Headache Flashcards
tension type headache?
episodic, can become chornic
migraine headache?
episodic & recurring
cluster headache
episodic & returning
epidemiology of headaches?
- 50% of population reports HA/year, 90% w/ lifetime prevalence
- most prevalent neurological disorder and most frequent symptom seen in primary care
- 18% lifetime prevalence of migraine
- tension HA more common than migraines (52%)
- chornic headache (a daily HA) occurs in ~3%
epidemiology of subtypes of headaches
- migraines: women>men
- tension HA: women = men
- cluster HA: men > women
primary vs secondary HA
primary: not associated w/ organic disease or structural neurologic abnormality. testing and imaging normal
secondary: associated w/ abnormality on clinical exam, testing & imaging confirming diagnosis. symptoms are caused by something else going on
pathophysiology of headaches
- not well understood
- migraine & cluster: believed to begin as a neurologic dysfunction w/ subsequent involvement in trigeminal nerve and cranial vessels. mot cluster HA involve the PNS
-tension: central neurologic disturbance as a result of increased cervical and pericardial muscle activity. flexion-extneion injury to neck, poor posture, anxiety, clenching/grinding teeth.
migraine pathophysiology?
- episodic instability of serotonin and neurotransmitters. serotonin may be diminished or receptors less sensitive
- trigeminal nerve may become hyperactive - efferent impulses over branches of trigeminal nerve go to the innervated cranial vessels, causing release of substances promotion perivascular inflammation and vascular dilation
- dysfunction of brainstem and hypothalamus are responsible for s/s such as N/V photophobia, photophobia & osmophobia
- central sensitization occurs. inflamed perivascular structures irritate nerve endings of trigeminal nerve->afferent stimuli back to trigeminal neurons -> sensitizing and continuing to fire. this causes the scalp to become painful and tender
cluster pathophysiology
- episodic neuronal dysfunction
- likely involving the hypothalamus more than brainstem
- marked increase in blood flow of ICA on side of HA during the attack of pain
before saying it’s just a headache, think…
- new onset neurologic or cognitive deficit
- worsening with fever
- thunderclap or worst head of life
- clinical features of glaucoma
- impaired LOC
- head trauma in past 3 months
- triggered by cough, sneeze vasalva or exercise
- changes with posture
- clinical features of GCA
- significant change in characteristics of HA
- personality changes
- atypical aura
- h/o malignancy, HIV, immunocompromised
signs & symptoms of tension
- a dull every day headache
- mild to moderate generalized pressure or tightness
- nausea, photophobia, photophobia may occur but not prominent
- increased muscle tension
- scalp tenderness
- TMJ, cervical or trapezius muscle groups w/ tightness & tenderness
signs & symptoms of migraine
- 15-20% with aura (visual or neurologic deficit lasting < 1 hour followed by migraine)
- prodromal symtoms - changes in mood, personality, failure or hyperactive in the day prior
- moderate to severe pounding/throbbing generally unilateral
- photophobia, phonophobia, osmophobia, N/V
cluster signs & symptoms
- steady, boring, intense pain behind one eye
- can spread to temple, face and upper neck
- unilateral tearing, nasal congestion, conjunctival injection (usually in the morning)
- often at same time each day (waking hours)
- short in duration, 30-45 minutes
- once to several times a day for a period of weeks to months then remit for months to years
history & examination for headaches
-detailed history including last 3 months. TEMPORAL profile: onset to peak, time of onset, frequency, duration, stable or evolving. AUTONOMIC features: nasal congestion, rhinorrhea, tearing, ptosis, edema. description, location, severity, percipitating or relieving factors, effective vs. ineffective treatment, aura, other PMH
physical exam: VS, extra cranial structures, neck flexion/rotation
neurologic exam: mental status, cranial nerves, motor, sensory, reflexes, coordination, gait
how do you diagnose headaches?
- based on patient history of signs, symptoms and duration
- for females investigate correlation with menstrual cycle - requires observation over 2-3 months, headache diary is useful
neuroimaging: not recommended unless strong suspicion for underlying intracranial abnormality. incidental abnormalities lead to increased anxiety. would do it on someone who’s 50 with their first occurence of headache.
tension treatment
prophylaxis not recommended.
- pharmacologic: ASA, acetaminophen, NSAID
- acupuncture
- chronic tension may overlap w/ chronic migraine. if so then migraine prophylaxis may be utilized
factors to consider for migraine prophylaxis
consider: frequency (>2 migraines per week), severity, comorbid conditions, risk of medication overuse and patient compliance
non pharamcoloic measures for migraine prophylaxis
acupuncture
first line pharmacologic agents for migraine prophylaxis
Topamax/propranolol are first line agents.
side effects of topamax?
topamax: side effect profile and teratogenic potential may preclude (short term memory loss)
other medications used for migraine prophylaxis
gabapentin found to show some benefit
commonly used but lacking evidence: amitriptyline (used more often in those w/ depression too), valproate, pizotifen
how long should you stay on migraine prophylaxis
once migraine controlled utilize for 6 months, then consider weaning
what are options for migraine rescue therapy?
combination therapy superior to monothreapy (triptan + acetaminophen OR triptan + NSAID)
if you fail one triptan does that take the whole class of the plate?
no!
lack of effectiveness of triptan is not class effect
additional pharmacologic measures for migraine rescue therapy
antiemetics may be used in combo therapy regardless of N/V due to dopaminergic action
can consider non-oral therapy when oral not effective (SubQ, IM, intranasal, sublingual, suppository)
migraine considerations….?
women of childbearing age suffering from migraines with aura should not use hormonal contraception d/t increased risk of ischemic stroke
perimenstrual prophylaxis with frovatriptan or zolmitriptan on expected migraine days
migraine w/out aura often improves during pregnancy. acetaminophen is first line drug of choice, triptan can be considered but discussed with provider.
what is status migrainosus
migraine > 72 hours
dihydroergotamine mesylate (given in monitored setting)
- IV DHE most frequently used for intractable migraine attacks and status
- effective in 90% of patients within 48 hours
- effective in terminating acute cycle of cluster HA
- contraindicated in cerebrovascular disease, heart disease, HTN, within 24 hours of receiving triptan
chlorpromazine, valproate, Mg sulfate
-if h/o dystonic reaction may pre-medicate with benadryl
cluster treatment?
- oxygen and/or subQ or nasal triptan
- oral triptans should not be used (not effective)
- prophylaxis: verapamil - dosage is much higher than utilized for cardiovascular indications, should be managed by a specialist
no used for opioids which may result in medication overuse
additional therapies for headache
acupuncture biofeedback butterbur root coenzyme Q10 cognitive therapy feverfew lifestyle / diet modification (avoid tyramine, sulfites, artificial sweeteners, processed foods) magnesium botox physical therapy relaxation therapy riboflavin cervical manipulation TENS unit
outcomes for headaches
- early treatment improves duration, severity and associated disability
- comprehensive outpatient treatment centers are promising for chronic daily HA and medication overuse patients.
- program includes detox from overuse medications, initiation of prophylactics, psychotherapy, PT, relaxation and biofeedback techniques, education of triggers - acute migraines treated with triptans are associated w/ reduced ED & primary care visits, fewer lost days and reduced disability
