Headache Flashcards
List some of the red flag symptoms
first/worst abrupt onset fundamental pattern change new headache & 50 yo cancer, HIV, pregnancy abnormal physical exam neuro sx <1hr later headache onset w/seizure or syncope, w/ exertion, sex or valsalva
List some of the comfort signs
stable pattern long-standing history family history of similar headahces normal physical exam consistently triggered by: hormonal cycle, specific foods, specific sensory input (light, odors), weather changes
Which type of headache is more common: primary or secondary?
primary
What are the 3 major types of primary headache?
migraine
cluster
tension-type
What are some causes of secondary headache?
Trauma Vascular infection metabloism oncologic inflammatory
What are the pain sensitive intracranial structures?
meningeal arteries
proximal portions of the cerebral arteries
dura at the base of the brain
venous sinuses
cranial nerves 5,7,9, 10 and cervical nerves 1,2, and 3
Which pain sensitive intracranial structures are innervated by V1?
meningeal arteries
proximal portions of the cerebral arteries
dura at the base of the brain
venous sinuses
When is imaging obtained for headache?
recurrent migraine with recent change in headache pattern, new onset seizures or focal neurologic signs or symptoms
What are common times of year for patients to expereince cluster headaches?
around the summer & winter solstices
What are the diagnostic criteria for cluster headache?
1/every other day to 8/day
must be: severe, unilateral oribtal/supraorbital and or/temporal location and last 15-180 minutes
plus have 1 of the following: conjunctival injection, lacrimation, rhinorrhea, nasal congestion, forehead and facial sweating, miosis, ptosis, eyelid edema
Can horner’s syndrome occur in a cluster headache?
yes
What are the diagnostic criteria for migraine?
headache attack last 4-72hrs
two of the following: unilateral, pulsating, moderate-severe intensity, aggravation by walking up stairs
one of the following: nausea, vomiting, photophobia and phonophobia
What are the 3 best predictors of diagnosis of migraine?
nausea, disability and photophobia
When do migraine aura’s usually occur?
~20 min before migraine
What are the diagnostic criteria for tension-type headache?
headache last hours or is continuous
two of the following: pressing/tightening quality (nonpulsating), mild/mod intensity, bilateral, no aggravation by walking up stairs/physical activity
no more than one of: photophobia, phonophobia, mild nausea, meither moderate or severe nausea nor vomiting
How high does pressure have to become in the sinuses to cause headache?
> 180mm Hg
What are not readily modifable risk factors for chronic daily headache?
migraine female sex low education low socioeconomic status head injury
What are readily modifiable risk factors for chronic daily headache?
attack frequency obesity medication overuse stressful life events snoring
What role does the trigeminovascular system play in migraine?
can generate or perpetuate pain
How can cortical neuronal hyperexcitability occur?
enhanced release of excitatory neurotransmitters -elevated plasma glutamate concentration -identified genetic mutations in FHM reduced intracortical inhibition low brain Mg2+ altered brain energy metabolism
What is cortical spreading depression?
wave of intense cortical neuron activity folowed b neuronal suppression (inc rCBF –> dec rCBF)
supp. often coincies with headache onset
How fast does CSD travel?
2-3mm/min
What is released during CSD that can lead to pain? (leaks out of neurons)
AA
NO
H+
K+
How does brainstem dysfunction contribute to initiating migraine?
dysfunction in areas involved in central control of nocicdption (PAG focal point)
facilitates activation and sensitization of TNC neurons?
What AA is serotonin derived from?
tryptophan
How is synthesis of serotonin limited in the brain?
by concentration of tryptophan in the brain (requires O2 and pteridine cofactor)
How is synthesis of serotonin limited in the gut?
by tryptophan hydroxylase (rate limiting enzyme)
How is serotonin metabolized?
converted to 5-hydroxyindole acetic acid by MAO
How is serotonin action terminated?
SERT uptakes serotonin, the converted by MAO
What does the pineal gland convert serotonin to?
melatonin
Where is the majority of serotonin located in the body?
gi tract
Where in the CNS is the most serotonin found?
midbrain raphe nucleus
projects to: hypothalamus, neostriatum, limbic forebrain, neocortex, medulla, spinal cord
What type of receptor is the 5-HT 3 receptor?
ligand gated cation channel
What kind of receptor is 5-HT1A-E?
inhibits adenylated cyclase, also opens K+ channel
What does the 5-HT2A-C receptor do?
PI hydrolysis
What do the 5-HT4-7 receptors do?
activate adenylate cyclase or unknown
What are the serotonin autoreceptors? What is their function?
1A and 1D like
decrease serotonin release
What are the effects of serotonin on the CV system?
potent vasoconstriction in large arteries/veins; cranial blood vessels (via 5-HT1D)
vasodilation in coronary, sk musc and cutaneous blood vessels
Bezold-Jarisch reflex (coronary chemoreceptors—>bradycardia, hypotension and hypoventilation)
platelet aggrevation—>active uptake of serotonin from circulation
What neuotransmitter activities is serotonin involved in?
sensory perception slow wave deep sleep temperature regulation neuroendocrine regulation-ACTH, GH, prolactin, TSH, FSH, LH learning and memory, esp short-term pain perception drug abuse
What does phenelzine treat?
depression
What does Odansetron treat?
nausea and vomiting
What does fluoxetine treat?
depression
What does cyproheptadine treat?
itch
What does buspirone treat?
anxiety
5-HT1A receptor partial agonist
What does tegaserod treat?
Constipation predominant IBS
How does LSD (lysergic acid diethylamide) affect the serotonin system?
relatively non specific, acts on 5-HT2 receptors
potent hallucinogen
What is the action of sumatriptan?
5-HT1B/D receptor agonist on cerebral blood vessels
used to treat migraines, stops existing ones
What is the major class of drug used to stop an existing migraine? How do they work?
triptans 5-HT1B/D receptor agonist inhibit release of vasoactive peptides (CGRP) promote vasoconstriction block brainstem pain pathways inhibit trigeminal nucleus caudalis
What groups of drugs serve as alternatives to triptans for stopping a migraine?
ergots
steroids
NSAIDS w/caffiene
What are common side effects of triptans?
peripheral vasoconstriction N/V angina dizziness flushing
What are contraindicators for triptans?
stroke and recent MI
uncontrolled HTN and Ischemic heart disease
What triptans are also used for migraine prevention due to their long half life?
Frovatriptan
Naratriptan
Why is butalbital w/caffeine and acetaminophen a bad choice for stopping a migraine?
high abuse potential
What are some classes of drugs used for prevention of migraine?
tricyclic antidepressants
antiseizure agents
-divalproex sodium, valproic acid, topiramate, gabapentin, pregabalin, lamotrigene
vasoactive agents
-beta blockers, calcium channel blockers (less effective)
