Headache

Question 1

Tension headache overview

Answer 1

worsens throughout day;
precipitants: anxiety, depression, stress
mild migraine can be confused with this and vice-versa

Question 2

Clinical characteristics tension headache

Answer 2

pain: steady, aching, “viselike,” encircles entire head (tight band-like pain around head)
can be accompanied by tender muscles (posterior cervical, temporal, frontal)
-tightness in posterior neck mucles

Question 3

Treatment of tension headache

Answer 3

find causal factor if possible!
–> evaluate for anxiety, depression; stress reduction important

NSAIDs, acetaminophen, aspirin (standard for mild or moderate)
if severe: meds used for migraines maybe

Question 4

Emergency evaluation headache!

Answer 4

• obtain a noncontrast CT scan to first rule out any type of intracranial bleed
• small bleeds (subarachnoid hemorrhage) may be missed by CT scan, so lumbar puncture may be necessary

Question 5

Differential diagnosis headache

Answer 5

1. primary headache syndromes: migraines, cluster headache, tension headache
2. Secondary causes of headache (“VOMIT”):
   Vascular: subarachnoid hemorrhage, subdural hematoma, epidural hematoma, intraparenchymal hemorrhage, temporal arteritis
   Other causes: malignant HTN, pseudotumor cerebri, postlumbar puncture, pheochromocytoma
   Medication/drug-related: nitrates, alcohol withdrawal, chronic analgesic use/abuse
   Infection: meningitis, encephalitis, cerebral abscess, sinusitis, herpes zoster, fever
   Tumor

Question 6

Cluster headaches

Answer 6

RARE
usually in middle aged men
subtypes:
episodic: 90%, last 2-3 months, remissions of months to years
chronic: 10%, last 1-2 years, do not remit

Question 7

Clinical features cluster headaches

Answer 7

excrutiating periorbital pain (“behind the eye”): almost always unilateral
“deep, burning, searing, or stabbing pain”
+
accompanied by ipsilateral lacrimation, facial flushing, nasal stuffiness/discharge

–> onset: usually starts a few hours after pt goes to bed, lasts 30-90 mins, wakes patient from sleep
(but daytime cluster headaches also possible)
–> frequency: nightly for 2-3 months then disappear (remissions can last up to years)
–> aggravating: worse with alcohol and sleep

Question 8

Treatment of cluster headaches

Answer 8

1. acute attacks
   sumatriptan (imitrex) = drug of choice
   O2 inhalation
   combo of sumatriptan and O2 effective, narcotics often not needed
2. prophylaxis
   –> of all headache types, cluster headaches most responsive to prophylactic treatment!
   verapamil daily = drug of choice
   alternative agents: ergotamine, methysergide, lithium, corticosteroids (prednisone)

–> cause resolution or marked reduction in # of headaches within 1 wk

Question 9

Migraine

Answer 9

Inherited disorder (probably AD trait with incomplete penetrance?)