E3: Headaches Flashcards
What is the most common diagnosis given in regards to headaches?
Migraine
What is the most debilitating headache?
Cluster headaches
What is the most frequentl type of headache?
Tension headache
What are common headache triggers?
- Diet; Alcohol, caffeine, chocolate
- Hormones
- Sensory stimuli: strong light, flickering light, odor
- stress
- Environment
- change in habits
A patient presents with a unilateral headache, photophobia, phonophobia, nausea, and vomiting. Their symptoms worsen with movement. What type of headache should you be concerned about?
Migraine
What are the two main types of migraines?
1) migraine without aura (common)
2) Migraine with aura (classic)
What type of migraine is the most frequent form that occurs without warning?
Migraine without aura
What are the 4 phases of a migraine with aura?
Prodrome, aura, headache, postdrome
What is the prodrome of a migraine?
Occurs before the aura (24-48 hours before) and may consist of food cravings, mood changes, yawning, constipation
What are the positive vs negative symptoms of a migraine aura?
- positive: visual, auditory, sensory, motor
- Negative: Loss of function, vision, hearing, sensation, motor
What is common described if a patient has a visual aura?
-Classically small area of visual loss or bright spots, flashing bright lights, shapes, or visual heat waves
What are the common symptoms of a sensory aura?
- May follow or occur without the visual aura
- unilateral tingling or muscle weakness
- abnormal sensations
What is cutaneous allodynia?
- Symptom commonly associated with migraines
- abnormal pain response from things like combing hair, shaving, wearing glasses, contact lens, tight fitting clothes, etc
What is the clinical scenarios that would warrant imaging for headaches?
- Worst headache of life
- Changes in HA presentation
- New or unexplained neurologic symptoms
- HA not responding to treatment
- New onset after 50 or in patients with CA or HIV
If a patient does require imaging for a headache, what should you order?
CT
How long does an aura typically last?
No longer than an hour
What are the first line medications for a mild to moderate migraine?
-Oral NSAIDs, acetaminophen, or OTC combination drugs like Exedrin
What are the medications used for Moderate-Severe Migraines?
-Triptans and ergots (used to abort the migraine before it gets too severe)
What are the common side effects of triptans?
- “triptan sensation”
- Injection site reaction, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, malaise, paresthesias
- resolves within 30 minutes of taking med
What are the contraindications to taipans?
-Since they are vasoconstrictors, avoid in uncontrolled HTN and pregnancy (NO ERGOTS IN PREGNANCY)
What are the medications that can help prevent migraines?
- Beta blockers
- Antidepressants
- Valproate and Topiramate
- NSAIDs
What types of drugs are Erenumab, Fremanezumab, and Galcanezuab?
CGRP antagonists that are used as preventative treatment against migraines
A patient presents with a bilateral headache in a band like distribution. What headache should you be concerned about?
Tension headache
What are the triggers for tension headaches?
Stress, jaw clenching, missed meals, depression, too little sleep, head and neck strain
What qualifies as chronic tension headaches?
> 15 days/month, lasts hours to days, may be unremitting
What is the treatment of tension headaches?
- Treat underlying cause (corrective devices for jaw, sleep study, less stress)
- NSAIDs, Tylenol, aspirin, for acute
- Hot shower or heat to back of neck
What are the common comorbidites with tension headaches?
Stress, anxiety, and depression
What are cluster headaches?
- Trigeminal autonomic cephalgias
- Sharp, boring, unilateral, periorbital HA with autonomic symptoms
- Excruciating and one of the worst pain syndromes known to man
A patient presents with a severe headache, conjunctival injection, lacrimation, eyelid edema, and mitosis. Patient is restless and unable to sit still due to pain. What type of headache should you be concerned about?
Cluster headache
What are the triggers for cluster headaches?
Alcoho, smoking, smells, and stress
What imaging should you order to work up cluster headaches?
MRI with and without contrast or pain CT
What is the treatment of cluster headaches?
- O2: Nonrebreathing facemask 100% O2 at >12/min. Continue for 15 minutes even if attack ends in less time
- Triptan: SubQ sumatriptan
What are the preventative treatments of cluster headaches?
- CCB: Verapamil
- Start at onset of cluster episode, goal to suppress attacks and minimize need for abortive medicines
What is hemicrania continua?
A continuous, fluctuating pain of the same side of face/head lasting minutes to days with associated tearing, irritated eyes, rhinorrhea, and swollen eye lids
What is the treatment of Hemicrania Continua?
Indomethacin
A patient presents with a headache that began abruptly and has been constant since. Patient states that it is bilateral and throbbing, and has associated light and sound sensitivity. Patient was recent sick with an infection and does not have a history of headaches. What type of headache should you be concerned about?
New daily persistent headaches
What is the treatment of new daily persistent headaches?
Muscle relaxants, antidepressants, and anticonvulsants
Patient presents with complaints of intense, stabbing headaches that come on without warning. Patient states the pain is usually around their eye and lasts between 1-10 seconds. What should you be concerned about?
-Primary stabbing headache (AKA “ice pick” or “jabs and jolts”
What is the treatment of a primary stabbing headache?
- Indomethacin or abortive medications if multiple episodes occur
- Avoid triggers
What are the common triggers for exertional headaches?
-Coughing, sneezing, intense activity
What imaging can you order for primary Exertional headaches?
MRI/MRA to rule out vascular abnormalities
What is the treatment for primary Exertional headaches?
-Warm up exercises, NSAIDS, Indomethacin (prior to exercise or for daily use)
What are hypnic headaches?
- AKA “alarm clock” headaches
- Occur later in life and develops during sleep and awakens people at night
- Usually >10 episodes per month lasting 15 minutes-3 hours
- Mild to moderate pain, bilateral
What imaging should you order for a new onset of Hypnic headaches?
MRI
What is the treatment of Hypnic headaches?
-Caffeine at night >indomethacin > Lithium
When should you be concerned about secondary headaches?
- First HA in patient over 50
- Sudden intense HA without previous hx of HAs
- Nichal rigidity, + Kernigs or Brudzinski sign
- Diplopia
- Papilledema or retinal hemorrhage
- persistent or new neurological signs
- Fever
- Excessive BP elevation
- Hx of head trauma, malignancy, coagulopathy
- Change in previous HA presentation
What are the structural abnormalities that can cause secondary headaches?
-Chiari malformation, syringomelia, septum deviation causing obstruction, and TMJ dysfunction
Patient presents with a headache that is increased with cough, exertion, straining, and position. Patient has papilledema, vision loss, and pulsatile tinnitus. Patient is also found to have increased ICP. What should you be suspicious of?
Idiopathic intracranial hypertension (pseudotumor cerebri)
What are the high risk medications that can lead to a medication overuse headache?
Opioids, barbiturates, and aspirin, or acetaminophen combinations
When do medication overuse headaches commonly occur?
Ha results from frequent use of analgesics and HA often occurs when analgesic is withheld
What is the treatment of medication overuse headaches?
-Withdrawal of mediations with NSAIDs, preventative medication for underlying headache disorder
