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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
What can Excedrin cause if not used intermittently
med-overuse headache
26
Abortive Tx for severe migraine
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!
27
What can chronic use of Triptans cause
Serotonin Syndrome (daily dull HA, or med overuse HA) if used >3-4x week
28
What can regular opioid use cause
tolerance hyperalgesia med overuse headache
29
What adjunct treatments can be used for Migraines
Antiemetic (phenergan, reglan) | Hydration (dehydration causes migraine, N/V Sx)
30
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
31
What are Migraine prophylaxis meds
``` Valporic acid Propranolol Verapamil Amitryptaline Venlafaxine ```
32
What Tx was recently approved by FDA for chronic migraine
Botox injections; 155-195 units into face, head, and neck muscles
33
How does botox work
Blocks release of CGRP and substance P= no peripheral signals to CNS, no central sensitization
34
What is the MC primary headache disorder
Tension Headache (but not that bad so it doesnt lead to many office visits)
35
RF for tension headaches include
``` stress/anxiety too much or too little sleep OSA depression muscle tension cervical spondylosis ```
36
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
37
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 ```
38
Abortive Tx for Tension HA
1. NSAID's | 2. Acetaminophen, ASA
39
Prophylaxis for chronic Tension HA
(>7-9x month) 1. Amitriptyline (start low titrate up) Non-pharm: CBT, relax technique, EMG biofeedback -also PT, acupuncture
40
What is the least common and most disabling HA
Cluster headache
41
RF for cluster headaches are
``` 1st degree FHx prior head injury smoking high alcohol male Type A ```
42
What is the etiology of a cluster HA
hypothalamus activated w/ trigeminal-autonomic reflex activation
43
What triggers initiate a cluster HA
``` Circadian rhythm disorder Sleep (low O2) volatile smell vasodilators (sildenafil) smoking ```
44
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
45
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
46
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) ```
47
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
48
Prophylaxis for Cluster HA
``` Verapamil (NO in heart block or arrhythmia) control RF (smoking, drinking) ```
49
What are MC types of secondary HA
``` Post-concussion Analgesic rebound Pseudotumor cerebri Temporal arteritis Trigeminal neuralgia SAH ```
50
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
51
A concussion is basically
a mild traumatic brain injury; neuro Sx occur d/t axon injury
52
Do you need imaging for concussion? if so, what?
Only to R/O ICH; but they dont diagnose concussion | CT and MRI
53
How do you manage a concussion
REST; physical, and cognitive | -But, no Tx speeds recovery
54
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
55
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
56
What underlying behavioral disorders rise concern for med overuse HA
Addictive personality depression anxiety
57
What Sx are associated with Drug rebound HA
``` Nausea asthenia hard to concentrate memory problem irritability ```
58
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)
59
How do you treat a drug rebound HA
D/C analgesics; should resolve w/in 2 mo
60
What is pseudotumor cerebri
Idiopathic IC HTN- chronically elevated ICP | *affects women of child bearing age, and obese mostly
61
What is the presenting Sx of pseudotumor
**Headache! (intermittent/persistent, +/- worse with posture change, +/- relief with NSAID or rest)
62
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 ```
63
What are PE findings of pseudotumor cerebri
``` Papilledema visual field loss (large blind spot w/ periph constriction) Abducens palsy (CN VI) ```
64
How do you diagnose pseudotumor cerebri
LP!
65
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
66
What med do you NOT give pseudotumor cerebri pt
Corticosteroids
67
What is the MC systemic vasculitis
``` Giant Cell (temporal) arteritis *Peak 70-79 y/o ```
68
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)
69
Other S/Sx of Temporal arteritis include
thickening of SF temporal artery gentle scalp pressure= pain +/- central retinal artery occlusion on eye exam
70
What is a hallmark of GCA
elevated ESR and CRP (not specific)
71
How do you Dx GCA
Temporal biopsy! (start Tx before biopsy
72
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
73
What is trigeminal neuralgia (Tic Doloureux)
Compression of trigeminal nerve root= ischemia= demyelination= ephatic cross talk btwn. light touch and pain fibers
74
Hyperexcitability is common over what areas
face lips tongue
75
Features of trigeminal neuralgia include
3+ UNIlateral Sharp electric shocks lasting few seconds, mostly in V2/V3 NO neuro deficit
76
What are triggers for trigeminal neuralgia
chewing, brushing teeth, puffs of air
77
How do you diagnose trigeminal neuralgia
Clinically! | MRA w/ con to see neovascular compression
78
What are red flags in trigeminal neuralgia
Sensory loss (CN V) bilateral Sx <40 y/o
79
How do you treat trigeminal neuralgia
Anti-depressants Anti-seizure meds (carbamazepime) Microvascular decompression (good long term outcome) -Narcotics NOT effective
80
What are RF for a SAH
``` Smoking, alcohol HTN sympathomimetics PKD coarcation of aorta Marfans ```
81
What are Sx of a SAH
sudden onset worst HA of life worse with exertion N/V +/- meningism, neck stiffness
82
What is emergent workup for SAH
Non-con CT | If (-), LP
83
How do you treat a SAH
Surgical clip
84
What is the MCC of SAH
Rupture of saccular aneurysm

Nayla Foundations Exam 4 (15 decks)

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