Headache *** Flashcards
Sx of cluster
Severe unilateral orbital/ supraorbital or temporal pain lasting 15-180 mins
Associated w/ (usually unilateral + ipsilateral):
Conjunctival injection
Lacrimation
Nasal congestion
Rhinorrhea
Forehead swelling
Miosis
Ptosis
Eyelid edema
Agitation
Daily HAs over weeks/ months
Red flags for HA
Fever, HTN
Confusion, altered MS, visual field defect, sz
Sudden onset
New onset in older pt
Triggers of clusters
Alcohol
Nitrates in food
Nitroglycerin
Strong odors
Rx for clusters - acute, bridging + maintenance
Acute: 100% O2 6-12L/min x15 mins + sumatriptan 6mg SC
Bridging: unilateral greater occipital nerve block 80mg methylprednisolone w/ 2ml 2% lido
Maintenance: verapamil 80mg TID (needs baseline ECG, repeat 10d after dose adjustments) , lithium, prednisone
Sx of concussion (acute)
Loss or reduced consciousness
Amnesia of events before or after injury
Altered MS at time of injury
HA, vision changes
Physical, emotional, cognitive + sleep sx of concussion
1) Physical:
HA
N/V
Visual disturbances
Photophobia
Phonophobia
Vertigo
Tinnitus
2) Emotional:
Irritability
Emotional lability
Anxiety
Fatigue
Inappropriate emotions
3) Cognitive:
Slowed reaction times
Difficulty concentrating
Poor memory
Confusion
4) Sleep:
Drowsiness
Sleeping more or less than usual
Immediate management of potential concussion inc how to determine need for imaging
Immediate: ABC, c spine control, serial monitoring for few hours (neuro + mental status). SCAT5 as sideline assessment tool
Determine need for imaging via PECARN + CT head rules
PECARN rules
GCS 14
Altered MS
Basal skull fracture
= CT
<2y/o: hematoma or hx of LOC >5s or severe mechanism or not acting normally = observation vs CT
>2y/o: LOC or vomiting or severe mechanism or severe HA = observation vs CT
Canadian CT head rules
GCS <15 2hrs from injury
Suspected open or depressed skull fracture
Basal skull fracture sign
>2 episodes vomiting
>65 y/o
Amnesia before impact >30 mins
Dangerous mechanism
DC instructions for concussion
No driving for 24hrs
Observed by responsible person for 24-48hrs
Return if deteriorates
Written + verbal advice re 1) sx of deterioration, 2) lifestyle advice + 3) typical post-concussive sx
Most recover within 3mo
Return to work/ school/ play guidelines
48hrs: physical + cognitive rest
Gradual return to activity while not increasing sx
No high risk activities for 7-10d
If symptomatic, rest for 24hrs then go back to last safe level
RF influencing recovery
Previous concussion
Skull fracture
Early onset HA
Anxiety
MVA
Delay returning to work
Lack of social supports
Sx migraines
unilateral, throbbing, N/V, photophobia, aura (visual distortion, food craving, increased sensory perception)
Triggers for migraines
temperature, noise, weather changes, odours, stress, poor sleep, menopause, menstruation, pregnancy, anxiety, OCP, citrus, caffeine, aspartame, cheese, chocolate, alcohol
Management (lifestyle, prophylaxis + acute) migraines
Lifestyle: HA diary, identify triggers, stress reduction
Prophylaxis: amitryptiline, metoprolol 47.5-200mg/d, gabapentin
Acute management: zolmitriptan + NSAIDs, maxalt 100mg
Tension sx
HA <15d/month
30mins - 7d
Pressure/ tightening
Mild-moderate
Bilateral
Not aggravated by exercise, photophobia and no N/V
Tension management
Acute: Tylenol 1g, ASA 1g, NSAIDs
Prophylaxis: amitriptyline, venlafaxine
CBT
Causes of HAs
Migraine
Cluster
Tension
Med induced
Tumor
Temporal arteritis
SAH
Increased ICP
Sx temporal arteritis
Sudden, localised to temple
Scalp tenderness
Jaw claudication
Vision loss/ diplopia
Fever
Ix for temporal arteritis
ESR/ CRP
Arterial biopsy
CBC
ALP (high)
Rx for temporal arteritis
Prednisone 60mg/d
Sx SAH
Thunderclap HA
Vomiting, neck stiffness
Orbital pain, diplopia, vision loss
Ix SAH
CT, LP, ESR
Rx SAH
mannitol/ lasix
sx increased ICP
Worse over time
Worse in AM
Ix increased ICP
CT or MRI
Rx increased ICP
Surgery
Types of migraine
Common Migraine (without aura)
Classic Migraine (with aura)
Complicated Migraine (sensorimotor symptoms)
- ophthalmoplegic
- basilar
- hemiplegic
- hemisensory
Cyclical Migraines (with menses)
Inclusion criteria for CT head rules
GCS 13-15
Min 1 of:
LOC
Amnesia to the event
Witnessed disorientation
Exclusion criteria for CT head rules
Age <16 years.
Blood thinners.
Seizure after injury.
Rx for postural hypotension
avoid large meals, avoid alcohol, adjust meds, increase salt intake, bed tilt, elastic stockings, midodrine (alpha 1 agonist) or fludrocortisone, refer to OT
What Ix for ?GCA
low risk = US, high risk = biopsy
What nerve block can you do for acute migraine management?
Sphenopalatine ganglion block
When can you use rimegepant + what class is it?
Migraine
Calcitonin gene-related peptide receptor antagonist
Ottawa SAH tool components
age >40, neck pain/ stiffness, witnessed LOC, onset during exertion, thunderclap HA, limited neck flexion on exam
When can you not use Ottawa SAH tool?
New neuro deficit, prior aneurysm, prior SAH, known brain tumor, chronic recurrent HA
When to offer prophylactic rx for migraines?
If HA frequency >8 days/month
What is cyclical vomiting syndrome associated w/?
Migraines
Rx for cyclical vomiting syndrome
antiemetics, topiramate
