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Clinical Decision Making II-Fall 21' > Evaluation of HA in primary care-jaynstein > Flashcards

Evaluation of HA in primary care-jaynstein Flashcards

1
Q

OLDCAARTS for HAs

A

Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors/Radiation and Treatment, severity

Does Excedrin usually help to resolve the pain? Is this unusual for you. At it’s worst, what level is the pain at? What is your current pain level?

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2
Q

“worst HA of my life”

A

subarachnoid hemorrhage (worst pain at the beginning and slowly pain resolves over time)

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3
Q

Work-up for HAs starts out with:

A
  • differentiating primary causes (80-90%) from secondary causes (10-20%)
  • Research has demonstrated a strong genetic component
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4
Q

Tension HA: describe

A

band-like tension that builds around forhead

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5
Q

Migraine HA: describe

A

-debilitating pain, pts present to primary care

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6
Q

Cluster HA: describe

A

small % (.4% of HAs), occur MC in males

tx: supplemental O2

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7
Q

What is a primary HA? List Ex’s

A

occur independently, rather than as a sequelae from another medical condition

  • Tension= MC type
  • Migraine - MC type of pt HA seen in PC

Cluster – 0.4% of all HA’s, male predominance

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8
Q

What is a secondary HA? list ex’s

A

=HA is a side effect of another process

Infection
Trauma
Stroke syndromes
REBOUND

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9
Q

If H&P is consistent with a secondary HA–> work-up based on your ddx
-infection ddx?

A

sinusitis, meningitis, encephalitis

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10
Q

If H&P is consistent with a secondary HA–> work-up based on your ddx
-vascular ddx?

A

CVA or TIA, SAH, dissections, temporal arteritis

-Temporal arteritis: tender to touch, HA located over temporal artery, dx: CSR/ERP definitive dx: temporal a biopsy

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11
Q

If H&P is consistent with a secondary HA–> work-up based on your ddx
-CSF fluid ddx:

A

Spinal headache (30%), pseudotumor cerebri

-Spinal HA= HA that occurs AFTER spinal fluid removal. **classic finding is it’s positional–pain goes away while lying down and returns when they sit up

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12
Q

If H&P is consistent with a secondary HA–> work-up based on your ddx:
trauma?

A

head injury

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13
Q

If H&P is consistent with a secondary HA–> work-up based on your ddx:
other ddx?

A

post-seizure, preeclampsia, intracranial mass

common to have HAs after seizures, and pregnant Pts with preeclampsia

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14
Q

IF H&P is consistent with a primary HA–> attempt to deduce ______

A

type of HA

–remember, do not dx migraine until pt meets the criteria)

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15
Q

Secondary HAs:

-ex’s of findings that might indicate a secondary HA?

A
  • Patients who have headaches secondary to a serious underlying cause usually have distinct historical or exam findings
  • Evidence of underlying systemic disease; new or different pattern from previous headaches or new headaches in patients over age 50; focal neurologic symptoms or seizures; symptoms provoked by standing, lying down, valsalva, cough, or sexual activity; history of neoplasia, immunosuppression, orHIV; systemic signs or symptoms; sudden onset symptoms; or papilledema

**^^Any of these findings indicates the need for workup

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16
Q

If a Pt responds to a specific tx, does this help confirm the dx of a HA?

A
  • short answer is NO (Pt may respond to pain meds and still have a brain tumor or bleed or anything)
  • -No meta-analyses or RCTS to support or refute using response to therapy as an indicator of underlying pathology

-Case reports exist of patients whose headaches have significantly improved with analgesia and then subsequently died from an intracranial hemorrhage

**Bottom line: Level C recommendation that response to therapy should not be used as the sole diagnostic indicator of the etiology of the headache

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17
Q

Papilledema is a strong indicator of _______

A

increased intracranial pressure

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18
Q

HA Red flags:

-list Exs of instances where further work-up for the HA is indicated (ie secondary instances)

A
  • 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
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19
Q

HA Red flags:

-list Ex’s of instances when a Pt w/ a HA should be sent to the ER:

A

-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

**Make sure HA does not have any red flags (take into consideration whether or not the pt currently has a HA)

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20
Q

HA- PE

-includes?

