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Clinical Medicine > HA and facial pain > Flashcards

HA and facial pain Flashcards

1
Q

Common headaches

A
  • tension
  • migraine
  • chronic daily headache (rebound)
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2
Q

Scary headaches

A
  • increased intracranial pressure “worst HA of my life” (bleeds)
  • progressive HA (tumors)
  • temporal arteritis (systemic vascular inflammation - eyesight problems)
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3
Q

HA

A
  • all about the history
  • really no exam finding
  • tension (women >male)
  • migraine (women > male) -strong familial component
  • most important question: are you taking something for the HA and how often
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4
Q

Location / Quality

A
  • unilateral, bilateral, frontal, occidental, temporal, eye/sinuses
  • dull, sharp, lancinating, steady, throbbing, single location, radiation?
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5
Q

Timing/Pattern

A
  • timing really matters
  • usual vs. new
  • pattern: varying during day, related to work stress, menses, clusters
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6
Q

Aggravating factors

A
  • stress
  • photo / phono phobia
  • menses
  • caffeine
  • foods
  • positional
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7
Q

Alleviating factors

A
  • sleep
  • medication
  • excercise
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8
Q

H & P

A
  • looking for causes that need immediate tx
  • vascular: hemorrhage, clot, vasculitis, aneurysm, HTN
  • infection
  • intracranial masses
  • preeclampsia
  • carbon monoxide poisoning (main sx is HA)
  • if they have thunderclap HA, HIV, or elderly need to get imaging even if physical is normal
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9
Q

Red flags

A
  • progressive HA
  • “worse HA of my life”
  • change in intensity, frequency, other characteristics, “familiar” HA
  • new severe HA in adult
  • meningeal signs
  • jaw claudication (reduction of arterial blood flow)
  • HA that disturbes sleep
  • cough induced HA
  • HA q/ focal neurologic
  • post lumber puncture HA
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10
Q

Whom to scan emergently

A
  • first and worst HA
  • abnormal neurological exam
  • abnormal mental status
  • abnormal funuscopic exam (papilledema)
  • meningeal signs
  • new headache over age 50
  • HIV positive
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11
Q

PE

A
  • temp: think meningitis
  • Kernig’s: flex hip, extend knees and pain (meningitis)
  • Brudzinski’s: flex neck, hand on chest, knee and hip flexion is positive sign (meningitis)
  • HTN: malignant HTN, preeclampsia, pheochromocytoma
  • scalp tender might be temporal arteritis
  • usually nonspecific exam
  • search for neurologic signs
  • neck muscle tenderness, spasm, relief of HA w/ pericranial muscle massage (prob tension)
  • palpate temporal arteries for tenderness
  • TMJ exam
  • sinuses
  • teeth/gum
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12
Q

Vascular HA

A
  • migraine, cluster, inflammatory, HTN
  • pulsatile/throbbing
  • pain related to vasodilation
  • caffeine withdrawal
  • Viagra HA
  • neurokinin: pro-inflammatory relative of bradykinin
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13
Q

Migraine

A
  • periodic, debilitating HA associated with n/v
  • migraneurs have hypersensitivity often to multiple stimuli and in multiple systems
  • multiple drug sensitivities common
  • current: theory: brain is involved, but pain is still partly vascular (vasoconstriction followed by vasodilation)
  • Trigeminal hypersensitivity innervation of cranial vessels and dura with inflammatory changes in peripheral targets
  • recurrent migraines will always be in the same location and feel the same
  • complicated migraines look just like a TIA
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14
Q

Migraine w/o aura

A
  • headache for 4-72 hours
  • has 2/4: unilateral pain, throbbing pulsatile quality, moderate to severe in intensity, aggravation by routine activity
  • and 1 of: nausea and/or vomiting, photophobia and/or phonophobia
  • include 5 previous attacks and no underlying disease
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15
Q

