Headache Flashcards
How does an intracranial lesion cause headache pain?
Tumors and hemorrhages do not produce pain by itself- the swelling around it may cause headache by stretching or compressing blood vessels or cranial nerves
Differentiate a primary from secondary headache
PRimary: Headache is primary manifestation
Secondary: headaches is secondary manifestation of an underlying disease process
What are the 4 most common headaches?
1) tension-type
2) Migraine and variants
3) Provoked by fever or hunger
4) Nasal, paranasal, ear, tooth, eye disease
“Worse headache of her life” usually indicates what etiology of head pain?
vascular
If someone presents with a headache that occurred in a split second, worst/horrible pain, and includes vertigo, vomiting or LOC, what must you immediately check for?
Aneurysmal subarachnoid hemorrhage or cerebellar hematoma
If someone presents with a headache accompanied by a fever and a rash, what are you concerned of?
Meningitis
If someone presents with a headache in an immunocompromised state, what are you concerned for?
Cryptomeningitis or toxoplamosis
If someone presents with a headache and either a coagulopathy or anticoagulation, what are you concerned about?
Subdural or intradural hematoma
What is a migraine?
Primary headache disorder- genetic condition in which a person has a predisposition to episodic headaches, GI dysfunction or neurologic dysfunction
What are three clinical questions to ask your patients to determine whether or not their headaches are migraines?
Headaches are combined with:
1) Nausea
2) photophobia
3) discomfort that limits daily activities
Severity is not a factor
What are the symptoms of a migraine?
POUND P-Pulsatile (usually unilateral) O- One-day duration U- Unilateral N- Nausea D- Disabling
What is the first phase of a migraine headache?
- Prodrome: 6 days –> 48 hours before a migraine occurs. Includes feelings of depression, irritability, drowsiness, fatigue, yawning, rhinorrhea/lacrimation, and hunger/thirst
WHat is the second phase of a migraine headache?
Aura - most commonly visual, but could also be sensory/motor.
Most commonly occurs before a headache, but can also occur during or after
Due to spreading cortical depression
How does an aura affect reading?
Auras are characterized by a blind spot near the center of vision
What is the third phase of a migraine?
Pain- may be in the head, abdomen or chest
Describe the onset of pain in a migraine
THe onset of pain is GRADUAL over minutes to hours, and can last hours to days.
Can be associated with photophobia, phonophobia, nausea/vomiting, and osmophobia/thermophobia
- patients want to lie down in a cool, dark, quiet room.
What is the role of the NMDA receptor in migraine headaches?
Spreading cortical depression
A genetically susceptible patient has a multifocal defect in brain metabolism leading to a gain of function of the NMDA receptor function
Excitation of the NMDA receptor leads to a burst of focal cerebral activity –> positive symptoms
Burst is followed by a loss of neuronal activity –> Cortical depression
In which lobe does spreading cortical depression usually originate?
Occipital
What is the trigeminovascular reflex?
The trigeminal nerve wraps around pain sensitive structures, releases local neuropeptides, and conveys information to the trigeminal nucleus in the brainstem.
This can lead to neurogenic inflammation, evoke vasodilation of pain producing structures, and create a feedback loop with the trigeminal pathway.
Which neuropeptides are released in the trigeminovascular reflex?
CGRP, Substance P, and neurokinin A.
What is the 4th phase of a migraine headache?
Postrome: present for several hours after the event. INcludes mood changes, impaired concentration and scalp/muscle tenderness
When do you treat a migraine?
AS EARLY AS POSSIBLE. Much more effective if you begin treatment during the Prodrome time, rather than when symptoms have already onset
What is the first line treatment of migraines
simple analgesics (over the counter NSAIDS). Use effective doses!
Medications containing what active ingredient should always be avoided in the treatment of migraines. Why?
Butalbital-containing meds. It has a high potential for addiction/overuse
How do triptans work in the treatment of migraines?
All triptans are agonists of 5HT 1B/D receptors. They may lead to vasoconstriction
How does failure of one triptan predict the efficacy of a different triptan?
Failure of one drug to work does not mean all triptans wont work- they have variable pharmacokinetics
What are contraindications for the use of triptans?
Avoid triptans in people with vascular disease/vascular risk factors (ischemic heart disease, uncontrolled hypertension, renal disease, pregnancy, evidence of basilar or hemiplegic migraine, ergotamine, MAO inhibitors….)
What is serotonin syndrome?
Caused by excessive activation of 5HT-1a and 5HT2 receptors.
Leads to leg-predominant rigidity, dysautonomia, and encephalopathy characterized by myoclonus, hyper-reflexia and seizures
Name two ERgot alkaloids used in the treatment of migraines
Ergotamine and DHE (dihydroergotamine)
ERgotamine is rarely used since the introduction of triptans due to side effects of nausea and uterine contractions
DHE is give as IV, SC and nasal sprays
What are contraindications of ergot alkaloids?
vascular disease/vascular risks..
When is botox indicated for the treatment of migraines?
indicated only for chronic migraine headaches, generally only approved following failure of multiple medications and following multiple episodes per month
Are cluster headache more common in men or women?
Men
What is the timing of a cluster headache?
1-4 attacks/day lasting 20 minutes to 3 hours
Rapid onset of 15-30 minutes
Are cluster headaches unilateral or bilateral?
Cluster headaches are invariably unilateral, but may switch sides between clusters
What triggers a cluster headache?
Alcohol nearly always triggers cluster headaches.
Can be associated with a partial Horner’s and unilateral rhinorrhea
What oral meds are taken for cluster headaches?
None- cluster headaches are so short (usually 30-90 minutes) so that oral medications are not helpful in time.
WHat are first line treatments for cluster headaches?
Injectable sumatriptan, inhaled 100% O2, nasal spray triptans or intranasal DHE
Which is the most common form of headache?
Tension-type
Are tension headaches bilateral or unilateral?
Bilateral-
What is the timing of a tension headache?
> 30 minutes, usually 4-6 hours
Are phonophobia and photophobia associated with tension headaches?
One or the other, but never both
What is trigeminal neuralgia?
Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes. Effects one or more division of V.
TN usually affects the jaw and is lightening like.
What is the treatment for trigeminal neuralgia?
Carbamazepine- 200-1200 mg/d
What is the opening pressure in pseudotumor cerebri
> 250 mm H2O
What is the most common presenting feature of pseudotumor cerebri?
Headache.
What are the treatments for pseudotumor cerebri?
acetazolamide, topiramate, surgical intervention
