Headache

Question 1

what do red flags in the headache history alert us towards?

Answer 1

secondary headache disorder. these patients should be sent for imaging.

Question 2

phases of migraine

Answer 2

1. prodrome 2. aura 3. headache 4. resolution

Question 3

prodrome

Answer 3

hours to days before headache. change in mental status: drowsy, depressed, irritable, euphoric, hyperactive, talkative. neurological: photo/phonophobia, yawning, difficulty concentrating, dysphasia. anorexia, food craving, thirst, urination, fluid retention, diarrhea, constipation, stiff neck

Question 4

aura

Answer 4

complex of focal neurologic symptoms that precedes, accompanies, or follows headache. visual aura is most common, paresthesias are second most common.

Question 5

headache

Answer 5

unilateral, throbbing, moderate-severe, aggravated by physical atcivity. may evolve from uni to bilateral and vice versa. most start from 5AM-12PM and last 4-72 hours. gradual onset and resolution. anorexia, nausea, vomit, osmo/photo/phonophobia.

Question 6

resolution

Answer 6

headache wanes. person feels tired, washed out, irritable. impaired concentration. scalp tenderness. depression. rarely refreshed or euphoric

Question 7

migraine genetic basis

Answer 7

strong familial influence. more common in monozygotic twins. familial hemiplegic migraine (weakness of one side) due to calcium channel mutations on chromosome 19

Question 8

aura phase pathophys

Answer 8

associated with reduction of cerebral blood flow that moves across the cortex at 3 mm/min. usually begins in occipital lobe. this oligemia is not due to vasoconstriction and doesn’t respect vascular territories. rates of progression of spreading oligemia, migrainous scotoma, and spreading depression are equal.

Question 9

headache phase pathophys

Answer 9

nerve fibers of V1 of trigem release vasodilators and permeability promoting peptides. cause a sterile inflammation which increases intercranial mechanosensitiity and hyperalgesia. peptides release blocked by triptans.

Question 10

nonpharmacologic treatment of primary headaches

Answer 10

healthy habits. address psychological factors. psychopsysiological: stress management, etc. trigger identification and avoidance

Question 11

nonspecific med groups for acute headache treatment

Answer 11

NSAIDs, COX-2 inhibitors, combination analgesics, neuroleptics/antiemetics, corticosteroids, opiods.

Question 12

specific meds for acute headache treatment

Answer 12

triptans, ergotamines/DHE

Question 13

rebound

Answer 13

most symptomatic medications when taken daily may cause “rebound” phenomenon. caffeine and barbituate containing meds are leading culprits. most common cause of chronic daily headaches

Question 14

when are corticosteroids used?

Answer 14

patients with prolonged headache syndromes (headache for more than 72 hours)

Question 15

DHE

Answer 15

like ergotamine, but fewer side effects. less likely to cause nausea or rebound. avoid in women planning pregnancy, HTN, renal/hepatic failure, vascular disease

Question 16

triptans

Answer 16

selective 5-HT 1B-D receptor agonists. also effective for photo/phonophobia and N/V. avoid in vascular disease, HTN, complicated migraines.

Question 17

drug groups for preventive treatment of migraines

Answer 17

antidepressants, antihypertensives, antiepileptic drugs, NSAIDs, COX-2, and miscellaneous (supplements, botox, etc)

Question 18

tension type headache

Answer 18

unknown pathophys. not caused by muscle contraction.

Question 19

tenstion headache acute treatment groups

Answer 19

simple analgesics, analgesic combination with opioids, barbituate, caffiene.

Question 20

chronic tension headache treatment groups

Answer 20

TCA (amitriptyline). SSRIs, muscle relaxants, and botox can be used as well

Question 21

cluster headaches

Answer 21

clockwork daily and annual rhythm. onset 27-31 years. 14-39 fold increase if 1st degree relative has them. some patients have heavy facial features. hypothalamus likely basic site of dysfunction and interacts with trigem system.

Question 22

cluster headache acute treatment

Answer 22

O2 via non-rebreathing mask. sumatriptan. DHE and lidocaine.

Question 23

cluster headache preventive treatment

Answer 23

short term: daily steroids or DHE. long term: verapamil, topiramate, valproic acid, lithium

Question 24

lithium

Answer 24

alters circadian rhythms, but unknwon how it helps cluster headaches. need constant blood level monitoring as toxicity is problem. food can knock lithium into blood. avoid indomethacin and sodium depleting diuretics since they increase lithium levels