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Nayla Foundations Exam 4 > Headache > Flashcards

Headache Flashcards

1
Q

How are headaches classified

A

primary (90%)
secondary
neuropathies/facial pain

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2
Q

What are the primary headaches

A

Migraine
Tension HA
Cluster HA

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3
Q

What are some social factors that can affect headaches

A 
Alcohol
tobacco
marijuana
caffeine 
diet changes
illicit drug use
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4
Q

What is HIT6

A

headache impact test, to quantify level of disability

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5
Q

What are some red flags

A 
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
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6
Q

What is the most common type of HA to lead pt to the ED

A

Migraine-

MC in women, white, low SES, genetic predisposition, obese, depressed/anxious

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7
Q

What is the etiology behind a Migraine HA

A

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

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8
Q

What step is associated with “aura”

A

During brainstem hyperexcitability and increased blood flow

The change in nerve activity cause numb/tingle/dizzy/visual change

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9
Q

How do triggers affect threshold

A

The more triggers you have, the lower your threshold

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10
Q

MC migraine triggers are

A 
emotional stress
hormones in women (estrogen inversely related to HA) 
not eating
weather
sleep disturbance
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11
Q

What is the Migraine prodrome

A

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
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12
Q

What is a Migraine Aura

A

Slow ramp up (gradual over 5 min) lasting 5-60 min

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13
Q

Types of aura include

A

Visual (shimmering shapes)
Sensory (tingling unilateral face/limb)
Language (frank dysphasia)
Motor (weakness unilateral)

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14
Q

What are characteristics of Migraine HA

A 
4-72 hours
UNIlateral
Throbbing
mod-severe pain
*leads to SOME degree of disability
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15
Q

What are symptoms of a migraine HA

A 
N/V
photophobia
phonophobia
osmophobia
cutaneous allodynia
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16
Q

What is the post-dromal/resolution phase

A

up to 24 hours
sudden head movement causes transient HA
fatigue, hard to concentrate, not feeling like self

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17
Q

What are the types of Migraines

A

*Common: w/o aura
Classic: w/ aura (retinal, brainstem, hemiplegic)
Chronic (8+ days/mo for >3 mo)

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18
Q

Classify a Migraine WITHOUT aura

A

5 attacks lasting 4-72 hours
2+: unilateral-pulsating-mod/severe pain-cant do routine phys. activity
During HA: N/V or photo/phonophobia

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19
Q

Classify a migraine WITH aura

A

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

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20
Q

Classify a retinal migraine

A

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

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21
Q

Classify a brainstem migraine

A

fully reversible visual, sensory, or language aura Sx (NOT retinal or motor)
2: brainstem Sx: dysarthria- vertigo- tinnitus- hypacusis- diplopia- ataxia- decreased LOC

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22
Q

Classify a hemiplegic migraine

A

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

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23
Q

What are types of migraine treatment

A

Abortive (stop progression, reduce pain and Sx)

Preventive (daily for mo-yr, reduce frequency and severity)

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24
Q

Abortive Tx for mild-mod migraine

A
  1. NSAIDs (ibuprofen, naproxen, toradol)
  2. Acetaminophen
  3. ASA/caffeine/APAP (Excedrin)
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25
Q

What can Excedrin cause if not used intermittently

A

med-overuse headache

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26
Q

Abortive Tx for severe migraine

A
  1. Triptans (serotonin agonist)- vasoconstrict and decrease pain; not analgesic (Sumatriptan)
  2. Ergotamines (non-selective serotonin agonist); more ADE (Dihydroergotamine)
  3. Opioids (rescue use, last resort if nothing else works); Dependence!
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27
Q

What can chronic use of Triptans cause

A

Serotonin Syndrome (daily dull HA, or med overuse HA) if used >3-4x week

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28
Q

What can regular opioid use cause

A

tolerance
hyperalgesia
med overuse headache

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29
Q

What adjunct treatments can be used for Migraines

A

Antiemetic (phenergan, reglan)

Hydration (dehydration causes migraine, N/V Sx)

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30
Q

When should you use migraine prophylaxis

A

if pt has frequent attacks (>3x month) with disabling Sx
If migraine lasts >48 hours
if acute Tx contraindicated

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31
Q

What are Migraine prophylaxis meds

A 
Valporic acid
Propranolol
Verapamil
Amitryptaline 
Venlafaxine
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32
Q

What Tx was recently approved by FDA for chronic migraine

A

Botox injections; 155-195 units into face, head, and neck muscles

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33
Q

How does botox work

A

Blocks release of CGRP and substance P= no peripheral signals to CNS, no central sensitization

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34
Q

What is the MC primary headache disorder

A

Tension Headache (but not that bad so it doesnt lead to many office visits)

35
Q

RF for tension headaches include

A 
stress/anxiety
too much or too little sleep 
OSA
depression
muscle tension
cervical spondylosis
36
Q

What is the proposed etiology of Tension headaches

A

Myofascial nociceptors peripherally activated
Nociceptor threshold is decreased
Normally innocuous stimuli perceived as pain
Prolonged nociceptive stimuli sensitize pain pathway in CNS

37
Q

Describe a Tension headache

A 
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
38
Q

Abortive Tx for Tension HA

A
  1. NSAID’s

2. Acetaminophen, ASA

39
Q

Prophylaxis for chronic Tension HA

A

(>7-9x month)
1. Amitriptyline (start low titrate up)
Non-pharm: CBT, relax technique, EMG biofeedback
-also PT, acupuncture

