weakness in a circumscribed distribution

4) Family history often positive for headaches

5) May have associated nausea and vomiting

Answer 18

Migraines:
Overview and presentation

Question 19

Migraines:
Diagnosis

Answer 19

Made clinically by HPI

Question 20

Migraines:
Management

Answer 20

1) Avoidance of precipitating factors, together with prophylactic or symptomatic pharmacologic treatment if necessary.
2) During acute attacks - rest in a quiet, darkened room until symptoms subside.
3) Migraine Abortive Treatment
4) Zolmitriptan (Zomig)

Question 21

Simple analgesics/NSAIDS: Ibuprofen, Naprosyn, Aspirin, Acetaminophen, Ketorolac (Toradol) 30mg IV/IM once or every 6 hours or 60mg IM once (max 120mg/day)

Sumatriptan (Imitrex)

Answer 21

Migraine Abortive Treatment

Question 22

HA occurring for more than 2-3x a month
Antihypertensive: Beta-blockers such as Propranolol, Metoprolol
Antidepressants: Amitriptyline
Anticonvulsants: Topiramate

Answer 22

Migraine Prophylaxis

Question 23

Treatment for concurring symptoms:
Migraine

Answer 23

Antiemetics: Promethazine (Phenergan) - 1st generation antihistamine, anti- nausea and vomiting medication

(1 Dosing: 12.5 to 25 mg PO/IM/IV/Rectal every 4-6 hours as needed

Question 24

1) After head injury, it is common to have headaches
2) Symptoms occur within 1-2 days of injury, and subside within 7-10 days
3) Often accompanied by impaired memory, poor concentration, emotional instability, and increased irritability

Answer 24

Overview and presentation:
Post-Traumatic Headache

Question 25

Treatment:
Post-Traumatic Headache

Answer 25

1) No special treatment required
2) Simple analgesics are appropriate first line therapy

Question 26

1) Present in about 50% of patients with chronic daily headaches
2) Patients typically present with chronic pain or with complaints of headache unresponsive to medication
3) History will often reveal heavy use of analgesics

Answer 26

Overview and presentation:
Medication Overuse Headache

Question 27

Treatment:
Medication Overuse Headache

Answer 27

Treatment is to withdraw medications
a) Expect improvement in months, not days