Headache Flashcards
Secondary headaches are a sign of?
Organic disease
What are the 10 worrisome signs which may indicate headache of pathologic origin (secondary HA)?
- “Worst HA”
- Onset of HA after age 50
- Atypical HA for patient
- HA w/ fever
- Abrupt onset (max. intensity in sec. to min.)
- Subacute HA w/ progressive worsening over time
- Drowsiness, confusion, memory impairment
- Weakness, ataxia, loss of coordination
- Paresthesias/Sensory loss/ Paralysis
- Abnormal medical or neurological exam
Any patient presenting with a headache who has a “worrisome history” or abnormal examination needs what?
- Urgent imaging study
- Perhaps even a L.P. and possibly arteriogram
Differentiate a common migraine from a classic migraine.
- Common migrarine = without aura
- Classic migraine = with aura
What is the intensity, age of peak prevalence, and gender ratio for common migraines?
- Intensity: moderate to severe
- Prevalence peaks between 35-40 years
- Gender ratio: F:M = 3:1
What is the location, patient description of pain, and patient behavior with a common migraine?
- Location: unilateral or bilateral
- Description: throbbing/sharp/pressure
- Behavior: retreat to dark, quiet room
What are the 4 most common associated symptoms with a common migraine?
- Nausea
- Vomiting
- Photophobia
- Phonophobia
How long does the aura associated with Classic Migraines usually last?
Usually 15-30 mins, but sometimes longer
What are the common visual symptoms associated with Classic Migraines?
- Scintillations: flashes of light
- Scotoma: an interruption or break in the visual field (blind spots)
*Often hemianopic
The most widely discussed theory about the cause of migraines says that they are caused by?
Neurogenic inflammation
To be defined as a chronic migraine which criteria must be met?
Headache for 15 or more days/month, lasting 4 hours or longer, for a period of at least 3 months
What is the intensity and disability caused by Tension-Type HA’s?
- Intensity: Mild to Moderate
- Disability: May inhibit, but does NOT prohibit daily activities
What is the common location, patient description of pain, and is there an associated aura/prodrome with a Tension-Type HA?
- Location: bifrontal, bioccipital
- Description: dull, aching, squeezing, pressure
- No prodrome or aura
Which type of headache has an association with sleep apnea as a comorbidity?
Cluster HA
*This will be on the exam!
What is the intensity and gender ratio for Cluster HA?
- Intensity: severe, excruciating
- Gender ratio: F:M = 1:6
In regards to monthly frequency what constitutes an episodic type vs. chronic type of Cluster HA?
- Episodic type: 1 or more attacks/day for 6-8 weeks
- Chronic type: several attacks per week without remission
What is the most common location/distribution of Cluster HA’s?
- 100% unilateral
- Generally orbitotemporal
Frenetic, pacing, and rocking behaviors are most often associated with what type of headache?
Cluster HA
What are some of the associated symptoms of Cluster HA’s?
- Ipsilateral ptosis
- Miosis
- Conjunctival injection
- Lacrimation
- Stuffed or runny nose
What is the normal duration for a Cluster HA?
- 30 minutes to 2 hours
- Classic is 45 min
What are the 5 primary types of HA?
- Classic migraine
- Common migraine
- Chronic migraine
- Tension type HA
- Cluster HA
What is the only FDA approved treatment for chronic migraines?
BOTOX injections
What are some underlying conditions which are contraindications for the use of Triptans in the acute treatment of migraines?
- Ischemic heart disease
- Cardiovascular, cerebrovascular, or peripheral vascular disease
- Raynaud’s syndrome
- Uncontrolled HTN
- Hemiplegic or basilar migraine
- Severe renal or hepatic impairment
Which agent/therapy can be used to break the cycle of a prolonged migraine or several weeks of frequent migraines?
Also, a good treatment for people who get in frequent cluster HA’s?
A prednisone taper
What’s Trigeminal Neuralgia?
Treatment?
- Excruciating sharp, shooting, electrical quality pain occuring in paroxysms in one or more distributions of the trigeminal nerve, often freqent through the day
- Treatment is usually carbamazepine or oxcarbamazepine
A group of headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features, describes what?
Trigeminal autonomic cephalgia (TAC’s)
What 5 types of headache disorders are classified as Trigeminal Autonomic Cephalgias (TAC’s)?
- Cluster HA
- Paroxysmal hemicrania
- Hemicrania continua
- SUNCT syndrome
- SUNA syndrome (similar to SUNCT, but with autonomic sx’s)
What are the characteristics of SUNCT syndrome?
Location?
Onset and which sex is most commonly affected?
- Shortlasting, unilateral, neuralgiform headache attacks w/ conjunctival injection and tearing
- Excruciating, burning, stabbing electrical HA in periorbital area lasting seconds to a few mins, occuring frequently throughout the day
- Onset typically over 50 in men
What is the treatment for SUNCT syndrome?
- Usually anticonvulsants
- Particularly lamotrigine
Which HA type is very similar to cluster HA, but shorter duration (often only a few mins) and increased frequency (usually >5 times per day)?
Paroxysmal Hemicrania
Paroxysmal Hemicrania (HA) is exquisitely reponsive to which drug?
Indomethacin
As a general rule, many physicians (including neurologists) believe that any person with HA should have what type of evaluation?
A one-time, thorough neuroimaging study (CT head with AND w/o contrast or MRI of head)
What’s a good oral tx for someone experiencing multiple cluster HA’s in a year?
Verapamil (Ca2+ channel blocker)
What medication is known to cause meningitis?
lamotrigine
(IVIg)
If a pt presents with s/s of meningitis, and you are unable to get an immediate LP, what should you do?
draw blood
give dexamethasone, ceftriazon IV, vancomycin IV
switch up to more specific tx once resutls are in
What are the key features of HSV1 Encephalitis?
fever, HA, impaired consiciousness seizures, focal neuro s/s
focal abnormalities in temporal lobes
tx: acyclovir
*up to 25% can develop recurrent neuropsychiatric sx (sometimes with associated ABs with secondary AI encephalitis)
What should be on the ddx if a pt presents with rapidly progressive encephalopathy or psych disturbances?
AI Encephalitis
especially if assoc with seizures!! –> some are well known causes of intractable epilepsy
How is AI Encephalitis typically tx?
combo of immune therapies:
high dose steroids
IVIg
plasma exhange
rituximab
cyclophosphamide
other immunosuppressive agents
Who does NMDA Encephalitis typically affect? What s/s are present?
young or middle aged women
rapid onset (<3 mo) of 4 of the following 6:
- abnormal psych behavior or cognitive dysfunction
- speech dysfunction
- seizures
- movement disorders, dyskinesias, rigidity/abnormal postures
- dec level of consciousness
- autonomic dysfunction or central hypventilation
To dx NMDA Encephalitis, you need at least one of what two tests?
abnormal EEG (focal or diffuse or slow or disorganized activity, epileptic activity, or extreme delta brush)
CSF with pleocytosis or oligocloncal bands and/or NMDA R ABs
What is NMDA Encephalitis commonly associated with?
teratoma
What is a hallmark of LGI1 Encephalitis?
more common in men
faciobrachial dystonic seizures (brief, involve one side of face and ispi arm)
sleep disturbance
may see temporal lob abnormality in some pts acutely
Why is it important to tx LGI1 Encephalitis?
failure to tx results in permanent brain damage (esp short term membory)
even with tx, 1/3 relapse
*faciobrachial seizures do NOT respond to AEDs*
