Headache

Question 1

What are the main headache types and subtypes?

Answer 1

Primary:
- migraine
- tension
- cluster

Secondary:
- underlying pathology

Question 2

What are the headache high-risk features/Red Flags?

Answer 2

Age > 50 years, new onset headache (assume secondary until proven otherwise)

History of cancer

Pregnancy

Immunosuppression

Fever

Lyme Disease

Papilledema

Change in pattern, frequency, or severity of headache

Worsening despite treatment

Unexplained neuro signs/symptoms

Onset with exercise, cough, intercourse

Personality change, cognitive impairment

Question 3

What is papilledema and what are the key points in regards to headache?

Answer 3

Papilledema:
- swelling of the optic disc due to increased intracranial pressure

Key points:
- papilledema is almost always bilateral
- REFER IMMEDIATELY!!!

Question 4

What are the symptoms of migraine headache?

Answer 4

Location:
- 60% - 70% unilateral
- 30% bifrontal or global

Characteristics: crescendo

Patient Appearance: wants cool, quiet, dark room

Duration: 4-72 hours

Associated symptoms:
- nausea
- vomiting
- possible aura

Question 5

What are common migraine triggers?

Answer 5

• stress
• Menstruation
• fasting
• alcohol (especially wine)
• aack of sleep
• nitrates
• bright lights
• weather changes
• smoking
• dehydration
• diet:
  
  • red wine
  • some cheeses
  • caffeine
  • MSG
  • others

*Migraine triggers are unique to each patient

Question 6

What are the recommended OTC medications for migraines?

Answer 6

Simple analgesics:
- Tylenol

NSAIDs:
- ibuprofen
- aspirin
- naproxen
- ketorlac (Rx only)

Question 7

What are the main Rx medication classes for migraine?

Answer 7

Triptans

Calcitonin Gene Related Peptides (CGRP)

Other Prophylatic Agents:
- beta-blockers
- antidepressants
- anticonvulsants

Question 8

Name common triptans.

Answer 8

Sumatriptan

Zolmitriptan

Naratriptan

Rizatriptan

Almotriptan

Eletriptan

Question 9

Name common CGRP medications.

Answer 9

Ubrogepant

Erenumab

Fremanezumab

Etc

Question 10

Name the prophylactic agents for migraine.

Answer 10

Beta-blockers:
- propranolol
- timolol

Antidepressants:
- amitriptyline
- venlafaxine

Anticonvulsants:
- valproate
- topiramate

Question 11

What category are cluster headaches and what is the cause?

Answer 11

Trigeminal autonomic neuralgias

Hypersensitized ophthalmic branch of the trigeminal nerve

***One of the most powerful headaches!!!

Question 12

When is the typical first onset of cluster headaches and which gender is more likely to get them?

Answer 12

20-30 years old

Men

Question 13

Describe the location, characteristics, and patient appearance of cluster headaches.

Answer 13

Location:
- ALWAYS unilateral!!!
- begins around eye or temple

Characteristics:
- pain peaks within minutes
- excruciating
- explosive

Patient appearance: varies

Question 14

Describe the duration and associated symptoms of cluster headaches.

Answer 14

Duration:
- usually 30 - 90 minutes
- max 180 minutes

Associated Symptoms:
- red eyes
- tearing
- rhinorrhea
- alcohol-triggered

Question 15

What is the treatment for cluster headaches?

Answer 15

100% oxygen by mask at 7 - 15L/min for about 15 mins

Sumatriptan IM

Indomethacin

Zolmitriptan intra-nasal

Question 16

Describe the location and characteristics of tension headaches.

Answer 16

Location:
- bilateral

Characteristics:
- pressure
- band-like
- tightness
- waxes and wanes

Question 17

Describe the patient appearance, duration, and associated symptoms of tension headaches.

Answer 17

Patient appearance:
- may or may not affect daily activities

Duration: varies

Associated symptoms: none

Question 18

What is the treatment for tension headaches?

Answer 18

OTC pain relievers:
- aspirin
- NSAIDs
- acetaminophen

Muscle relaxants

Comfort measures

Stress reduction