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Head and Face Pain > Head and Face Pain Secondary Headaches > Flashcards

Head and Face Pain Secondary Headaches Flashcards

1
Q

What are secondary HA disorders defined as?

A

HA associated with:

  1. Head Trauma
  2. Vascular d/o
  3. Nonvascular Intracranial d/o
  4. Substance and Withdrawl
  5. Non cephalic Infection
  6. Metabolic d/o
  7. d/o of face and cranial structures
  8. Cranial Neuralgias and Nerve Trunk Pain
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2
Q

What are the RED FLAGS for secondary HA?

A
  1. New Onset HA
  2. Significant change in ongoing HA
  3. “Thunderclap”
  4. HA Triggers like sitting up, coughing, straining, sex, exertion activity
  5. HA with fever
  6. HA with underlying disease
  7. Abnormal neurological exam like papilledema, weakness, or mental status
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3
Q

What is the most important component in the evaluation of secondary HA?

A

Physical Examination, because these d/o are due to another physiological or pathological process

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4
Q

Which advanced diagnostic studies may be helpful in Dx 2’ HA?

A 
MRI
MRA
MRV
CT
Cerebral Angiography
Lumbar Puncture
Blood Laboratories
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5
Q

What are the 6 types of Head Trauma HAs?

A
  1. Acute post traumatic
  2. Chronic post traumatic
  3. Acute d/t whiplash
  4. Chronic d/t whiplash
  5. Traumatic d/t intracranial hematoma
  6. HA d/t other head or neck trauma
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6
Q

What are the first and second most common Sx’s following head trauma?

A
  1. HA

2. Dizziness

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7
Q

(T/F) Whiplash is a type of closed brain injury.

A

True

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8
Q

What are Post Traumatic HAs most frequently caused by?

A
  1. MVAs
  2. Athletic
  3. Neck Injuries
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9
Q

How does Post Traumatic HA present?

A

Chronic Intermittent
or
Daily HA

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10
Q

What is the clinical presentation of Post Traumatic HA?

A 
Dizziness
Difficulty Sleeping
Decreased Energy and Appetite
Blurred Vision
Cognitive Difficulties
Psychological Disorders
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11
Q

Head trauma may result in:

A

Intracranial Hemorrhage
Edema
Dural Tears leading to Low Pressure HA

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12
Q

What is common in PTH suffers?

A

Overuse of medication

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13
Q

What is the main pathophysiology paradigm of PTH?

A

Activation of Trigeminal Sensory r/c and continues nociceptive input resulting in maintained pain

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14
Q

In PTH, what are the sites of nociceptive input?

A 
Meninges
Blood Vessels
Skin and Subcutaneous Tissue
Periosteum
Neck mm. Vertebral joints and ll.
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15
Q

What is the pathophysiology of chronic PTH?

A

Central sensitization and biological changes secondary to the trauma

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16
Q

What is the relationship observed about PTH incidence?

A

Incidence of PTH is inversely proportional to the severity of head trauma

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17
Q

In PTH, what does imaging show?

A

Multifocal damage to the axons, d/t shearing and impaired axonal transport

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18
Q

In PTH, how long does the cascade d/t damage last?

A

Several Days

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19
Q

In PTH, where does the damage to the axons occur?

A

Near the junction of gray and white matter

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20
Q

What is almost implicated in the chronicity of PTH?

A

Downstream Deafferentation

Diaschisis

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21
Q

What is proportional to the clinical outcome of PTH?

A

Excess release of glutamate resulting in excitotoxicity

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22
Q

(T/F) PTH related glutamate excitotoxicity only occurs in moderate to severe head trauma?

A

False

This occurs in even mild cases of head trauma

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23
Q

In PTH, what changes with blood flow?

A

Decreased regional blood flow and inter hemispheric perfusion

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24
Q

In PTH, which regions are most affected by decrease blood flow and perfusion?

