Headache Flashcards
Define Primary Headache
Headache with no underlying disease process
Generally benign and will not be fatal or cause long term neuro deficit
Define Secondary Headache
Headache as a secondary manifestation for another disease process
Much more concern about imminent death or neuro deficits
What are some “red flags” for Aneurysmal SAH or cerebellar hematoma?
Split second, unexpected worst headache of life
LOC
Vertigo
Vomiting
What are some “red flags” for meningitis?
Headache, fever, skin rash
What are some “red flags” for cryptomeningitis or toxoplasmosis?
Immunocompromised
What are some “red flags” for subdural or intradural hematomas?
Coagulopathy or the patient is on anticoagulation therapy
What is a migraine?
Genetic condition in which a person has a predisposition to episodic headaches, GI disturbance (nausea) or neuro dysfunction
How often do migraines typically occur? Where? What kinds of patients tend to develop migraines?
Typically once or twice a month
Unilateral
Often begin in late childhood or early adulthood (menarche to menopause)
What are the 4 typical phases of a migraine?
- Prodrome
- Aura
- Pain
- Postdrome
Describe the Prodrome phase of a migraine
Occurs days-hours before the migraine begins
May develop depression, irritability, drowsiness, fatigue, hunger/thirst, rhinorrhea/lacrimation, yawning
Describe the Aura phase of a migraine
Often visual aura (“fortification phenomenon”)
Usually develops over 5-20 min and lasts over an hour
Numbness/tingling of face or arm
Dizziness
Diplopia
How would you differentiate between the aura of a migraine versus the aura of Retinal Detachment?
Retinal detachment– flashing lights that come and go after a few seconds
Migraine Aura–stay for an extended period of time before the migraine
Describe the Pain phase of a migraine
Pain may be in head, abdomen, or chest
Onset is gradual, over min-hours
May last for hours or days
Maybe associated with photophobia, phonophobia, nausea
People who get migraines are often genetically setup for them. What is the mutation and how does it cause the migraines?
Gain of function mutation in an NMDA receptor, which is excitatory
NMDA receptor activation leads to burst of focal cerebral activity, which leads to local hyperemia and increased blood flow
Describe the feedback loop that allows migraines to persist
Trigeminal nerves become activated and they release neuropeptides (CGRP, substance P, neurokinin A)
CN V sends a message to dilate blood vessels in brain
Creates a constant feedback loop
Describe the Postdrome phase of a migraine
Present for several hours after the pain ends
Mood changes (euphoria, fatigue)
Impaired concentration
Scalp and muscle tenderness
What is the first line treatment for mild migraines? What if that doesn’t work?
First line treatment is NSAIDs
Move on to stronger drugs if that fails (triptans)
Triptans
MOA
Agonists of the 5-HT 1B/D receptors
Cause vasoconstriction of blood vessels
Triptans
Contraindications
Do NOT use in pregnant women or in patients who are at risk for ischemic heart disease
Also avoid with renal disease or HTN
Avoid if on MAO inhibitor
Triptans
Adverse Effects
Warm/hot sensations
Chest tightness
Tingling
Pressure sensations
Potential risk for serotonin syndrome
What is Serotonin Syndrome?
Excess activation of 5HT 1A and 5HT2 receptors
Leg rigidity Lacrimation Excess bowel sounds Myoclonus Hyperreflexia Seizures
Ergotamine
Indications
Less specific than triptans
Potent arterial vasoconstrictors
DHE = Dihydroergotamine
Indications
Significant arterial and venous vasodilator
More side effects associated than ergotamine
When are ergots (DHE, ergotamine) contraindicated?
Ischemic heart disease
Collagen vascular disease
cardiac valve disease
HTN
Hemiplegic/basilar migraine
Pregnant women
When would Botox be indicated for migraines?
Only for chronic migraine headaches
Only after patient has failed many other meds and has frequent headaches
Cluster Headaches
Who is most likely to get one?
Males, typically in their 40s, who smoke and drink alcohol
Cluster Headaches
How long do the headaches tend to last? Where are they?
Usually unilateral headaches
Clusters last 6-12 weeks and occur every 1-2 years, but the headaches themselves occur 1-4x per day and last 20-30 min each
Cluster Headaches
Effective therapies?
Inhaled O2
Injectable sumatriptan
Nasal sprays
Prednisone is a last ditch option
What is the most common form of headache in adults?
Tension-type headache
Tension-type headache
Clinical Features
Bilateral pain, lasting over 30min
Band-like, pressing or tightening pain
No nausea and not aggravated by activity
Could have photophobia or phonophobia, but NOT BOTH
Tension-Type Headaches
Treatment
Go to sleep,
Eat better,
Don’t smoke
Trigeminal Neuralgia
Clinical Features
Shooting pain radiating down jaw is classic distribution
Trigeminal Neuralgia
Causes
Likely due to tortuous artery compressing the trigeminal nerve in older people
In young people, often caused by MS
Trigeminal Neuralgia
Treatment
Carbamazepine is first line therapy for pain control
Pseudotumor Cerebri
Who gets it?
Often overweight females
Pseudotumor Cerebri
What is it?
Neurologic emergency
Weight increase –> inc in intraabdominal pressure –> impairs venous outflow and increases intracranial pressure
May cause blindness
Primary Exertional Headache
Clinical Features and treatment
Pulsating HA occuring only during or after physical activity
Treat with Indomethacin before they exercise