Caffeine withdrawal

A
  • causes vasoconstriction

- get vasodilation when stopped causing rebound HA

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16
Q

Calcium channelopathy

A
  • rare
  • genetic alterations in Ca channels and hypersensitivity to stimuli
  • probably genetic
  • triggers may be involved (nitrates, chocolate, menses)
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17
Q

Clinical signs and sx of migraines

A
  • Classic: with aura 20%
  • Common: w/o aura 80%
  • pain: usually lateralized (but can be bilateral), usually throbbing, builds up slowly and lasts several hours or longer
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18
Q

Migraine with Aura

A
  • headache follows aura
  • has 3 of the following:
    • 1 or more fully reversible sx indicating focal, cerebral, cortical, and/or brain stem dysfunction
      - develops gradually over more than 4 minutes or 2 or more sx occur in succession
      • no sx more than 60 min
      • HA before or within 60 min
  • if they have an aura it will be the same every time
19
Q

Special cases with aura

A
  • rarely get aura and no migraine (migraine w/o pain, migraine equivalent)
  • aura generally resolves (rarely permanent neurologic deficit)
  • AURA EQUALS DOUBLED STROKE RISK but baseline risk usually low
20
Q

Aura

A
  • focal disturbances of neurologic function
  • precede or accompany pain
  • visual: field defects, flashing lights to side opposite of pain
  • may include aphasia, numbness, tingling, clusiness, or weakness
  • generally resolves before or with pain
21
Q

Migraine tx

A
  • NSAIDs, Tylenol (APAP)
  • sleep
  • vasconstrictors (ergot, caffeine)
  • TRIPTANS (sumatriptan): acts centrally on 5-HT 1b/1d receptors - potent vasoconstriction (go to drugs)
  • antipsychotic (compazine): related rx, beyond hypnotic effect
  • combination of drugs tends to work better than one alone
  • narcotics don’t work well for migraines
22
Q

PE of migraines

A
  • critical: vital signs, neurologic exam and vision testing w/ funduscope (looking for IOP and papillaedema)
  • pt may appear uncomfortable
  • if aura may have focal neurologic deficit
  • most likely exam normal
23
Q

Lab and diagnostic testing for migraines

A
  • new onset migraine, may desire to do tests to rule out secondary causes (evaluation of new acute HA)
  • typical migraine HA (none needed)
24
Q

Migraine triggers

A
  • top 3: stress, lack of sleep, and hunger

- others: hormonal changes, weather changes (pressure), food (chocolate, nitrates), dehydration

25
Q

Prophylaxis of migraine when

A
  • more than 4 per month (according to insurance)
  • guidelines:
    • 2+ per month with 3 or more days of disability
      - contraindications, failures or intolerance w/ acute tx
      - use of abortive meds more than 2x/wk (triptans)
      • complicated migraines
26
Q

Prophylaxis migraine how

A
  • beta blockers and Ca channel blockers (really any antihypertensive helps)
  • tricyclic antidepressants
  • gabapentin (or other anticonvulsants)
  • SSRIs in depressed pt
  • avoidance of triggers
  • Exercise
27
Q

CGRP drugs for migraine

A
  • Mab drugs
  • infusion every 3 months for prophylaxis
  • down side: potential anaphyaxis, develop antibodies, expensive
28
Q

Sinus HA

A
  • pain can come for sinuses
  • tx sinuses the HA will resolve
  • chronic sinus HA may begin as sinusitis, but evolves
  • will respond to migraine-specific tx
  • chronic use of sinus medications - rebound headache
  • erosion of sinuses into CNS is a “scary HA” and needs immediate attention, but this is rare
29
Q

Tension HA

A
  • due to extracrainal structures
  • No focal neurologic deficit
  • bilateral pain
  • non-pulsating (pressure feeling), band like
  • not aggravated by activity
  • may inhibit but not prohibit activity
  • no n/v
  • minimal photophobia
  • most will successfully self-medicate with OTC
  • can use NSAIDS, benzodiazepines, tricyclic antidepressants, lifestyle changes
  • triptans for refractory or severe
  • prophylaxis
30
Q

