HEADACHE Flashcards
90% of all Headaches are :
Primary, meaning they are not caused by any underlying disease or structural problem
Main Primary Headaches:
Migraine
Cluster Headache
Tension Headache
Cluster Headache: Description
The “ALARM CLOCK” Headache comes on in early morning or wakes its victim
-Acute Onset of Excruciating Stabbing PAIN!!!
Unilateral, usually around one eye
- Drooping eyelid (Ptosis)
- Meiosis (pupil constriction)
- Tearing of that eye +/- Nasal Congestion
These folks kill themselves rather than endure this pain. QUICK!!! give them high flow O2!!!
-Last 30-90 Min & occur in clusters, multiple over one day/several days then remission for a few months
Cluster Headache Rx
High Flow O2
Give them a prescription so they always have it as these headaches come on fast. 10-15 min may abort the HA if used early.
Tryptans work but DONT USE TRYPTANS IN CAD - they constrict vasculature everywhere including the heart! Use Sumitriptan Sq Inj, works super fast, after or during O2 delivery.
Corticosteroids high then taper can help stop a cluster from perpetuating, not sure how
Add Verapamil during the cortico taper for prophylaxis (???) how this vasodilator helps control pain caused by vasodilation, I do not know but it is a treatment.
Lithium (???) this is due to Li’s use in treating cyclical BiPolar Disorder. Use it first line if you have a cluster HA pt who is also bipolar but not currently on Li.
Cluster Headache Rx, short form
High Flow 02
Sumitriptan SQ inn during 02 delivery
Script for Prednisone, high dose few days
with a Taper
Add oral Verapamil during taper for long term
prophylaxis.
Add Li to Verapamil if pt is also Bipolar.
Trigem Irritation and the Hypothalamus are involved in Cluster Headache and Substance “P” is released but the underlying cause remains unclear. Risk Factors:
Stress Extreme Temperature Tobacco Use (smoking or chew) Alcoholism Male Onset is 20-40
Migraine’s are caused by irritation of:
SENSORY NERVES
Eyes, Nose, Ears - over stimulation causes release of Substance “P” and Serotonin. The “P” leads to Histamine release (Inflammation) and the Serotonin causes vasodilation in the brain causing vessels to press on nerve tissue.
Most Common Cause of Med-Severe Recurrent Headaches
Migraine
Migraine Triggers
Red Wine
Chocolate
Aged Cheese
Flashing Lights
Strong Odors
Loud Sounds
Hormone Fluctuations (often premenstrual
as progesterone dives…. consider giving
progesterone if HA is premenstrual)
Stress
Sleep Deprivation
Area of visual disturbance
Scotoma: Zig Zag lines, geometric shapes
HAZY/FUZZY/Cloudy area of the vision field
All are associated with the migraine aura
Migrane Description
Unilateral HA that progresses to Pulsing then Throbbing and may eventually become generalized/Bilateral
- often preceded by an aura
- often w/photo phono Phobias
- often w/ Nausea & Vomiting w/o GI cause
- Might involve parasthesias
Abortive Migraine Meds
Caffeine + NSAID Combos OTC
Ketorulac (Toradol) Injection
Sumitriptan (Imitrex)- Do NOT use in CAD
constricts coronary arteries along with
those in the head.
Don’t Use SUMITRIPTAN In:
Coronary Artery Disease!!! it constricts vasculature , in the head (giving HA relief) and in the heart (causing MI…)
Abortive Migraine Drugs of LAST RESORT
Opiates
Always with an anti-emetic (Zofran/Reglan) AND
use the one with the NARCAN coating to prevent constipation.
Odansetron
Zofran
Anti-Emetic
Causes QT prolongation and Bradycardia so perhaps not with CHF/ Bradyarrythmias
5HT3 Serotonin Receptor Antagonist
Prophylactic Migraine Rx for more than 4 episodes of migraine:
Anticonvulsants: Depakote/Valproate
Topamax/ Topiramate
Propranalol may help if HTN/Stress is an inducer
Amitriptyline (TriCyclic) might kill two birds if your pt is also depressed - watch out for Suicide Risk and EKG changes
Maybe Verapamil - like for Cluster headaches
Amitryptyline Warnings
Suicide Risk Increases
Its a Na+ Blocker so we get Seizures and
Ventricular Arrythmias like V-Tach/V-Fib and ST Elevations
Prophylactic Behaviors for Migraine
SLEEP - get enough
HA Diary for dietary/environmental triggers
ID triggers and avoid them
Don’t overuse NSAIDs w/Caffeine - they can cause rebound headaches if overused.
Yoga/Stress Reduction by any alternative means that doesn’t give you headaches
Tension Headache:
A “SQUEEZING” band around the head @ forehead level
Lasts 30 Min to several Days if untreated
Not light/sound/smell sensitive
Consider Neck Pain cause, TMJ, Stress/
Eye Strain
Tension HA Rx
Avoid Triggers (Stress...) OTC NSAID (esp w/Caffeine) Address poor posture/see chiropractor
Unilateral Headache
Migraine or Cluster
Migraine has visual disturbance NV photophobia
Cluster is eye PAIN may cause unilateral tearing relieved by 02.
Pain behind sinuses
Sinus Headache
Esp if w/ viral inf or URI
Vice Like Pain, headband
Tension Headache
Give NSAIDs
Avoid Stressors
Headache with loss of visual field (Pt fails the bunny ears test or it’s unequal)
Think Optic Chiasm Pressure
Think Pituitary or other tumor
Order CT scan of Head/Neck
Headache and weigh loss…
Think cancer
Get CBC & follow up
Headache w/ Fever
think Meningitis
Neck ROM, Kernig (leg) & Brudinski (bent knee/Neck Flexion)
-Strep Pneumo most common
-Neisseria Meningititis 2nd
-Head Trauma a good way for these normal
Flora to invade CSF
-Treat empirically w/Cephtriaxone until culture comes back unless the strep Pneumo in your area is Cefalo- Resistant, in which case use a quinine (great CSF penetration) and Vanco.
Neonatal Meningitis bug
Group B Strep from mama’s vag. canal
Rx is Ampicillin + Gentamycin
Or… ensure Mama is tested @ 38 wks and labor and have her on Rx during labor/delivery
Rx for Syphylitic Meningitis and Neisseria Meningiditis and non-resistant Strep Pneumo
Pennicillin G
Listeria Meningitis is very deadly Rx?
Bactrim will do the trick if pt is penicillin allergic. Otherwise use Penn G.
Best Quinilone for CSF penetration is
Moxifloxacin
Use it with Vanco to treat strep pneumo meningitis that is resistant to cephtriaxone and penicillin.
Empiric Drugs for Meningitis
Cephtriaxone or
Carbapenem (big gun!)
(Moxifloxacin + Vanco for resistant strp pneumo)
Headache AND need to lose weight?
Topomax
Now explain why…
