Headache Flashcards
SNNOOP10 (Red Flags suggesting secondary headache)
Systemic symptoms including fever
Neoplasm in history
Neurologic deficit or dysfunction
Onset of headache is sudden or abrupt
Older age (>50y/o)
Pattern change or recent onset of headache
Positional headache
Precipitated by sneezing, coughing or exercise
Papilledema
Progressive headache with atypical presentation
Pregnancy or puerperium
Painful eye with automic features
Post-traumatic onset of headache
Pathology of immune system such as HIV/immunocompromised
Painkiller overuse or new drug at onset of headache
Features of Tension type headache
Bilateral, pressing/tightening, mild-mod pain, not aggravated by routine activities of daily living
no other symptoms
lasts 30mins-7d
Features of migraine
Unilateral or bilateral, pulsating/throbbing, mod-sev pain, aggravated by or causes avoidance of routine activities of daily living, other smx (n/v, unusual sensitivity to light or sight, aura), lasts 4-72hrs
Features of cluster headache
Unilateral (around the eye or along face), pain location varies, sev to very sev pain, feels restlessness or agitation, other smx (cranial autonomic smx in same side as headache- red, watery,swollen eye. nasal congestion, sweating), lasts 15-180mins
Triggers for TTH
Stress
Activities that cause head to be held in position for a long time
Alcohol
Caffeine
Cold/flu or sinus infections
Dehydration
Hunger
Common pharm tx for acute headaches
Paracetamol (alone or with caffeine), aspirin, NSAIDs (ibuprofen, naproxen, diclofenac, ketoprofen)
Common pharm prophylactic tx for headache
Amitriptyline (1st line), mirtazapine, venlafaxine
Non-pharm tx
CBT, relaxation/stress management, physical/occupational therapy, lifestyle modification (incl sleep hygiene), Headache dairy
Criteria for medication overuse headache
1) Headache on >= 15d/month in a pt with pre-existing headache disorder
2) Regular overuse of acute and or symptomatic headache drugs for >3months of:
- Ergotamines, opioids, triptans or combi of analgesics on >=10d/month
- Simple analgesics (para, nsaid) on >=15d/month
- Any combi of the above for >=10d/month
3) Headache cannot be better accounted for by another ICHD-3 diagnosis
Why is there a vicious cycle for medication overuse?
Take medicine for ST relief –> get rebound headache –> take higher dose –> cycle repeats
Red flags to look out for sudden onset of stroke
Numbness, weakness on one side of body
Sudden and severe headache w no apparent cause
Difficulty speaking or understanding
Dizziness, loss of balance/coordination
Vision loss
Seizures or loss of consciousness
ICHD3 criteria for episodic migraine
During lifetime, >=5 migraine attacks lasting 4-72hrs
ICHD3 criteria for chronic migraine
> 3months
=15 Monthly headache days (either TTH or migraine)
=8 Monthly migraine day
Possible acute pharm tx for migraine
-NSAID (1st)
- Triptans
- Ergotamine
- Ditans (costly)
- Gepants (costly)
When is triptans recommended?
When OTC analgesics do not work
Are triptans or ergotamine preferred?
Triptans due to its better SE profile
What adjunct antiemetics can be given?
Metoclopramide (dopamine antagonist) for N/V
Criteria for preventative migraine treatment
AHS:
Offered if (per month): >=6d with no disability or >=4d w some disability or >=3d w severe disability
Considered if (per month): 4-5d w no disability or 3d w some disability or 2d w moderate disability
EHF:
Impairs QoL and
1) Attacks cause disability on >=2 days/month and optimised acute therapy does not prevent the above
or
2) Risk of over-freq use of acute therapy and pt is willing to take daily meds
What are some medications to prevent migraine attacks?
Antiseizure/antiepileptics
Beta blockers (propanolol, metoprolol)
Anti-CGRP antibodies/Gepants (given SC or IV)
How to assess tx efficacy?
Headache diary to track progression before and after tx and identify triggers
Disability assessment (eg. MIDAS- migraine specific)
Adverse effect from medications
