Clinical care: Headaches Flashcards
Sudden onset or “thunderclap” headache
subarachnoid hemorrhage (SAH)
Absence of prior headache/s similar to present one
CNS infection
Focal neurologic signs other than auras
Could be stroke or tumor
Other physical symptoms like fevers
Could be meningitis
Rapid onset with exercise
Could be intracranial hemorrhage associated with brain aneurysm
Associated with nasal congestion
Could be sinusitis
Associated with papilledema
Could be increased intracranial pressure
(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
Reasons to refer for imaging
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.
Tension Headaches:
Overview and presentation
Tension Headaches:
Diagnosis
No diagnostic tests are required
Tension Headaches:
Treatment
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
-Dull, aching px in larges areas of the head
-Tightness/ pressure across forehead and sides
-Tenderness on scalp neck and shoulder muscles
Physical Examination:
Tension Headaches
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
Overview and presentation:
Cluster Headache
Other associated symptoms:
a) Ipsilateral congestion or rhinorrhea
b) Lacrimation and redness of the eye
c) Horner syndrome (Ptosis, miosis, anhidrosis)
Overview and presentation:
Cluster Headache
Cluster Headache:
Treatment
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.
Subcutaneous Sumatriptan (Imitrex) - Anti-migraine medication Dose and MOA
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.
Oral Zolmitriptans (Zomig) DOSE
Dose: Initial: 2.5 mg, may repeat if needed . 2 hour after initial dose
(maximum single dose: 10 mg per 24 hour period).
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
Migraines:
Overview and presentation
Migraines:
Diagnosis
Made clinically by HPI
Migraines:
Management
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)
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)
Migraine Abortive Treatment
HA occurring for more than 2-3x a month
Antihypertensive: Beta-blockers such as Propranolol, Metoprolol
Antidepressants: Amitriptyline
Anticonvulsants: Topiramate
Migraine Prophylaxis
Treatment for concurring symptoms:
Migraine
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
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
Overview and presentation:
Post-Traumatic Headache
Treatment:
Post-Traumatic Headache
1) No special treatment required
2) Simple analgesics are appropriate first line therapy
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
Overview and presentation:
Medication Overuse Headache
Treatment:
Medication Overuse Headache
Treatment is to withdraw medications
a) Expect improvement in months, not days
