Cluster Headache Flashcards
Symptoms / Diagnostic Criteria
• At least 5 headaches with the following characteristics: • Severe unilateral orbital, supraorbital +/- temporal pain lasting 15-180 min untreated • Attack is a/w 1>/ of the following autonomic symptoms (usually unilateral and ipsilateral): o Conjunctival injection o Lacrimation o Nasal congestion o Rhinorrhea o Forehead / facial swelling o Miosis o Ptosis o Eyelid Edema o Agitation, unable to lie down • Frequency from 8/d to q2d • r/o organic
Risk Factors
Male > Female
Red Flags
+LR10 for presence of serious abnormalities, you MUST r/o red flags
SNOOPS:
• Systemic: (fever, HTN, myalgias, weight loss)
• Neuro Symptoms: (confusion, AMS, papilledema, Visual Field Defect, FND, seizure)
• Onset: sudden / abrupt / split second
• Older patient: new onset or progressive > 50
• Previous Hx: New / Different H/A, Worsening over time / Change in severity / Worse in the am (↑ICP)
• Secondary Risk Factors: Hx of HIV / CA
o Precipitated by a valsalva
Investigations
- MRI only if red flags, atypical
* Consider TSH, prolactin, pituitary function screening
Medication Management: first line, second line, third line
First Line: • Inhaled 02 via non-rebreather mask at the beginning of the attack. o 100% at 6-12 L / min Consider: First Line: • Sumatriptan SC • Zolmitriptan IN Second Line • Zolmitriptan PO • Sumatriptan IN • Lidocaine ***Triptans ineffective BEFORE attack*** Third Line: • Octreotide
Bridging treatment: why do you take it, what is the first line & second line txt?
Start bridging treatment with Prophylaxis until ppx can suppress headaches
First Line:
• Unilateral greater occipital nerve block 80 mg methyprednisone with 2 mL of 2% lidocaine
Second Line:
• Corticosteroids – prednisone 60 mg x 5 d then decrease by 10 mg q 2 d until discontinued
• Ergotamine
Prophylaxis medication: first line, second line, third line
First Line:
• Verapamil
Second Line: • Lithium • Topiramate • Ergotamine Third Line: • Valproic Acid • Melatonin • Baclofen • Neuromodulators