40
Q

What is the least common and most disabling HA

A

Cluster headache

41
Q

RF for cluster headaches are

A 
1st degree FHx 
prior head injury
smoking
high alcohol
male
Type A
42
Q

What is the etiology of a cluster HA

A

hypothalamus activated w/ trigeminal-autonomic reflex activation

43
Q

What triggers initiate a cluster HA

A 
Circadian rhythm disorder 
Sleep (low O2)
volatile smell
vasodilators (sildenafil) 
smoking
44
Q

Describe a cluster HA

A

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

45
Q

What are the two types of cluster headaches

A

Episodic (MC)- 2-16 weeks, then cluster free for >6 mo

Chronic- not cluster free for > 1 month

46
Q

Cluster HA have at least 1 Sx on affected side

A 
conjunctival injection, tearing
congestion/rhinorrhea
eyelid edema
forehead sweating
Ear feels full
Miosis or Ptosis (Horner syndrome)
47
Q

Acute Cluster HA attack Tx

A

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

48
Q

Prophylaxis for Cluster HA

A 
Verapamil (NO in heart block or arrhythmia) 
control RF (smoking, drinking)
49
Q

What are MC types of secondary HA

A 
Post-concussion
Analgesic rebound
Pseudotumor cerebri
Temporal arteritis 
Trigeminal neuralgia 
SAH
50
Q

What are features of a concussion

A

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

51
Q

A concussion is basically

A

a mild traumatic brain injury; neuro Sx occur d/t axon injury

52
Q

Do you need imaging for concussion? if so, what?

A

Only to R/O ICH; but they dont diagnose concussion

CT and MRI

53
Q

How do you manage a concussion

A

REST; physical, and cognitive

-But, no Tx speeds recovery

54
Q

What are treatment considerations with concussion

A

Tx specific/prolonged Sx (APAP for HA)
Careful w/ Tx as to not mask Sx or ADE
-No drugs prevent or improve recovery

55
Q

What is a drug rebound HA

A

preceded by episodic HA disorder, usually related to Opioids, Excedrin, and Furocet (butalbital combo)
*MC due to lack of proper education to pt

56
Q

What underlying behavioral disorders rise concern for med overuse HA

A

Addictive personality
depression
anxiety

57
Q

What Sx are associated with Drug rebound HA

A 
Nausea
asthenia
hard to concentrate 
memory problem
irritability
58
Q

How do you classify a drug rebound HA

A
  • 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)
59
Q

How do you treat a drug rebound HA

A

D/C analgesics; should resolve w/in 2 mo

60
Q

What is pseudotumor cerebri

A

Idiopathic IC HTN- chronically elevated ICP

*affects women of child bearing age, and obese mostly

61
Q

What is the presenting Sx of pseudotumor

A

**Headache! (intermittent/persistent, +/- worse with posture change, +/- relief with NSAID or rest)

62
Q

What are Sx of pseudotumor cerebri

A 
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
63
Q

What are PE findings of pseudotumor cerebri

A 
Papilledema 
visual field loss (large blind spot w/ periph constriction)
Abducens palsy (CN VI)
64
Q

How do you diagnose pseudotumor cerebri

A

LP!

65
Q

How do you treat pseudotumor cerebri

A

weight loss (if obese)
decrease Na intake
Acetazolamide (reduce CSF production rate)
Furosemide (added to acetazolamide)
-Serial LP, optic nerve fenestration, CSF shunting

66
Q

What med do you NOT give pseudotumor cerebri pt

A

Corticosteroids

67
Q

What is the MC systemic vasculitis

A 
Giant Cell (temporal) arteritis 
*Peak 70-79 y/o
68
Q

How does Temporal arteritis present

A

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)

69
Q

Other S/Sx of Temporal arteritis include

A

thickening of SF temporal artery
gentle scalp pressure= pain
+/- central retinal artery occlusion on eye exam

70
Q

What is a hallmark of GCA

A

elevated ESR and CRP (not specific)

71
Q

How do you Dx GCA

A

Temporal biopsy! (start Tx before biopsy

72
Q

How do you treat GCA

A

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
73
Q

What is trigeminal neuralgia (Tic Doloureux)

A

Compression of trigeminal nerve root= ischemia= demyelination= ephatic cross talk btwn. light touch and pain fibers

74
Q

Hyperexcitability is common over what areas

A

face
lips
tongue

75
Q

Features of trigeminal neuralgia include

A

3+ UNIlateral Sharp electric shocks lasting few seconds, mostly in V2/V3
NO neuro deficit

76
Q

What are triggers for trigeminal neuralgia

A

chewing, brushing teeth, puffs of air

77
Q

How do you diagnose trigeminal neuralgia

A

Clinically!

MRA w/ con to see neovascular compression

78
Q

What are red flags in trigeminal neuralgia

A

Sensory loss (CN V)
bilateral Sx
<40 y/o

79
Q

How do you treat trigeminal neuralgia

A

Anti-depressants
Anti-seizure meds (carbamazepime)
Microvascular decompression (good long term outcome)
-Narcotics NOT effective

80
Q

What are RF for a SAH

A 
Smoking, alcohol
HTN
sympathomimetics 
PKD
coarcation of aorta
Marfans
81
Q

What are Sx of a SAH

A

sudden onset worst HA of life
worse with exertion
N/V
+/- meningism, neck stiffness

82
Q

What is emergent workup for SAH

A

Non-con CT

If (-), LP

83
Q

How do you treat a SAH

A

Surgical clip

84
Q

What is the MCC of SAH

A

Rupture of saccular aneurysm

Nayla Foundations Exam 4 (15 decks)

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