Headache Flashcards
How are headaches classified
primary (90%)
secondary
neuropathies/facial pain
What are the primary headaches
Migraine
Tension HA
Cluster HA
What are some social factors that can affect headaches
Alcohol tobacco marijuana caffeine diet changes illicit drug use
What is HIT6
headache impact test, to quantify level of disability
What are some red flags
Abrupt onset/thunder clap Trauma associated w/ neuro deficits Change in pattern of normal headaches Systemic symptoms New HA in cancer/HIV pt New onset after 50 HA wakes from sleep Jaw claudication posture/exercise/valsalva provoked
What is the most common type of HA to lead pt to the ED
Migraine-
MC in women, white, low SES, genetic predisposition, obese, depressed/anxious
What is the etiology behind a Migraine HA
Trigger causes brainstem to be hyperexcited= increased blood flow
Alteration of neuropeptide levels (decrease in serotonin, NE)
increased blood vessel dilation and inflammation to dura
Trigeminal nerve pain receptors are activated
What step is associated with “aura”
During brainstem hyperexcitability and increased blood flow
The change in nerve activity cause numb/tingle/dizzy/visual change
How do triggers affect threshold
The more triggers you have, the lower your threshold
MC migraine triggers are
emotional stress hormones in women (estrogen inversely related to HA) not eating weather sleep disturbance
What is the Migraine prodrome
Sx 24-48 hr prior to migraine including
- Yawning, depression, irritability, etc.
- *If a patient can ID the prodrome they can take meds prior to onset
What is a Migraine Aura
Slow ramp up (gradual over 5 min) lasting 5-60 min
Types of aura include
Visual (shimmering shapes)
Sensory (tingling unilateral face/limb)
Language (frank dysphasia)
Motor (weakness unilateral)
What are characteristics of Migraine HA
4-72 hours UNIlateral Throbbing mod-severe pain *leads to SOME degree of disability
What are symptoms of a migraine HA
N/V photophobia phonophobia osmophobia cutaneous allodynia
What is the post-dromal/resolution phase
up to 24 hours
sudden head movement causes transient HA
fatigue, hard to concentrate, not feeling like self
What are the types of Migraines
*Common: w/o aura
Classic: w/ aura (retinal, brainstem, hemiplegic)
Chronic (8+ days/mo for >3 mo)
Classify a Migraine WITHOUT aura
5 attacks lasting 4-72 hours
2+: unilateral-pulsating-mod/severe pain-cant do routine phys. activity
During HA: N/V or photo/phonophobia
Classify a migraine WITH aura
2 attacks
1+ reversible aura Sx: visual- sensory- motor- language
2+: 1 aura Sx over 5 min or 2 in succession- each aura lasts 5-60 min- 1 aura is unilateral- HA <60 min after aura
Classify a retinal migraine
Aura w/ reversible monocular or negative visual phenomenon confirmed with (clinical visual field exam OR drawing visual field deficit)
2+: aura spreads over 5 min- Sx last 5-60 min- HA <60 min after
Classify a brainstem migraine
fully reversible visual, sensory, or language aura Sx (NOT retinal or motor)
2: brainstem Sx: dysarthria- vertigo- tinnitus- hypacusis- diplopia- ataxia- decreased LOC
Classify a hemiplegic migraine
Aura w reversible motor weakness AND visual/sensory/speech/ Sx
2+: 1 aura over 5 min or 2 in succession- each lasts 5-60 min (motor <72 hr)- 1 aura is UNI- HA <60 min after
What are types of migraine treatment
Abortive (stop progression, reduce pain and Sx)
Preventive (daily for mo-yr, reduce frequency and severity)
Abortive Tx for mild-mod migraine
- NSAIDs (ibuprofen, naproxen, toradol)
- Acetaminophen
- ASA/caffeine/APAP (Excedrin)
What can Excedrin cause if not used intermittently
med-overuse headache
Abortive Tx for severe migraine
- Triptans (serotonin agonist)- vasoconstrict and decrease pain; not analgesic (Sumatriptan)
- Ergotamines (non-selective serotonin agonist); more ADE (Dihydroergotamine)
- Opioids (rescue use, last resort if nothing else works); Dependence!