A
  • Blood pressure
  • Fundoscopy
  • Auscultation for bruits
  • Temporal artery inspection and palpation
  • Meningismus
  • Neurologic exam: motor, sensory, coordination and gait
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21
Q

Meningismus=

A

Meningism is the clinical syndrome of headache, neck stiffness, and photophobia, often with nausea and vomiting. It is most often caused by inflammation of the meninges

how to test for meningismus?
the MC used sign (Brudzinski’s neck sign) is positive when the forced flexion of the neck elicits a reflex flexion of the hips, with the patient lying supine.

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22
Q

Primary HAs: Dx

-are lab studies indicated for Pts with primary HAs?

A

Laboratory studies are not indicated (if you’re thinking of ordering labs, you should be working on a secondary HA ddx)

23
Q

Primary HAs:

Will my patient benefit from neuroimaging? ______ is first line imaging study

A
  • CT without contrast= first line

- -this helps r/o intracranial bleed

24
Q

What symptoms associated with HAs require neuroimaging?

A

-Focal neurological signs
-Onset of headache with exertion or sexual activity
-Worst HA of life
-CHI with LOC
(THESE are all secondary causes)

25
Q

What symptoms associated with HAs maybe require neuroimaging?

A
  • CHI without LOC
  • Recent significant change in headache pattern
  • Progressive worsening of HA despite appropriate therapy
  • Onset after age 50

CHI=closed head injury

26
Q

Research has shown that HA _______ are more helpful for clinicians than labs or imaging in most cases

A

diaries/logs

27
Q

Primary HA’s: Migraines

-___% in women, ___% of men have migraines

A

Even though tension headache is more common, most of the disability we see in the office is from migraine

-18% of women and 6% of men have migraines

28
Q

Primary HA’s: Migraines

-characteristics that suggest migraine are:______

A

**HAs lasting 4-72 hours, unilateral pain, throbbing pain, HA worsens with exercise/activity, moderate to severe pain, associated nausea, vomiting, and light and sound sensitivity

29
Q

___% of patients with migraine have an aura that occurs before or at the onset of the HA and is most often visual but may be sensory, linguistic, or motor

A

30%

-Pts with aura are at increased risk of stroke

30
Q

Primary Headaches – Migraine, dxInternational Headache Society

A

Migraine w/out Aura:
A. at least 5 attacks fulfilling criteria B-D
B. HA attacks lasting 4-72 hrs
C. HA has at least 2 of the following characteristics:
-unilateral
-pulsating quality
-mod or severe intensity (inhibits or prohibits daily activities)
-aggravated by walking stairs or similar routine physical activity
D. during HA, at least 1 of the following:
-N and/or Vomiting
-Photophobia and phonophobia

Migraine w/ aura criteria:
A. at least 2 attacks fulfilling criteria B below
B. at least 3 of the following 4:
-1 or more fully reversible aura Sx indicating focal,cerebral, cortical, and or brainstem dysfunction
-at least 1 aura sx gradually develops over more than 4 min, or 2 or more sx occur in siccession
-no aura sx lasts longer than 60 min
-HA follows aura with a free interval of less than 60 min
C. Hx, physical and neuro exam do not suggest any underlying organic disorder

31
Q

Primary Headaches – Migraine, Tx

-What tx leads to better outcomes?

A

**Treating migraine early (during the first two hours of the attack) leads to better outcomes

32
Q

Primary Headaches – Migraine, Tx

-episodic HA syndromes can progress into ______

A

chronic HA syndromes if undertreated – we too often undertreat headaches

33
Q

Primary Headaches – Migraine, Tx

-Set treatment expectations IMMEDIATELY –to:

A
  • ** 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)
34
Q

Primary Headaches – Migraine, Tx

-treatment goals:

A 
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
35
Q

Migraine tx options: list preventative meds

A

Antidepressants
Anticonvulsants
Beta-blockers
CCB

36
Q

Migraine tx options: list abortive meds

A 
NSAIDs, APAP, ASA
Triptans – Sumatriptan (Imitrex)
Combinations – butalbital/APAP/caffeine (Fioricet)
DHE
Narcotics
37
Q

Most patients with mild-to-moderate migraine will respond to _______ (meds)

-pros and cons of caffeine containing meds?