A

Basal Ganglia

Frontal Lobes

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25
In PTH, which Cx structures are involved?
AA-AO Joints ZP Joints and Vert Discs mm. and ll. of the Cx spine
26
Why doesn't head and neck pain follow dermatomal patterns?
D/t the convergence of first order trigeminal neurons and Cx afferents onto the second order neuron
27
What are the Tx therapies for PTH?
``` Patient Education Medication Psychotherapy PT CMT Occipital Nerve Block ```
28
What are the HA from vascular d/o's?
1. Giant Cell Arteritis (GCA) 2. Cranial Arteritis 3. Large Vessel Arteritis 4. System Inflammatory Syndrome 5. Arterial Dissection 6. Ischemic Stroke 7. TIA 8. Hemorrhage
29
What is GCA?
an immune mediated inflammatory condition affecting medium and large sized arteries
30
What is the first stage of GCA?
1. Activated T-cells and macrophages cause granulomatous changes in the artery walls 2. Release PDGF, metalloproteinases, and ROS that injure vessel wall 3. Vessel develops intimal hyperplasia leading to lumen occlusion
31
What is the second stage of GCA?
1. Macrophages release IL-1 and IL-6 promoting inflammatory cascade 2. Acute phase response seen in Liver, CNS, vascular tissue, bone marrow, and immune system resulting in distinct clinical syndromes
32
What clinical syndromes are associated with GCA?
Cranial Arteritis Large Vessel Arteritis System Inflammatory Syndrome with Arteritis
33
What is Cranial Arteritis?
Acute phase response involving branches of the carotid artery
34
What branches of the carotid artery are implicated in Cranial Arteritis?
``` Superficial Temporal Ophthalmic Occipital Posterior Ciliary Vertebral Arteries ```
35
What is the clinical presentation in GCA?
Scalp tenderness Temporal arteries tender and thickened unilateral or bilateral Jaw claudication with decreased flow to the masseter, temporals, and the tongue
36
What is AION?
Anterior Ischemic Optic Neuropathy
37
What is AION present with?
Posterior ciliary artery involvement
38
What is the presentation of AION?
Painless vision loss, sudden and often unilateral blindness
39
What is AION treated with?
Corticosteroids
40
What is Benign Cerebral Fluid Pressure HA due to?
1. High and low production of CSF 2. Reduced or increased absorption of CSF 3. Obstruction of CSH pathways
41
What is idiopathic intracranial hypertension also known as?
Pseudotumor Cerebri
42
Are there structural problems associated with Pseudotumor Cerebrr?
No
43
What are examples of High CSF pressure HAs?
1. Pseudotumor Cerebri 2. Intracranial Hypertension 3. Hydrocephalus
44
What causes Intracranial Hypertension?
Metabolic, toxic, or hormonal causes
45
What are examples of Low CSF pressure HAs?
1. Postdural Puncture 2. CSF Fistula 3. Idiopathic
46
How does a post dural puncture present?
Develops within 5 days Worse with sitting/standing Associated w/ tinnitus, neck stiffness, Nausea and photophobia
47
How does a CSF Fistula present?
D/t leaking Develops within 5 days Worse with sitting/standing Associated w/ tinnitus, neck stiffness, Nausea and photophobia
48
What is idiopathic low CSF pressure linked to?
Leaks of CSF
49
What is the current model of HA and Sleep d/o?
HA or Sleep Disturbance is Sx of 1' sleep disorder | HA and Sleep Disturbance is 2' to unrelated d/o, or common pathogenesis
50
What areas are involved with HA and Sleep d/o?
Hypothalamus 5HT Melatonin
51
What is wakefulness dependent on?
The reticular activating system (RAS) in brainstem and influenced by NE, DA, and ACh
52
What initiates REM sleep?
Release of ACh stim pontine neurons in the Dorsal Raphe Nuc (5HT)
53
What is the MOA of HA and Sleep d/o?
Wakefulness and REM sleep
54