What can chronic use of Triptans cause
Serotonin Syndrome (daily dull HA, or med overuse HA) if used >3-4x week
What can regular opioid use cause
tolerance
hyperalgesia
med overuse headache
What adjunct treatments can be used for Migraines
Antiemetic (phenergan, reglan)
Hydration (dehydration causes migraine, N/V Sx)
When should you use migraine prophylaxis
if pt has frequent attacks (>3x month) with disabling Sx
If migraine lasts >48 hours
if acute Tx contraindicated
What are Migraine prophylaxis meds
Valporic acid Propranolol Verapamil Amitryptaline Venlafaxine
What Tx was recently approved by FDA for chronic migraine
Botox injections; 155-195 units into face, head, and neck muscles
How does botox work
Blocks release of CGRP and substance P= no peripheral signals to CNS, no central sensitization
What is the MC primary headache disorder
Tension Headache (but not that bad so it doesnt lead to many office visits)
RF for tension headaches include
stress/anxiety too much or too little sleep OSA depression muscle tension cervical spondylosis
What is the proposed etiology of Tension headaches
Myofascial nociceptors peripherally activated
Nociceptor threshold is decreased
Normally innocuous stimuli perceived as pain
Prolonged nociceptive stimuli sensitize pain pathway in CNS
Describe a Tension headache
daily/episodic HA 30 min- 7 days BIlateral pressing/tightening mild-moderate TTP over pericranial myofascial tissue -Rarely photo/phonophobia -not worse w/ activity -No N/V
Abortive Tx for Tension HA
- NSAID’s
2. Acetaminophen, ASA
Prophylaxis for chronic Tension HA
(>7-9x month)
1. Amitriptyline (start low titrate up)
Non-pharm: CBT, relax technique, EMG biofeedback
-also PT, acupuncture
What is the least common and most disabling HA
Cluster headache
RF for cluster headaches are
1st degree FHx prior head injury smoking high alcohol male Type A
What is the etiology of a cluster HA
hypothalamus activated w/ trigeminal-autonomic reflex activation
What triggers initiate a cluster HA
Circadian rhythm disorder Sleep (low O2) volatile smell vasodilators (sildenafil) smoking
Describe a cluster HA
UNIlateral
15-180 min (usu. <60)- pain peak @10-15 min
Piercing, exploding, penetrating, ice pick pain
Agitation, restless, pacing
1 every other day- 8/day for > 1/2 time episode is active
What are the two types of cluster headaches
Episodic (MC)- 2-16 weeks, then cluster free for >6 mo
Chronic- not cluster free for > 1 month
Cluster HA have at least 1 Sx on affected side
conjunctival injection, tearing congestion/rhinorrhea eyelid edema forehead sweating Ear feels full Miosis or Ptosis (Horner syndrome)
Acute Cluster HA attack Tx
1 (nonmed). Oxygen! (face mask)- OK if HTN or vasc. dz
1 (med). Sumatriptan/Zolmitriptan- FDA approved, NO in HTN or vasc. Dz
2. Prednisone taper (5 days + taper)
3. Intranasal lidocaine
Prophylaxis for Cluster HA
Verapamil (NO in heart block or arrhythmia) control RF (smoking, drinking)
What are MC types of secondary HA
Post-concussion Analgesic rebound Pseudotumor cerebri Temporal arteritis Trigeminal neuralgia SAH
What are features of a concussion
D/t direct or indirect blow to head, face, or neck
Rapid onset impairment of neuro fxn resolving spontaneously
No imaging abnormalities usually
No LOC usually
A concussion is basically
a mild traumatic brain injury; neuro Sx occur d/t axon injury
Do you need imaging for concussion? if so, what?