A

OTC analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, acetaminophen, and combinations containingcaffeine

-Caffeine-containing combinations may be somewhat more effective but also have a higher risk of bringing on rebound HAs

38
Q

when are abortive meds taken?

A

Pt develops migraine (break through migraine while Pt is on preventative tx) and this is when they should take the abortive med

39
Q

Aspirin may be a particularly good choice for migraine tx, if tolerated, as it is cardioprotective rather than increasing cardiovascular risks, as most NSAIDs do.
Which Pt population should use caution with Aspirin as HA tx?

A

Caution in patients whom you suspect SAH!

40
Q

Primary Headaches – Migraine, Tx

  • Pts who have more than one day of headache per week, who miss work because of their headaches, or have associated complex symptoms can benefit from migraine-preventive treatment rather than just treatment of each acute headache attack
  • Preventive therapy often takes ____ weeks to become effective
A

8 to 12

41
Q

Preventative Migraine tx:

Particularly good OTC/supplement treatments to prevent migraine include _______

A
  • Petadolex® brand butterbur
  • Magnesium supplements
  • Coenzyme Q10
42
Q

Petadolex® brand butterbur: how is this OTC med effective for migraine tx?

A

– Petadolex is effective in both adults and children and is very well-tolerated. A brand such as this, which has been purified of potentially toxic alkaloids, is an important consideration when using butterbur.

43
Q

Magnesium supplements are especially good for which Pt population with migraines?

A

Magnesium is especially beneficial for patients with aura, and when given at bedtime can also help sleep and sleep quality.

44
Q

how is Coenzyme Q10 goof for migraine tx?

A

Coenzyme Q10 has also been effective but can be more expensive than other choices. Coenzyme Q10 also lowers blood pressure slightly which is of value for some patients.


45
Q

list 3 classes of meds and ex’s that are good for migraine prevention (As and B’s for quality of evidence)- these are first line medication classes**

A
  • Antiepileptics: gabapentin, topiramate
  • antidepressants: amytriptiline, Nortriptiline, Fluoxetine
  • Beta-blockers: propranolol, timolol, atenolol
46
Q

List other classes of meds used for migraine prevention (2nd/3rd line)

A
  • Ca channel blockers: diltiazem, verapamil
  • NSAIDs: aspirin, ibuprofen, naproxen
  • Serotonin antags: cyproheptadine
  • Other: Feverfew, riboflavin
47
Q

Patients with migraine with aura are at increased risk of _________.
What can exacerbate this risk?

A

heart attack and stroke, particularly occipital stroke

**Therapy with estrogen hormones, particularly at doses in oralcontraceptives, can exacerbate this risk. Opinions differ on whether this is a relative or an absolute contraindication to their use. At a minimum, having and documenting a discussion of risks/benefits and alternatives is of value in this circumstance.


MUST document really well why you are prescribing an OCP to a pt with migraines w/ auras

48
Q

Rebound HAs: define

A

a recurring HA that is induced by repetitive and chronic use of acute medications.

  • -Rebound is a self-sustaining clinical phenomenon, which makes acute med use ineffective until meds have been withdrawn and washout or med withdrawal occurs.
  • -Medication induced or medication misuse HA has been referred to as drug-induced headache, analgesic rebound headache, and ergotamine rebound headache.
  • -**Nearly all medications used to treat HA can lead to rebound
  • Opioids, caffeine
49
Q

Common migraine triggers:

  • lifestyle? (list)
  • foods?
  • Pysical?
  • Environmental?
A

Lifestyle:

  • emotional stress
  • depression
  • too little sleep
  • exercise or overactivity
  • skipping meals/fasting

Food:
chocolate, Nuts/peanut butter, cheese/yogurt, sour cream, red wine or other alcohol, processed meats, monosodium glutamate (MSG)

Physical triggers:
menstrual cycle or hormonal changes

Environmental:
weather or seasonal changes, travel through different time zones, odor/pollutants, bright light

50
Q

HA pitfalls (list Ex’s)

A
  • Misdiagnosing migraine
  • Over treating HAs with medications linked to rebound HA
  • Under-treating migraine, limit of abortive treatments in lieu of analgesics
  • Blaming headaches solely on stress
51
Q

When to refer pts with chronic HAs to neurology?