Cluster HA

A
  • Men > women
  • unilateral, transient, very severe, often incapacitating
  • non throbbing, not worse w/ activity, pt often restless, may pound on head
  • ipsilateral nasal congestion, lacrimation, redness, tearing, Horner’s syndrome
  • +/- triggers
  • “feels like stabbing to eye”
31
Q

Cluster HA tx

A
  • frequently ineffective
  • 100% O2 is the best
  • triptans/ergotamine
  • Ca channel blockers (verapamil) - next best
  • indomethacin for indomethacine sensitive hemicranias
  • intranasal 4% lidocaine
  • prophylaxis w/ beta blockers, CCB, tricyclices, anticonvulsants, steroids
32
Q

Cluster vs Migraine

A
  • Cluster: male>female, suddent, retro orbital, short duration, nocturnal, pt pacing
  • migraine: female>male, gradual, uni or bilateral, last hours, variable times of day, pt bedrest
33
Q

Horner syndrome

A
  • sx due to impaired sympathetic innervation to the eye and nearby skin glands
  • Ptosis
  • miosis and dilation lag
  • anhydrosis (lack of sweating of ipsilateral face/brow)
  • syndrome not a dx
34
Q

Other facial pain

A
  • postherpetic neuralgia (CN V affected) - after herpes zoster outbreak (very painful)
  • sinusitis
  • dental pain
  • TMJ pain
35
Q

Transformed migraine

A
  • chronic daily HA that usually starts as a migraine, but can originate as tension HA
  • usually involves daily drug use of HA (makes better but does not get rid of it)
  • rebound headache
  • rebound can be from any drug used to tx HA including decongestants
36
Q

Neuropathic pain

A
  • Trigeminal nerve pain (sensory_
  • tx w/ anticonvulsants for lancinating/neuropathic pain
  • Tegretol (carbamazepine) works best
  • low does amitryptiline or nortyptiline very effect for pain (especially in diabetic neuropathy)
  • Gabapentin
  • Lyrica
  • Cymbalta
37
Q

Neuopathic pain vs cluster HA

A

Neuropathic: pain in cheek/jaw and more constant

-cluster: pain behind eye and short duration

38
Q

Temporal arteritis presentation

A
  • over 50
  • unilateral HA w/ tenderness to palpation of temporal artery
  • possible hx of jaw claudication
  • elevated ESR/CRP (have really high SED rates - over 100)
39
Q

Temporal arteritis management

A
  • oral prednisone (high dose for a long time) - reduce inflammation and risk of thrombus/blindness
  • urgent ophthalmology consult
  • temporal artery bx before steroids take effect (stop steroids if bx is not TA)
  • very slow taper from steroids, monitoring ESR/CRP
40
Q

Temporal Patterns of HA

A
  • migraine: common, but comes in episodes and has a pattern
  • tension HA: always there and never go away - low level (dull and squeezing)
  • Cluster HA: cluster in time (period where you have a bunch then a long break then another cluster
  • brain tumor: progressive HA
41
Q

Clinical features: aura

A
  • migraine w/ aura: focal neurologic deficits
  • migraine w/o aura: no focal neurologic deficit
  • tension HA: no focal neurologic deficit
42
Q

Clinical features: HA & associated symptoms

A
  • migraine w/ aura: unilateral, throbbing/pulsating, aggravated by activity, inhibits/prohibits activity, +/- n/v, photophobia, phonophobia
  • migraine w/o aura: unilateral, throbbing/pulsating, aggravated by activity, inhibits/prohibits activity, +/- n/v, photophobia, phonophobia
  • tension HA: bilateral, non-pulsating, not aggravated by activity, may inhibit, but not prohibit activity, no n/v, minimal photophobia
43
Q

Temporal Arteritis

A
  • systemic vascular inflammatory condition
  • inflammation causes tenderness of arteries, especially temporal
  • can cause retinal artery occulsion and blindness from thrombus/embolism

Clinical Medicine (19 decks)

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