Headache Flashcards
2 classes
1ary vs 2ary
1ary EXCUSION Dx = migraine, tension, cluster HA
2nary = bleeding, NOT STROKE, hydrocephalus, meds, CO poisoning
Path
1ary - don’t know
Combo of these:
- Genetics
- Triggers
- CNS pain pathways
- Med overuse
History Most important question
Have you ever had like this before?
1ary likely if:
- Typical HA (character)
- Ran out of meds
- Slow onset (over 10-15 minutes)
Concerning Factors in assessment
- NOT Typical HA
- Worst of Life
- Onset quick
- progressively worsening daily HA = growing tumor
- Toxic appearing
- altered neuro (Focal) - consciousness change
Time course of HA
Migraine
Tension
Cluster
Tumor
Migraine = regular periodic
Tension = constant (a few breaks)
Cluster= 6-8 SEVERE together in 3 week period, then nothing for months, then cluster
Tumor - growing
Tension HA
Spread to neck muscles
- 10 previous
- 30 mins - 7 days (long)
- 2 of follwing
- NO N/V
- Photophobia OR phonophobia
Dx
Tension
Tension HA
Risk factors
- women slightly more
- lower SES
- Cause: TMJ, Stress, Analgesic overuse, Depression
Tension HA
Tx
- NSAIDs/Acetamenophen
- combo products w/ caffeine
- Trigger ID
- Heat, warm, bath, muscle relaxants
- PT
- severe = anti-emetics, barbituates, opiates
- Treat depression (also CSD - serotonin action)
Tension headache
Chronic Daily Headache
Cause
- 2ndary to med overuse
- depression
- PTSD
- Hx sexual abuse
Tension headache
Chronic Daily Headache
Tx
- underlying issue
- wean off meds - support with ADD
- psycotherapy, cognitive therapy
*healthy lifestyle
- unilateral, throbbing, behind eye
- w/. Or w/o aura
- visual/taste + smell/depression out of nowhere
- N/V
- photophobia, phonophobia
- want to NOT MOVE, NO SOUND/LIGHT
S/s
Migraine
Migraine
Who?
*more women
(“Menstrual migraines”)
*heredity
*impairs life function
Aura types
Scotoma
Fortification spectra
Classic Migraine
- aura
- focal neuro deficits
- N/V
Common Migraine
NO aura
No focal neuro definitions
Migraine
Tx
*Triptans (BEST)
*ergots
Right at beginning
WATCH w/ Vascular problems = Rx vasoconstricts
- anti-emetics
- Steroids
- opiates = rebound HA possible!!
Acute Migraine
Tx
1st line = Triptans
*5HT1 ags = vasoconstrict
- ASA, tylenol, NSAIDS
- usually tried something b/f
- steriods, opiates
Migraine Triggers
Caffeine Foods Strong scents Change in weather SLEEP HYGIENE Mood stress Meds Period
Cluster HA
Tx
- High flow O2
- abortive Tx (triptan, ergotamines)
- opiates
- steroid = break cluster cycle
Cluster HA
Prevention
1st line = CCB (verapamil)
- lithium (but S.E.)
- NO BBlocker = not like migraine
Subarachnoid Hemorrhage
Ateriorvenous Malformation (AVM)
Venous + artery hooked together w/o capillary = too much pressure to veins (stretch, rupture)
Aneruysm
cause?
Congenital, HTN
Sub-arachnoid Hemorrhage
if Normal CT…
Can diffuse out over CSF w/ time
*LP!
Patient waits too long b/f coming in
If suspect Sub-arach hemorrhage or Meningitis… CT +…
LP!
- SAH = xanthochromia
- Meningitis = up protein, down glucose
Aneurysm treatment
Clipping vs. coiling
Coiling = don’t need to dig thru brain tissue to get at circle of willis
But must have neck (not bell curve)
2ndary HA common causes
Dehydration CO Sinusitis Otitis Acute Glaucoma Influenza Toxins Concussion
- bilateral
- non-throbbing
- slow onset
- NO N/V
- NO Photo/phonophobia
- NO focal neuro signs
- wants rest
- “stress”/”bad nerves”
S/s
Tension HA
Tension HA
Prevention
- stress management
* healthy lifestyle
Chronic Daily Headache
Possible other path/causes
- Tumor
- CSF leak
- COPD
- Thyroid conditions
- HTN
- Sleep apnea
Migraine
Initiation of Prophylaxis guidlines
6+ per month - DEFINITELY
2+ w/ severe impairment - CONSIDER
(Others)
Migraine Prophylaxis
Rx
Level A =
- BBlocker (Propranolol, Metoprolol)
- Anti-convulsants (Divalproex sodium, Valproate, Topiramate)
Level B =
- ADD (amitriptyline, Venlafaxine)
- BBlocker
- Intermittent HA
- Men
- Unilateral
- Unilateral rhinorrhea/lacrimation
- maybe unilateral ptosis/myosis
s/s?
Cluster HA
*rare
Cluster HA
Path
- unknown
- hypothalamic
- trigeminal pain pathways
- quick onset
- eye/temple pain
- unilateral w/ lacrimation/rhinorrhea
- no other focal signs
- restless, pacing patient
S/s?
Cluster HA
Cluster HA looks like what else?
Sub-Arachnoid Hemorrhage
RULE OUT
- “worst HA of life”
- N/V
- nuchal rigidity
- Photophobia
- “Sentinal bleed” = Hx of recent severe headache that resolved
Present?
Sub-arachnoid hemorrhage
Subarachnoid Hemorrhage
CT
- Fresh blood
* NO common vascular distribution
What if HA, then normal CT, but still S/s?
*Motor weakness, aphasia, dysartria, droop?
Early ischemic stroke
What if HA, then normal CT, but still S/s?
*Acute onset HA, vomiting, photophobia, nuchal rigidity
SAH possible
What if HA, then normal CT, but still S/s?
*Fever, infx exposure, nuchal rigidity?
Meningitis possible
Sub-Arach Hemorrhage
Tx
- Neurosurgeon evaluation
- Large bleeds - surgical decompression
- Avoid UP ICP = anti-emetics
- Manage HTN (rebleed)
- Nimodipine = DOWN vasospasm
Can we do LP for epidural or subdural hemorrhage?
NO
*not in subarachnoid space
AVM
Tx
Excision
Cauterization
Aneurysm
Tx
- small = watch + wait
* clip/coil
