Eval of HA - Jaynstein Flashcards
Whats the classic for SAH
Maximal intense
T/F Migraine will start off slow and increase
True
What is the 8th most common PCP complaint?
HA
Is there a strong genetic component with HA?
yes!
What is primary HA vs secondary HA?
Primary is from independently rather than from another medical issue
What are examples of primary HA?
Tension, migraine, cluster
What is secondary HA?
Ha from another issue
What is example of secondary HA?
Infection
Trauma
Stroke syndromes
REBOUND
What is approach to HA?
- Good H&P
- If secondary then you can do work up
- If primary HA then deduce type of HA
What kind of infection cause HA?
sinusitis, meningitis, encephalitis
What kind of vascular cause HA?
CVA or TIA, SAH, dissections, temporal arteritis
What kind of CSF cause HA?
Spinal HA, pseudotumor cerebri
What are other causes of HA?
post-seizure, preeclampsia, intracranial mass
T/F You can’t dx the migraine until pt meets the criteria
True
T/F Patients who have headaches secondary to a serious underlying cause usually have distinct historical or exam findings
True
Whats age is a red flag in HA?
New HA in pt over 50 is bad until proven other wise
What are vascular sx that is red flag?
standing, lying down, valsalva, cough, or sexual activity
Can be due to elevated CSF, papilledema
If there is evidence of systemic/secondary HA they need what?
They need neuro imaging!
Is it common for kids to get random HA?
No its scary complaint
What sx is to the ER?
- Worst HA of life (SAH, CNS infection)
- Sudden onset reaching severe, maximal intensity within minutes - Thunderclap Headache – (ICH, meningitis)
- Rapid onset with strenuousexercise (SAH, carotid artery dissection)
- Neuro deficits, LOC, AMS
What kind of pt needs further workup?
- Age < 5 or > 50 with no prior headache history (mass lesion)
- Progressive in frequency or severity (medication misuse, subdural hematoma, mass lesion)
- HA awakens pt from sleep
- Change in HA pattern
- Systemic symptoms – fever, neck stiffness
- Temporal artery tenderness
what is systemic symptoms indicated for and can’t miss?
meningitis
what kind of PE should you do with HA?
- Blood pressure
- Fundoscopy
- Auscultation for bruits
- Temporal artery inspection and palpation
- Meningismus
- Neurologic exam: motor, sensory, coordination and gait
Should you get labs for primary HA?
Nope
What kind of pt should get neuroimaging? CT w/o contrast is the 1st line
- Focal neurological signs
- Onset of headache with exertion or sexual activity
- Worst HA of life
- CHI with LOC or on anticoagulants
T/F Research has shown that HA diaries/logs are more helpful for clinicians than labs or imaging in most cases
True
What are the characteristics of migraine
- HA lasting 4-72 hrs
- Unilateral pain
- Throbbing pain
- HA worsens with exercise/activity
- Moderate to severe pain
- Associated N/V
- Light and sound sensitivity
What is the most common HA?
Tension
Which HA causes the most disability?
Migraine
If they have auditory HA what should you do
get psych??
What is treatment of migraine?
T/F Earlier you tx migraine, the better it is?
True!!
Episodic HA can progress into what if we dont tx it?
Chronic HA syndrome
What should you do with migraine tx?
- To decrease the number of days pt has HA rather than set the expectation of no HA’s ever
- Set limit to the number of HA related visits for pain control (2/month)
What is the tx of goal for migraine?
- Treat HAs promptly
- Limit HAs to two hours or less
- Optimize out pt treatment
- Reduce healthcare costs – decrease ER visits
- Minimize adverse SE of meds
- Minimize use of narcotics
What are some preventative medications?
- Antidepressants
- Anticonvulsants
- Beta-blockers
- CCB
Which is the best preventative for ppx migraine?
Bblocker
What are the 1st line abortive medications?
NSAIDs, APAP, ASA, Excedrin, Tordol
Start 1st line
Whats best meds for otc?
Excedrin
Whats in excerdrin?
Caffeine, APAP and ASA
What is s/e for tordol been linked with?
Renal failure
What is the most effective DOSE for ibuprofen for pain relief? (not anti-inflammatory)
400mg, nothing bigger!
T/F all nsaids have therapeutic ceiling
True
What is black box of tordol?
?
Should you give them triptans right away?
Yes, if you think its migraine
Does triptans need dx for migraine?
No, does not need dx for us to prescribe
What are abortive medications?
NSAIDs, APAP, ASA, Excedrin, Tordol
Triptans – Sumatriptan (Imitrex)
Combinations – butalbital/APAP/caffeine (Fioricet)
DHE
Narcotics
Can you use narcotics for abortive?
you cant but plz don’t
Whats the tx for mild-moderate migraine?
OTC analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, acetaminophen, and combinations containingcaffeine
Caffeine containing meds at risk for what?
more effective but also have a higher risk of bringing on rebound headaches
What do aura put pts at most risk for?
Heart attack and occipital stroke
Why could aspirin be a good choice?
- Cardioprotective rather than increasing cardiovascular risks, as most NSAIDs do
- Caution in patients whom you suspect SAH!
Who can benefit from migraine tx?
- more than one day HA per week
- Miss work bc of HA
- Associated complex symptoms
How long will migraine tx take to be effective?
8-12 weeks
What are good OTC tx to prevent migrain?
- Petadolex (adult and children)
- Magnesium supplements
- Coenzyme
Can you put aspirin for HA ppx?
NO!
Pt with migraine with aura, estrogen BC, what are they at risk for?
Stroke
What causes rebound HA?
recurring headache that is induced by repetitive and chronic use of acute medications.
T/F Acute med is ineffective in Rebound HA
True until medications have been withdrawn and washout or medication withdrawal occurs.
T/F Nearly all med used to treat HA can lead to rebound
True
What are common lifestyles triggers for HA?
- Emotional stress, depression, too little sleep, exercise or overactivity, skipping meals/fasting
What are common lifestyle food triggers for HA?
Chocolate, nuts,peanut butter, cheese, yogurt, sour cream, red wine, processed meat, MSG
What are common phsyical triggers for HA?
Menstrual cycle/hormonal changes
What are common environmental triggers for HA?
- Weather or seasonal changes
- Travel through different time zone
- Odors/pollution
- Bright light
What are the pitfalls to HA?
- Misdiagnosing migraine
- Over treating HA with medication linked to rebound HA
- Under-treating migraine, limit of abortive treatment in lieu of analgesic
- Blaming HA solely on stress
When to refer pt w/ chronic HA’s?
Most pt w/ HA, chronic, can be managed in PC
When to refer pt w/ chronic HA’s?
Consider obtaining a head CT (if not already done) and sending to neuro if:
- <5 or >50 years old
- Progressive headaches despite treatment
- History of cancer
- Uncertain dx
Whats the best drug in HA cocktail that Jaynstein?
Benadryl, compazine and tordol
Whats the most common s/e of zofran?
Prolonged QT