How does REM sleep connect with central modulation of pain?
The dorsal raphe nucleus is part of both systems
55
What is the MOA in sleep d/o HAs that are Migrainous?
The Spinal Trigeminal Nuc activates the vasculature during migraine attacks
56
How is the hypothalamus implicated in HA and sleep d/o?
Involved with yawning, hunger, cravings, mood changes, sensory and visual distortions.
57
What structures does the hypothalamus have a connection to in HA and Sleep d/o?
``` Limbic System Pineal Gland NTS Locus Ceruleus PAG ```
58
What role does the Pineal Gland play in HA and Sleep d/o?
Melatonin
59
What role does the Locus Ceruleus play in HA and Sleep d/o?
Sleep Stage and Motor Control
60
What role does the PAG play in HA and Sleep d/o?
Pain
61
How do you evaluate HA and Sleep d/o?
Polysomnography Actigraphy Questionnaires Sleep Diary
62
What is an Medication Overuse HA (MOH)?
1. HA > 15 days/mo Med overuse 2. > 3 mo of 1+ drug used to treat HA Sx 3. HA worse with meds 4. HA improves w/in 2 mo of discounting meds
63
Which medication are found in overuse HA?
Ergotamine Triptans Opiates Compound Analgesics
64
Which meds are used for TTH?
Analgesics and Ergotamine preps
65
Which meds are used for daily Migraine?
Triptans
66
How can opiod use result in pain?
Down regulation of opiate r/c and inc production of adenylyl cyclase (AC), which is inhibited by opioids. .: rebound pain sensitivity with cessation of chronic opioid use
67
What do opiates activate?
descending pain facilitation pathways in the RVM (5HT) which results in higher tonic firing of the "on" cells
68
What do the activation of the "on" cells cause?
Release of GLU and CGRP, through inc dynorphin concentrations, causing increased excitation in the dorsal horn and trigeminal caudal nun, increasing pain signaling
69
What can result from impaired GLU uptake?
Excitotoxicity leading to apoptosis of the pain inhibitory cells, which may lead to permanent pain sensitization
70
How can excessive NSAID use cause pain?
Localized inflammation prevention activate the PAG descending opiod pathways, triggering anti-opioid proprioception leading to hyperalgesia
71
How can acetaminophen use result in pain?
It inc 5HT and NE in the hypothalamus and brainstem. Compensatory neuroplasticity contributes to HA
72
How can triptans and ergotamins use result in pain?
vasodilation
73
How can caffeine use result in pain?
Upregulates pain inhibition centrally and locally in muscle tissue.
74
How can chronic caffeine use result in pain?
Use then withdrawal results in HA due to alteration of pain inhibition pathways
75
Tx for HA and substance abuse
Education Detoxification Preventative Medication
76
What is a chronic daily HA?
``` Occur 15+ days/mo 4+ hrs/day 3+ mo duration High level of disability and impairment Most are 1' but some are intracranial and systemic abnormalities ```
77
What are the RED FLAGS for chronic daily HA?
1. Focal Neurological S/Sx 2. Alteration of Mental Status 3. Systemic Sx 4. Cancer 5. Sudden Onset 6. New HA over age of 50 7. "Thunderclap" 8. Explosive HA with orgasm 9. Valsalva induced HA 10. Exertional, 1st/Worst, Change in HA
78
What is Occipital Neuralgia also known as?
C2 Neuralgia | Arnold's Neuralgia
79
What is Occipital Neuralgia?
Chronic pain in the upper neck, back of the head, and behind the eyes.
80
What does the location of pain in Occipital Neuralgia correspond to?
The locations of the lesser and greater occipital nerves
81
What S/Sx may be seen in Occipital Neuralgia?
Photophobia Aching, Burning, and Throbbing pain at the base of the head Tender scalp Pain with neck movement

Head and Face Pain (8 decks)

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