Exam 1: Headaches Flashcards
What are the red flags of a headache in and adult?
Sudden onset Worst or first headache ever Thunder clap headache Fever, neck stiffness (meningitis, encephalitis?) Mental status changes New headache in patient <5 or >50 Worsening pattern to a chronic headache Focal neurological signs (other than aura) Papilledema
What are 3 types of headaches, typically seen in primary care, that have no specific cause?
Migraine
Tension-type
Cluster
T/F: Primary headaches do not have a specific cause?
True
T/F: Secondary headaches have an underlying structural or metabolic cause?
True
T/F: Migraines, tension, and cluster headaches are secondary headaches?
False; they are all examples of primary headaches
T/F: Mild HTN can cause a headache?
False; must have malignant HTN to cause a headache
T/F: Eye strain is a common cause of headache?
False
What patient history is important for headache?
Any aura or prodrome Number/frequency per month Family history (especially females of family) Recent trauma Time and mode of onset Age of onset Changes in vision Quality, site, radiation of pain Precipitating/relieving factors Response to previous treatments Changes in sleep, exercise, weight, or diet Birth control method Effects of menses Change in work and lifestyle
What is included in the physical exam for headache?
BP, heart rate
Listen for carotid bruit in neck
Palpate head, neck and shoulder areas (rule out sinus isues)
Check temporal/neck arteries
Examine spine and neck muscles for tightening
What is included in the neuro exam for a headache?
Cranial nerves Fundoscopic exam (papilledema, etc) Tandem gait (walk straight line) Romberg test Symmetry of motor, sensory, and reflex skills
What are symptoms of a migraine headache?
Pain: pulsatile, throbbing, unilateral
Nausea/vomiting
Photophobia/Phonophobia
What are symptoms of a brain tumor?
Can have pain at any time, day or night; can awaken person from sleep
What are symptoms of a tension-type headache?
Pain: band-like, dull, nagging, vice-like, steady, non-throbbing
Location: usually bilateral
*** No N/V or photo/phonophobia
What are the indications for sending a patient for imaging for headache?
Worst headache ever
Unexplained abnormal neuro exam finding
Recent change in pattern, frequency, or severity
Progressive worsening despite appropriate treatment
Onset with exertion, cough, or sexual activity (could suggest lesion/mass)
Onset after age 40-50
What imaging/procedure would you order for worst headache ever?
CT (quick check for bleed)
Lumbar puncture if concern for meningitis
Name some common migraine triggers
Foods (chocolate, cheese, red wine, msg, nitrites, fried foods, oranges) Menses Change in weather Stress Alcohol Hunger Fatigue or lack of sleep Loud noises Flickering lights Noxious stimuli (perfumes, etc) Nitroglycerin Minor head trauma Exertion Surgical menopause
Which headache is most common: migraine, tension, or cluster?
Tension headache is most common but patients usually present for treatment of migraine as they can treat at home for tension headache
T/F: All migraine sufferers get an aura 30-60 minutes prior to the headache?
False: Only about 20% of migraines have auras (mostly visual)
What is scotoma?
Partial vision loss, loss of visual field, or blind spot in vision (aura)
What is the criteria to diagnose migraines?
Attacks lasting 4-72 hours
Normal neuro exam
No other reasonable cause for headache
AND, at least 2 of the following: Unilateral pain 60% of time Throbbing/pulsating pain Aggravation by movement or activity Moderate to severe intensity
PLUS, at least 1 of the following:
Nausea and vomiting
Photophobia or phonophobia
What are common abortive treatments for mild migraine symptoms?
OTC: NSAIDS, APAP, ASA, Excedrin, caffeine
If one NSAID doesn’t work, try another one
Prescription: Triptans, Fioricet
- Early treatment is most effective
- Large, single dose works best
- Over use of Fioricet can cause rebound headaches
What are common abortive treatments for moderate to severe migraine symptoms?
- Moderate inhibits daily activity but not incapacitating
OTC: NSAIDS, Aleve, antiemetics for N/V
Triptans especially in combination with Aleve
Benzos can be used to get the patient to sleep (possibly breaking the migraine) - Severe incapacitating should go to ED for IV treatment
What is the first-line preventative (prophylactic) treatment for migraines?
Beta blockers (propranolol) - most effective treatment studied
CCB (verapamil) - not as effective as a BB but may relieve aura
Tricyclic antidepressants (amitriptyline)
Anticonvulsants (valproate/Depakote, topiramate/Topamax) [BLACK BOX WARNING: risk for suicide for those with major depression]
** If first-line doesn’t work, refer to neuro
Define episodic tension headache
At least 2 of the following:
Pressing/tightening, non-pulsating, squeezing, vice-like
Mild to moderate intensity (inhibits but does not prohibit activity)
Bilateral
No aggravation from routine physical activity
Both of the following:
No nausea or vomiting
Photophobia or phonophobia absent, or only one present
What are the treatments for tension headaches?
OTC: APAP, ASA, NSAIDs (start with ibuprofen), Aleve
Triptans NOT helpful
If OTC does not work may add caffeine but can cause rebound headaches
Prophylaxis usually unnecessary but if prescribed - Amitriptyline
What are the characteristics of a cluster headache?
Severe “ice pick” piercing pain behind one eye and temple
Tearing
Rhinorrhea
Ptosis
Miosis (extreme constriction of pupil) on one side (Horner’s syndrome)
Typically affects middle aged males
What is the treatment for a cluster headache?
Oxygen at least 12L with mask for 15 minutes
Sumatriptan (Imitrex) by injection or intranasal
Prophylaxis: verapamil daily
What are the red flags in pediatric headaches?
Patient < 5 New onset Focal neurological signs Nocturnal awakening with headache Difficulty waking child in the morning Vomiting Significant change in headache pattern Papilledema Head trauma with LOC > 10 minutes Inability to control headache with appropriate treatment
T/F: Pediatric migraines are bilateral and often shorter in duration than an adult’s.
True: pediatric migraines are often bilateral
What are the abortive treatments for pediatric migraines?
OTC: NSAIDs most effective, APAP (NSAIDs most effective per studies)
Antiemetics (suppositories, PO)
Sedatives (Benadryl, then benzos)
Triptans (not FDA approved for younger than age 18 but are used safely and effectively)
Sumatriptans > age 12
What are the most common headaches in kids?
Migraine
Tension
Secondary headaches in pediatric patients are usually due to _______.
Viral infections, possibly with:
Fever Sinusitis Pharyngitis Acute otitis media Mono Mild head trauma
T/F: Most headaches in kids/teens are not due to serious underlying disorders.
True
What is the risk of mixing triptans and SSRIs?
Serotonin syndrome (often begins within about 6 hours of taking the medication or increasing the dose)
Mild cases include high blood pressure and a fast heart rate; usually without a fever. Symptoms in moderate cases include high body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils…
T/F: Parents are the best source for patient history when seen for headaches?
False: Interview patient alone as well as with the parents. Children often describe history more accurately than their parents.
A patient complains of headache that occurs regularly and may worsen with changes in atmospheric pressure or when stooping. Which type of headache could this be?
Sinus headache
An older patient comes in with complaints of a headache to his right temple. He admits to tenderness to his scalp and the right temple. You examine his temple area and it is reddened and warm to the touch. What is your diagnosis?
Temporal arteritis; this is a medical urgency to prevent blindness
