HA Flashcards
What is the 6th most disabling disorder in the world?
Migranes
How are HAs classified?
- Primary (90%)
- Secondary
- Neuropathies & facial pains
What are primary HAs composed of?
- Migraines
- Tension HAs
- Cluster HAs
What are red flags?
- Abrupt onset of severe HA (“thunderclap”
- Trauma associated HA w/ neurological deficit/ worsening sx
- Focal neurological sx
- Change in HA presentation
- Systemic sx/illness
- New onset in pt w/ CA or HIV
- New onset after 50 yo
- Wakes from sleep
- Jaw claudication/temporal tenderness
- Posture, exercise, valsalva provoked
What is the MC type of HA leading to pts seeking medical attention?
Migraines
Migraines are most common in what population?
- White females
- Low SES
- Genetically predisposed (1st degree relatives)
- Obese
- Depression/anxiety
What triggers can cause a migraine?
- Emotional stress
- Hormones (women)
- Not eating
- Weather
- Sleep disturbances
When do migraine prodrome sx typically appear?
24-48 hours prior to HA
What are prodrome sx of a migraine?
- Yawning
- Depression
- Irritability
- Cravings
- Constipation
- Neck stiffness
What are characteristics of a migraine aura?
- Gradual, over 5 mins
- Duration of 5-60 mins
- Visual: shimmering or scintillating shapes/lines
- Sensory: tingling on 1 side of face or limb
- Language: dysphagia, difficulty w/ wording
- Motor: weakness of face & limbs on 1 side
What are characteristics of migraine HA?
- Duration 4-72 hrs
- Unilateral
- Throbbing, pulsating
- Mod-severe pain
What sx are associated w/ a migraine HA?
- N/V
- Photophobia
- Phonophobia
- Osmophobia
- Cutaneous allodynia
What is 1st line tx for migraine mild-mod attack?
NSAIDs (ibuprofen, naproxen, indomethacin, diclofenac, ketorolac)
- More effective if given early
What is 2nd line tx for migraine mild-mod attack?
Acetaminophen (Tylenol)
- Use if NSAID contraindication or previously unsuccessful
What is 3rd line tx for migraine mild-mod attack?
ASA/Acetaminophen/Caffeine (Excedrin)
- For intermittent use
- Common cause of med-overuse HA
What is 1st line tx for migraine SEVERE attack?
Serotonin agonists “Triptans”
- Sumatriptan
- Zolmitriptan
- Eletriptan
What can happen if you use a “triptan” for > 2-3 times/wk?
Can lead to daily dull HA or migraine-like overuse HA
What is 2nd line tx for migraine SEVERE attack?
Ergotamines
- Dihydroergotamine
- Ergotamine/caffeine
What is alternative tx for migraine attack?
Opioids
- Regular use can lead to tolerance, opioid-induced hyperalgesia, & med overuse HAs
- Abuse & dependence
What is adjunct tx for migraine attacks?
- Antiemetic: For pts w/ N/V
- Metoclopramide
- Prochlorperazine
- Promethazine - Hydration
What type of pts should you administer migraine prophylaxis?
- Pts w/ frequent (≥ 3 attacks/month), recurring & disabling sx
- Migraines lasting over 48hrs
How do you prevent migraines?
Avoid triggers & modify behavior
- Regular meals, exercise, sleep hygiene
- Relaxation techniques, CBT
What was recently FDA approved for chronic migraine?
Botulinum toxin
- Inject into face, neck, head
How do you dx migraines?
Based upon subjective & objective findings
What is the MC primary HA disorder? What population is mostly affected?
- Tension HA
- Mid teens to < 50, Men
What are the RFs for tension HAs?
- stress/anxiety
- depression
- too little or too much sleep
- OSA
- muscular tension
- cervical spondylosis
What are the clinical findings of tension HAs?
- daily or episodic HAs lasting from 30mins to 7 days
- Bilateral
- Pressing/tightening
- Mild-mod intensity
- Increased tenderness of pericranial tissue
What is the 1st line tx for acute tension HA attack?
- NSAIDs (ibuprofen = drug of choice, naproxen)
- Acetaminophen
- ASA
When are tension HAs considered “chronic”?
If > 7-9 HAs per month
How do you tx chronic tension HAs?
Amitriptyline
- Reduces frequency & intensity
- Start w/ low dose
What is non-pharmacological therapy for tension HAs?
- CBT, relaxation, EMG
- PT, acupuncture, spinal manipulation
What is the least common primary HA d/o? What population is most affected?
- Cluster HA
- > 30 yrs (peak in 40s), men
What are RFs for cluster HAs?
