Headache Flashcards
A 32-year-old male presents to your office because of a 3-month history of severe headaches. The pain is localized to the right orbital area and is accompanied by a red, watery eye. He notes rhinorrhea and sweating on the right side of his face along with feeling restless. The headaches occur daily and usually last 30 minutes to 1 hour. They can be triggered by strong odors or consuming alcohol. The patient reports that his symptoms improved when he tried a friend’s sumatriptan (Imitrex). A neurologic examination is unremarkable. He asks about medication to prevent these bouts of pain.
The first-line prophylactic medication for this condition is (check one)
-lithium
- topiramate (Topamax)
-ubrogepant (Ubrelvy)
-valproic acid
-verapamil
Verapamil
While cluster headache is rare, it can be diagnosed clinically and the individual can be properly managed. It is much more common in males, with a mean age of onset of 30. Attacks are severe and unilateral, and located in the supraorbital, orbital, or temporal regions. They can occur as frequently as every other day or as often as eight times per day. The pain is severe and has accompanying autonomic symptoms, including nasal congestion, rhinorrhea, unilateral watery eye, eyelid edema, sweating of the forehead, and a constricted pupil. The pain may last for only 15 minutes but can last up to 3 hours. One key feature is a sense of restlessness or agitation. These bouts can be triggered by alcohol, nitrates in food, strong odors, and nitroglycerin.
Abortive treatments include triptans or supplemental oxygen 100% at 12–15 L/min for 15–20 minutes. The first-line prophylaxis for cluster headache is verapamil.
Lithium is also effective for prophylaxis, however it is not first line.
Topiramate has been recommended, but clinical trials have shown no evidence.
Ubrogepant is indicated for acute treatment for migraine.
Valproic acid is ineffective for prophylaxis for cluster headache.
A 41-year-old male presents with a complaint of headaches for the past 6 weeks. He has severe, sharp, right-sided periorbital pain 3–4 days each week. When these headaches occur his right eye gets watery, his right nostril feels clogged, and his forehead feels sweaty. When he gets the headaches he takes four 200-mg ibuprofen tablets and goes into a dark, quiet room. The headaches usually resolve in about 90 minutes. Currently he is feeling well and his examination is completely normal.
What type of headache does he most likely have?
(check one)
Medication overuse headache
Migraine
Paroxysmal hemicrania
Temporal arteritis
Cluster headache
Cluster headache
This patient has cluster headaches. Most people with cluster headaches are male. These headaches typically present with severe unilateral pain that lasts from 15 minutes to 3 hours. The pain is generally extremely sharp, continuous, and incapacitating. In addition to the pain, the headaches are associated with at least one of the following ipsilateral signs: conjunctival injection, lacrimation, nasal congestion, miosis or ptosis, eye edema, and forehead and facial sweating. Patients may also have a sense of restlessness or agitation. The headaches occur anywhere from every other day up to 8 times a day, often in cycles for 4–12 weeks. Cluster headaches respond to most of the same medications as migraine headaches (DHE, ergotamines, triptans). They also respond well to 100% oxygen therapy.
Paroxysmal hemicranias are very unusual and present with a similar type of pain, but the attacks are usually short and they are more common in women. Medication rebound headaches tend to be diffuse, bilateral, almost daily headaches. These occur in people who are overusing medications, and they tend to get worse with physical or mental exertion. Temporal arteritis usually occurs in older adults. Migraines are also often unilateral but they are usually pulsatile, and are associated with nausea and vomiting or photophobia and phonophobia.
A 35-year-old white female complains of unilateral frontotemporal headaches. During these episodes, which occur every 2-3 weeks, she becomes nauseated, sometimes to the point of vomiting. The headaches are throbbing in character and last for 1-3 hours, often causing her to leave work early. Relief is sometimes obtained with simple analgesics, but more often with sleep or the passage of time. On the basis of this history alone, the most likely diagnosis is (check one)
sinusitis
a brain tumor
muscle tension headache
cluster headache
migraine headache
migraine headache
Migraine is the most likely diagnosis in this scenario, because the patient is young and female; the headaches are unilateral, infrequent, and throbbing; the headaches are associated with nausea and vomiting; and sleep offers relief. Symptoms of sinusitis usually include fever, facial pain, and a purulent nasal discharge. The pain of cerebral tumor tends to occur daily and becomes more frequent and severe with time. Furthermore, the prevalence of brain tumor is far less than that of migraine. The pain of muscle tension headache is described as a pressure or band-like tightening, often in a circumferential or cap distribution. This headache also has a pattern of daily persistence, often continuing day and night for long periods of time. Cluster headache is more common in males, and presents as a very severe, constant, agonizing orbital pain, usually beginning within 2 or 3 hours after falling asleep.
A 75-year-old female presents with a 2-month history of bilateral headache, diffuse myalgias, and diplopia. On examination she has substantially diminished vision in her left eye, but no other neurologic findings. A moderately tender, cordlike structure is palpable just anterior to her ear and extending up to her lateral scalp. Blood tests show a markedly elevated erythrocyte sedimentation rate.
Which one of the following would be most appropriate at this point?
