Headache (*7Q)

Question 1

List some important causes of secondary HA

Answer 1

intracranial lesions, head injury, cervical sondylosis, dental or ocular disease, TMJ dysfunction, sinusitis, HTN, depression.

Question 2

Migraine: pathophysiology (likely)

Answer 2

neurovascular dysfunction- dilation of blood vessels innervated by trigeminal nerve (V). May be inherited in polygenic fashion.

Question 3

Familial hemiplegic migraine

Answer 3

Autosomal dominant inheritance pattern- attacks of lateralized weakness represent aura that preceeds migraine.

Question 4

Migraine: symptoms

Answer 4

W/o aura: 5+ attacks; 4-72 hours duration if untreated; 2+ of following: Unilateral location, pulsating, moderate-severe intensity, aggravated by physical activity; AND 1+ of: nausea/vomiting OR photo AND phonophobia.

aura: visual disturbance or parasthesias that develop before pain. Headache occurs within 1 hour of aura.

Question 5

Basilar artery migraine

Answer 5

uncommon migraine variant in which blindness or visual disturbances occur throughout both visual fields. Accompanied or followed by dysarthria, dysequilibrium, tinnitus, perioral and distal paresthesias followed by transient LOC or change in consciousness.

Followed by a throbbing (usually occipital) HA with NV.

Question 6

Opthalmoplegic migraine

Answer 6

Lateralized pain, often about the eye, accompanied by nausea, vomiting, and diplopia due to transient external opthalmoplegia from 3rd nerve palsy (and possibly CN VI too). Opthalmoplegia may outlast pain by several days-weeks.

Note: opthalmoplegic migraine is very rare. Internal carotid artery aneurysm and diabetes are more common causes of painful opthalmoplegia.

Question 7

Migraine: treatment principles

Answer 7

avoid precipitating factors, prophylactic and symptomatic pharmacotherapy.

Question 8

Migraine: primary symptomatic treatment

Answer 8

rest in a quiet, dark room + simple analgesic taken right away (NSAIDS). Limit use of simple analgesics to 15 days or fewer per month (combinations <10 days).

Question 9

Cafergot (ergotamine+caffeine)

Answer 9

combination of ergotamine tartrate and caffeine, provides symptomatic relief for migraine.
1-2 at onset, then 1 every 30 mins as needed (up to 6 per attack, 10 days/month).

Avoid: in pregnancy, with CVD.

Question 10

Sumatriptan

Answer 10

Sumatriptan- SQ rapidly effective at aborting attacks (binds to 5HT1 receptor). Nasal and oral preps absorb slowly.

Avoid: in pregnancy, with CVD (CI in CAD, PVD), for basilar or hemiplegic migraine, if risk factors for stroke are present.

Question 11

When is preventive therapy for migraines indicated?

Answer 11

Occur > 2-3x/month and are accompanied by significant disability is associated with attacks. May need to try several drugs before an effective one is found.

Question 12

Topiramate

Answer 12

Antiepileptic indicated for prevention of cluster headaches (and migraine). SE: somnolence, nausea, dyspepsia, irritability, ataxia…

Question 13

Valproic acid

Answer 13

Antiepileptic indicated for migraine prevention. SE: Nausea/vomiting, diarrhea, drowsiness, alopecia, weight gain, hepatotoxicity

Avoid in pregnancy.

Question 14

Verapamil

Answer 14

Ca-channel blocker approved for prevention of cluster headaches and migraines. SE include HA, hypotension, flushing, edema, constipation. May aggravate AV block and heart failure.

Question 15

Amitriptyline

Answer 15

Tricyclic antidepressant approved for migraine prevention. SE include sedation, dry mouth, constipation, weight gain, blurred vision, edema, hypotension, urinary retention

Question 16

Botulinum toxin A

Answer 16

Approved for migraine prevention. May cause injection site reactions, hypersensitivity, muscle weakness.

Question 17

Tension-type headache: clinical

Answer 17

Can be episodic (15 days/mo). Hx of 10+ attacks that last 30 mins-7 days if untreated. Must include 2+ of following: 
-Pressing or tightening quality
-mild-moderate intensity
-bilateral
-no aggrevation by physical activity
AND both:
-No nausea/vomiting (anorexia OK)
-photo OR phonophobia

Question 18

Tension headache: therapy

Answer 18

NSAIDs.

Techniques to induce relaxation (massage, hot baths, biofeedback) may help.

Question 19

Cluster headache: patient, pathophysiology

Answer 19

middle-aged men. Related to activation of cells in ipsilateral hypothalamus triggering trigeminal autonomic vascular system. NO family Hx of HA or migraine.

Question 20

Cluster headache: clinical

Answer 20

May be episodic (with remissions every 4-8 weeks) or chronic (no remissions). Episodes typically at night, wake pt. Requires Hx of 5+ attacks fulfilling diagnostic criteria:

1) severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 min untreated.
2) associated with 1+ ipsilateral feature: (conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehad and facial diaphoresis, miosis (constricted pupil), ptosis, eyelid edema.
3) frequency is between every other day and 8x/day.

Question 21

Hemicrania continua

Answer 21

primary HA syndrome with unilateral head pain and associated autonomic symptoms. Unlike cluster type, pain is continuous without pain-free periods and it completely resolves with indomethacin.

Question 22

Horner’s syndrome

Answer 22

Ptosis, miosis, and anhidrosis. Associated with cluster headache. May occur only during attack (transiently) or remain a residual deficit between attacks.

Question 23

Cluster HA: Acute treatment

Answer 23

100% O2, sumatriptan

Question 24

Cluster HA: prevention (2)

Answer 24

Verapamil or topiramate;

Question 25

Posttraumatic headache

Answer 25

Headache following head trauma (within 1 day-2 weeks). Usually constant, dull ache with superimposed throbbing that may be localized, lateralized, or general. May be accompanied with nausea/vomiting, visual aura. May occur with impaired memory, poor concentration, dysequilibrium, postural changes.

Question 26

Posttraumatic headache: imaging/EEG findings

Answer 26

Imaging will be normal. EEG may show non-specific changes. Electronystagmogram may show central or peripheral vestibulopathy.

Question 27

Posttraumatic HA: treatment

Answer 27

Encourage gradual rehabilitation (PT/occupational therapy). Simple analgesics help. Usually resolve spontaneously within a few months. May require same preventative treatments as migraine.

Question 28

Primary cough headache

Answer 28

Severe pain produced by coughing (straining, sneezing, and laughing). Usually only lasts a few minutes. If patients presents with several of these, get CT or MRI to rule out space-occupying lesion.

Tx: symptomatic, Indomethacin works best. LP may clear HA.

Question 29

Headache due to intracranial mass lesion

Answer 29

Highly variable (mild-severe) and depends on location of lesion. May be relieved by STANDING. Get imaging for any progressive headache disorder presenting in middle or later life.

Question 30

Medication overuse headache

Answer 30

Responsible for about half of chronic daily headaches. Early intro of a migraine preventive therapy may allow withdrawal of analgesics and relief. Avoid analgesic use for >15 days (combo>15)