headache Flashcards
what are approach to headaches
mnemonic TOSS IT:
Timing
Other symptoms: nausea, photophobia, phonophobia, motion sensitivity, tearing, ptosis
Site
Severity
Influences: aggravating and relieving factors
Type: character
+ R/O red flags & secondary causes of headache SNOOP4
S Systemic (fever, weight loss)
Secondary risk factors (HIV> toxoplasmosis, Ca)
N Neurological signs and symptoms (confusion)
O Onset: sudden SAH presents as sudden severe headache, find bleed before aneurysm rupture (sentinel bleed)
Older age: giant cell arteritis (>50%). GS is biopsy for diagnosis
P Previous headache history: 1st time? Change in pattern?
Progression
Papilledema
Postural aggravation and aggravation by Valsalva Pregnancy (cerebrovenous thrombosis)
what is the most common primary headache Mild-moderate, bilateral, band-like tightening, non-throbbing
tension type headache
triggers of tension type headache
stress, sleep deprivation, dehydration, hunger
tx of tension type headache
o NSAIDS (ibuprofen, naproxen sodium, aspirin)
o Acetaminophen (a bit less effective but better in pregnancy)
o If combined with caffeine –> more effective
o Avoid medication overuse (limit to 9 days/month on average)
• Prophylactic treatment:
o If headaches are frequent, long-lasting, or associated with significant disability
o Amitriptyline (TCA)
how long can migraine last
May last 4-72 hours
auras in migraine percentage
80%- no aura, 20%- aura
what are auras in migraine
1)Visual aura (most common):
-Positive: zigzag or wavy lines (fortification spectra) fragmented image
-Negative (These remove normal sensory perception or motor abilities ): central scotoma, hemianopia, tunnel vision
2) Sensory aura: tingling, dysphasia
3) Motor symptoms is never aura, rather it is a hemiplegic migraine
symptoms of migraine
Unilateral, throbbing, moderate to severe headache (may be bilateral)
• Associated with nausea ± vomiting, photophobia, phonophobia, osmophobia
what exacerbates or relieves the symptoms of migraines
• Exacerbated by movement (patients prefer to lie still in a dark, quiet room)
• Relieved by sleep, usually resolves spontaneously
how are symptoms in children with migraine presented
Migraine in children presents as abdominal pain, motion sickness, ataxia,frequent bumping into things.
Usually girls with a positive family history
complications of migraine
prolonged symptoms (>72 hours),
infarction (stroke),
seizures
what indicates headache chronification
Headache “chronification” (≥15 days/month for 3 consecutive months) may be associated with medication overuse, caffeine overuse, poor sleep/OSA, stress, obesity, repeated head injury, comorbidity.
phases of migraine
- Prodrome (Warning Phase – Hours to Days Before)mins to 48 hrs b4 onset of headache
• Subtle signs that a migraine is coming
• Symptoms: Fatigue, mood changes (irritability, depression, or euphoria), food cravings, frequent yawning, neck stiffness - Aura (Visual or Sensory Disturbances – 5 to 60 Minutes Before or During the Attack)
• Not everyone gets this phase (only about 25% of migraine sufferers)
• Symptoms: Flashing lights, zigzag lines, blind spots, tingling in hands/face, trouble speaking - Attack (Headache Phase – Lasts 4 to 72 Hours)
• Symptoms: Throbbing or pulsating headache (usually one-sided), nausea, vomiting, sensitivity to light, sound, and smells
• Movement often makes it worse - Postdrome (Recovery Phase – Hours to a Day After)
• “Migraine hangover”
• Symptoms: Fatigue, brain fog, difficulty concentrating, mild headache, body aches
tx of acute migraine
- Mild to Moderate Migraine
• NSAIDs (first-line): Ibuprofen, naproxen, aspirin, or diclofenac
• Acetaminophen (paracetamol): If NSAIDs are contraindicated
• Caffeine-containing medications: Can enhance pain relief (e.g., Excedrin) - Moderate to Severe Migraine
• Triptans (first-line for severe attacks):
• Sumatriptan (oral, nasal, or subcutaneous)
• Rizatriptan, eletriptan, zolmitriptan, etc.
• Contraindications: Heart disease, stroke, uncontrolled hypertension
migraine prevetive treatment
• 1st choice (level A evidence)
o Propranolol but not for diabetic or asthmatics
o Valproic acid: best for males (SE in women: PCOS, weight gain, teratogenic)
o Topiramate: best choice for obese women (à weight loss). SE: kidney stones. Contraindicated in nephropathy (1% risk)
• Group 2/ level C evidence
o Riboflavin (Vitamin B2): very safe. 1000mcg
o Magnesium
• Botox is used as preventive treatment in some cases (31 injections over the scalp & neck every 3 months)
what is Strictly unilateral severe pain following the distribution of the trigeminal nerve
TRIGEMINAL AUTONOMIC CEPHALGIA (TAC)
what does TAC cause symptoms of
Prominent ipsilateral autonomic features:
o Conjunctival injection and tearing
o Nasal congestion & rhinorrhea
o Eyelid edema
o Forehead & facial sweating
o Horner’s: ptosis, miosis (constriction), anhidrosis
TAC includes three types
3 types differentiated by duration & response to treatment:
o SUNCT (lasts for 5-40 secs)
o Paroxysmal hemicranias (lasts for 15-30 mins)
o Cluster headache (lasts for 15-180 mins)
what lasts for 5-40secs mote common in men a feeling of stabbing electric pain May manifest as single stabs OR group stabs OR saw tooth (continuous pain + superimposed stabs)
SUNCT: short-lasting unilateral neuralgiform headache with conjunctival injection & tearing
treatment of SUNCT
IV lidocaine (acute), does not respond to O2 & indomethacin like the other types of TACs
what type of headache lasts for 15-30min more in females usually in adulthood Icepack-like pain. Recurrent. Associated with tearing & rhinorrhea
paroxysmal hemicrania
what headache lasts from 15-180min more in males especially SMOKERS
cluster headache
what are symptoms of cluster headache
Attacks of excruciatingly severe (suicide headache) unilateral orbital, supraorbital, or temporal pain + autonomic phenomena & eye redness
cluster headache triggers
o Triggered by alcohol
o Patients prefer moving during attacks
trigeminal neuralgia
Severe paroxysms of unilateral knife/electric shock like pain, abrupt in onset & termination, in one or more sensory divisions of the trigeminal nerve
what are trigeminal neuralgia triggered by
Triggered by stimulation of nerve root/trigger zones (washing, eating, shaving)