(check one)
Clopidogrel (Plavix)
High-dose corticosteroids
NSAIDs
Dipyridamole/aspirin (Aggrenox)
High-dose corticosteroids
The clinical findings in this patient are consistent with temporal arteritis: age over 50, new-onset headache, abnormalities of the temporal artery, and an elevated erythrocyte sedimentation rate. A temporal artery biopsy is needed to confirm the diagnosis, but when the findings are this compelling, corticosteroids should be started even before a biopsy, to prevent further vision loss. Temporal arteritis is the most common clinical pattern of giant cell arteritis, which can also involve other branches of the carotid artery.
A 36-year-old female presents with a 10-year history of daily headaches. The headaches are bilateral, have a pressure and tightening quality, and are not aggravated by activity. They tend to worsen as the day progresses. There is no associated prodrome, nausea, or sensitivity to light or noise. A neurologic examination is normal.
Which one of the following has been shown to reduce the severity and duration of this type of headache? (check one)
Amitriptyline
OnabotulinumtoxinA (Botox)
Propranolol
Sertraline (Zoloft)
Topiramate (Topamax)
Amitriptyline
Amitriptyline may reduce headache duration and severity compared with placebo for chronic tension-type headaches (SOR B). SSRIs have no proven benefit for headache prophylaxis over placebo or tricyclic antidepressants in patients with chronic daily headaches. Propranolol reduces the frequency of migraine headaches, although its effectiveness for chronic migraine is unclear. Propranolol is not effective for tension headaches. Topiramate can reduce the frequency of chronic migraine headaches by 50% but is not effective for tension-type headaches. OnabotulinumtoxinA has been shown to reduce headache frequency in chronic migraine, but evidence of its effectiveness is lacking for chronic tension-type headaches.
A 26-year-old female has a 4-month history of continuous right-sided headache. The headache is associated with tearing and nasal congestion only on the right, and has not responded to over-the-counter analgesics. The patient went to the emergency department a few nights ago because of the pain, and CT of the head at that visit was normal. On examination you note conjunctival injection on the right. Findings are otherwise normal.
Which one of the following would be the most appropriate treatment at this time? (check one)
Sumatriptan (Imitrex)
Amitriptyline
Indomethacin
Topiramate (Topamax)
Indomethacin
There are several types of chronic headaches, and they often respond to different treatments. Migraine is very prevalent and is characterized by headaches that are periodic, often unilateral, and frequently pulsatile. Migraine is familial and typically starts in childhood, adolescence, or young adulthood, and the headaches decrease in frequency over time. Some are associated with aura, which causes visual disturbances. In mild cases, over-the-counter medications may control symptoms. For most patients, however, treatment to control the attack can include triptans such as sumatriptan, and/or ergot alkaloids such as ergotamine. Treatment to prevent attacks may also be appropriate, and could include a β-blocker, antiepileptic drugs, or amitriptyline.
Tension headaches are usually bilateral and are typically described as dull or aching, but patients often describe tightness or pressure. They are not associated with symptoms such as throbbing, nausea, or photophobia. Tension headaches are more frequent than migraine but patients often treat them at home without seeking medical treatment. Frequent or persistent tension headaches can be treated with several drugs used for anxiety or depression, including amitriptyline. Stronger analgesics and ergotamine are not helpful.
Cluster headache is another type of chronic headache. This occurs most frequently in adult males, and often occurs over a period which may extend over many weeks, with repeated episodes or clusters. It most often occurs at night, and may recur several times during the night. The headache is unilateral and is associated with orbital pain and vasomotor phenomenon such as blocked nasal passages, rhinorrhea, conjunctival injection, and miosis. The headache can be treated with inhalation of 100% oxygen, and the headache cycle can be terminated with verapamil. Ergotamine or sumatriptan can be used at night to prevent attacks.
There are also variants of cluster headaches, including chronic paroxysmal hemicrania, which resembles cluster headache but has some important differences. Like cluster headaches, these headaches are unilateral and accompanied by conjunctival hyperemia and rhinorrhea. However, these headaches are more frequent in women, and the paroxysms occur many times each day. This type of headache falls into a group of headaches that have been labeled indomethacin-responsive headaches because they respond dramatically to indomethacin.
A patient comes to your outpatient clinic with a persistent migraine that she has been unable to treat effectively at home. The symptoms began several hours ago and are typical for her. She has already tried her usual treatments of ibuprofen, 800 mg, and rizatriptan (Maxalt), 10 mg, but they have not provided any relief. She took a second dose of rizatriptan 2 hours later without benefit. She is in significant pain, which is causing mild nausea, and she has photophobia and phonophobia.
Which one of the following would be most appropriate at this point? (check one)
Oral butalbital/acetaminophen/caffeine (Fioricet)
Oral ergotamine/caffeine (Cafergot)
Subcutaneous sumatriptan (Imitrex)
Intramuscular morphine
Intramuscular prochlorperazine
Intramuscular prochlorperazine
Multiple studies have determined that parenteral antiemetics have benefits for the treatment of acute
migraine beyond their effect on nausea. Most outpatient clinics do not have the ability to administer
intravenous metoclopramide, which is the preferred treatment. However, most clinics do have the ability
to administer intramuscular prochlorperazine or promethazine. Due to concerns about oversedation,
misuse, and rebound, treatment with parenteral opiates is discouraged but may be an option if other
treatments fail. Oral butalbital/acetaminophen/caffeine and oral ergotamine/caffeine have less evidence of
success in the treatment of acute migraine. Sumatriptan is contraindicated within 24 hours of the use of
rizatriptan.