- 1st degree relative
- prior head injury
- ciggs
- high alcohol
- male
- type A personality
What are triggers of cluster HAs?
- d/o of circadian rhythm
- sleep
- volatile smells
- smoking
- sildenafil
How do cluster HAs present?
- 15 to 180 mins, up to 8 times/day
- Piercing, exploding, penetrating
What are the 2 forms of cluster HAs? Describe them.
- Episodic (80-90%): lasts 2-16 wks followed by free period of 6 mos to yrs
- Chronic: no sustained free episodes for > 1 month
What are sx of a cluster HA?
On the affected side:
- injection, lacrimation
- eyelid edema
- Miosis, ptosis
- nasal congestion, rhinorrhea
- forehead & facial sweating
- Fullness in ear
How do you tx acute cluster HAs?
- 1st line = O2 & sumatriptan/ zolmitriptan
- Prednisone taper
- Intranasal lidocaine
What can be used for prophylaxis of cluster HAs?
CCB verapamil
Secondary HAs can be attributed to…
- head/neck trauma
- vascular d/o
- non-vascular intracranial d/o
- substance or its withdrawal
- Infection
- d/o of homeostasis
- psychiatric d/o
What type of HAs are considered secondary?
- Post-concussion
- Analgesic rebound
- Pseudotumor cerebri
- Temporal arteritis
- Trigeminal neuralgia
- Subarachnoid hemorrhage
What are features of a concussion? What is it caused by? What does it result in?
Mild TBI
- Caused by direct blow
- Results in rapid onset of neurological impairment that resolves spontaneously
What type of imaging is used to r/o intracranial hemorrhage?
CT & MRI
How are concussions managed?
Rest (physical & cognitive)
What are drug rebound HAs (AKA - overuse HAs) related to?
Acute symptomatic meds:
- opioids
- butalbital/analgesic
- ASA/acetaminophen/caffeine
What is the most significant factor in the development of rebound HAs?
Lack of awareness by health providers & pts
What are sx of rebound HA?
- nausea
- asthenia
- difficulty concentrating
- memory problems
- irritability
When do rebound HAs resolve?
2 months after discontinuation of analgesia
What is pseudotumor cerebri? What population is most affected?
AKA - idiopathic intracranial HTN
- Women of childbearing age
What are the MC presenting sx of pseudotumor cerebri?
- variable, non-specific
- pain of unusual severity
- intermittent or persistent
- +/- exacerbation w/ changes in posture
- +/- relief w/ NSAIDs or rest
What are PE findings of pseudotumor cerebri?
- Papilledema *
- Visual field loss
- Abducens palsy
How do you tx pseudotumor cerebri?
- wt loss
- decrease Na
- carbonic anhydrase inhibitors
- loop diuretics
- serial LPs
- optic nerve fenestration
- CSF shunting
Describe: temporal arteritis. What population is most affected?
AKA - Giant cell arteritis
- MC systemic vasculitis
- Peak = 70-79 yo
What is the clinical presentation of temporal arteritis?
- Abrupt or insidious
- HA
- Neck, torso, shoulder, pelvic pain
- jaw claudication
- fever
- constitutional s/s (malaise, wt loss, night sweats)
What are PE findings of temporal arteritis?
- 50% have tenderness over SF temporal artery
- nodularity/thickening over SF temporal artery
- scalp pain
- 10% develop central retinal artery occlusion
What is the hallmark of GCA?
Elevated ESR & CRP
What is the standard diagnostic procedure for temporal arteritis?
Temporal artery biopsy
How do you tx temporal arteritis?
High dose corticosteroids due to danger of blindness
- Sx improve in 72hrs
Describe trigeminal neuralgia. What population is most affected?
“Tic Douloureux”
- compression of trigeminal root
- Peak = 60-70 yo
- MS pts, females
What are clinical features of trigeminal neuralgia?
- sharp electric shock, lasting few secs to several mins
- may be triggered by simple actions
What are dx studies for trigeminal neuralgia?
- Based on H & P
- MRA w/ gadolinium
What are red flags of TN?
- trigeminal sensory loss
- bilateral
- < 40 yrs of age
How do you tx TN?
- Antidepressant & anti-seizure (carbamazepine effective)
- Narcotics rarely effective
- Surgical decompression
What are RFs for subarachnoid hemorrhages?
- HTN
- Smoking, alcohol
- sympathoimetic drugs
- polycystic kidney disease
- coarctation of aorta
- marfans
What are sx complaints of SAHs?
- sudden onset worst HA of life
- worse on exertion
- N/V
- meningism
- neck stiffness
SAH emergency workup should include…
Noncontrast CT
- If negative, get LP
How do you tx SAH?
Emergent surgery
- Surgical clip