A

Most pts with headache, even chronic, can be managed in Primary care

  • Consider obtaining a head CT (if not already done) and sending to neuro IF:
  • <5 or >50 years old
  • Progressive HAs despite treatment
  • History of cancer
  • Uncertain dx
52
Q

A 46 year old woman presents your urgent care for evaluation of a “migraine.” Pt states the headache started yesterday morning and has continued.
O – yesterday morning (approximately 24 hours PTA)
L – diffuse
D – constant since onset, not increasing or decreasing in intensity
C - “pressure,” not worst of life, has never had this type of HA before
A - - photophobia, - phonophobia, + N, - V, no neuro deficits, no recent head injury, no f/c, no neck stiffness, denies systemic complaints
A – Excedrin helped for about 4 hours yesterday, only took one dose. Lights and loud noises make worse. No positional or exertional component.
R – no
T – constant since onset
S – 6/10

PMH – hypothyroidism, G2P2
Meds – synthroid 112mcg QD, MV
Allergies: NKDA
Surgical: C/S x 2
Social: occ ETOh, no tob or illicits. Accountant. Daily exercise.
Family: M: 72, alive, HTN, OA F: 72, alive, CAD No FHx of CVA, migraines

PE: VS all normal
Full PE unremarkable except mod distress, wants lights off

Assessment and plan?

A

**Case 1= Acute headache. Tx is aimed at controlling pain from this current HA.

–Pt is in UC for HA– pain control is reason for visit. Pt has no red flags and Is not on chronic pain meds.

Assessment: HA (pt does not meet criteria for dx migraine)
Plan: break the HA with medications – LOTS of choices!
PO, IM, IV?
Narcotics or no?

Case 1– no concerning factors, no secondary causes likely. Goal: control current pain, w/ abortive meds. Give them the migraine cocktail in the ED setting: Benadryl + Reglan (metoclopramide) is a dopamine antagonist that is used as an antiemetic (anti-vomiting) agent used to treat nausea, vomiting + Compazine + caffeine+ acetaminophen . +/- torodol—causes increased bleeding risk, use caution with this med
-dehydration is also a significant cause for a HA, may be contributing. Pt may improve with IV fluids

53
Q

Acute HA cocktails:

A

Benadryl 25-50mg IM/IV + Compazine 10mg IM/IV or Reglan 10mg IM/IV or Phenergan 25mg IM/IV
-** +/- Toradol 30mg IM/IV – CAREFUL!

Narcotics only if necessary!!! last resort

54
Q

A 46 year old woman presents your primary care clinic for evaluation of headaches. She states that over the last 2 months she has had several headaches.
O – few headaches per week for last 2 months
L – “behind left eye,” “throbbing”
D – intermittent, each lasts about 8 hours
C - “pressure,” not worst of life, has missed several days of work with a HA
A - + photophobia, + phonophobia, + N, - V, no neuro deficits, no recent head injury, no f/c, no neck stiffness, denies systemic complaints
A – Excedrin helps. Lights and loud noises make worse. No positional or exertional component
R – no
T – intermittent, no HA currently
S – 6/10

PMH – hypothyroidism, G2P2
Meds – synthroid 112mcg QD, MV
Allergies: NKDA
Surgical: C/S x 2
Social: occ ETOh, no tob or illicits. Accountant. Daily exercise.
Family: M: 72, alive, HTN, OA F: 72, alive, CAD No FHx of CVA, migraines

PE: VS all normal
Full PE unremarkable except mod distress, wants lights off

Assessment? Plan?

A
  • Chronic headaches–>Tx is aimed at prevention
  • Pt meets criteria for migraine dx. No red flags. Is currently pain-free – needs preventative tx.
  • Discuss w/ her how it is appropriate to place her on preventative therapy (ie propranolol) to minimize HAs AND also prescribe abortive therapy like Imitrex

Clinical Decision Making II-Fall 21' (5 decks)

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