Only to R/O ICH; but they dont diagnose concussion
CT and MRI
How do you manage a concussion
REST; physical, and cognitive
-But, no Tx speeds recovery
What are treatment considerations with concussion
Tx specific/prolonged Sx (APAP for HA)
Careful w/ Tx as to not mask Sx or ADE
-No drugs prevent or improve recovery
What is a drug rebound HA
preceded by episodic HA disorder, usually related to Opioids, Excedrin, and Furocet (butalbital combo)
*MC due to lack of proper education to pt
What underlying behavioral disorders rise concern for med overuse HA
Addictive personality
depression
anxiety
What Sx are associated with Drug rebound HA
Nausea asthenia hard to concentrate memory problem irritability
How do you classify a drug rebound HA
- HA 15+ days/mo in pt with pre-existing HA disorder
- Overuse for 3+ months taken for HA Tx; 10+ days/mo for 3+ mo of higher potency drugs/combos– 15+ days/mo for 3+ mo of simple analgesics (APAP ASA, NSAID)
How do you treat a drug rebound HA
D/C analgesics; should resolve w/in 2 mo
What is pseudotumor cerebri
Idiopathic IC HTN- chronically elevated ICP
*affects women of child bearing age, and obese mostly
What is the presenting Sx of pseudotumor
**Headache! (intermittent/persistent, +/- worse with posture change, +/- relief with NSAID or rest)
What are Sx of pseudotumor cerebri
Transient visual obstruction (dimming in uni/bi up to 30 sec, worse with change in position) Pulsatile tinnitus photopsia back pain retrobulbar pain diplopia sustained visual loss
What are PE findings of pseudotumor cerebri
Papilledema visual field loss (large blind spot w/ periph constriction) Abducens palsy (CN VI)
How do you diagnose pseudotumor cerebri
LP!
How do you treat pseudotumor cerebri
weight loss (if obese)
decrease Na intake
Acetazolamide (reduce CSF production rate)
Furosemide (added to acetazolamide)
-Serial LP, optic nerve fenestration, CSF shunting
What med do you NOT give pseudotumor cerebri pt
Corticosteroids
What is the MC systemic vasculitis
Giant Cell (temporal) arteritis *Peak 70-79 y/o
How does Temporal arteritis present
abrupt/insidious onset
HA (throbbing, continuous, local to temporal/occipital)
Neck, torso, shoulder, pelvic girdle pain (polymyalgia rheumatica)
jaw claudication, fever (low grade 98.6-100.4)
Constitutional Sx (malaise, wt loss, myalgia, night sweat)
Other S/Sx of Temporal arteritis include
thickening of SF temporal artery
gentle scalp pressure= pain
+/- central retinal artery occlusion on eye exam
What is a hallmark of GCA
elevated ESR and CRP (not specific)
How do you Dx GCA
Temporal biopsy! (start Tx before biopsy
How do you treat GCA
High dose corticosteroids (prednisone)
- Sx should improve in 72 hrs
- Start to taper when ESR and CRP stay low, but may need a “boost” if inflammation waxes and wanes
What is trigeminal neuralgia (Tic Doloureux)
Compression of trigeminal nerve root= ischemia= demyelination= ephatic cross talk btwn. light touch and pain fibers
Hyperexcitability is common over what areas
face
lips
tongue
Features of trigeminal neuralgia include
3+ UNIlateral Sharp electric shocks lasting few seconds, mostly in V2/V3
NO neuro deficit
What are triggers for trigeminal neuralgia
chewing, brushing teeth, puffs of air
How do you diagnose trigeminal neuralgia
Clinically!
MRA w/ con to see neovascular compression
What are red flags in trigeminal neuralgia
Sensory loss (CN V)
bilateral Sx
<40 y/o
How do you treat trigeminal neuralgia
Anti-depressants
Anti-seizure meds (carbamazepime)
Microvascular decompression (good long term outcome)
-Narcotics NOT effective
What are RF for a SAH
Smoking, alcohol HTN sympathomimetics PKD coarcation of aorta Marfans
What are Sx of a SAH
sudden onset worst HA of life
worse with exertion
N/V
+/- meningism, neck stiffness
What is emergent workup for SAH
Non-con CT
If (-), LP
How do you treat a SAH
Surgical clip
What is the MCC of SAH
Rupture of saccular aneurysm
