Headache Flashcards
doesn't include migraine or idiopathic intracranial hypertension
Aneurysm and dissection or stroke presentation will NOT have
pain with eye movement but will have headache and visual changes
multiple short attacks (15-180 min) of severe unilateral orbital and supraorbital or temporal pain and headache
cluster headache presentation
ipsilateral autonomic symptoms of ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea/nasal congestion with short multiple headache attacks over the temporal area
cluster headache presentation with autonomic symptoms
what is characteristic of cluster headache presentation?
see agitation and restlessness and attacks occurring in clusters 6 to 12 weeks with separated periods of remission
acute treatment of cluster headache
100% oxygen at 6 to 12 L/min for 15 minutes sumatriptan (subcutaneous) zolmitriptan nasal spray
preventative treatment cluster headache
verapamil (plus maybe a short course of steroids) lithium topiramate
when to consider a cluster headache?
when pts has 5 or more severe headache attacks with 1 or more ipsilateral autonomic symptoms (ptosis, miosis, lacrimination, conjunctival injection, rhinorrhea and nasal congestion. MRI may also be done of the brain to exclude other diagnoses
When should you start preventative therapy for cluster headache?
right away after first presentation of cluster headache.
medication induced headache happens after
someone uses medications >15 days per month Usually if they’ve been on opioids or other analgesic medications.
unilateral throbbing headache with nausea and vomiting and photophobia?
migraine headache
bilateral non throbbing headache with gradual onset, mild to moderate without pericranial muscle tenderness
gets worse at the end of the day
has band like around neck
tension type
headache that develops or worsens with daily medication use episodic migraine or tension like
medication overuse headache
unilateral with trigeminal distribution and see ipsilateral autonomic symptoms duration of headache is 2-30 minutes with >5 attacks a day. See complete resolution with indomethacin
chronic paroxsymal hemicrania.
sometimes called indomethacin responsive headaches.
unilateral in trigeminal distribution, ipsilateral autonomic sympotms which lasts for 15 min to 3 hrs and has a circadian “alarm clock headache” that can be invoked by nicotine or ETOH. seen in men?
cluster headache
trigeminal auto cephalalgias are
unilateral trigeminal pain with associated ipsilateral autonomic findings.
difference between cluster headache and paroxysmal hemicranias?
high frequency and shorter duration of attacks and response to indomethacin headaches
paroxysmal hemicrania can turn into
daily chronic headache or chronic paroysmal hemicrania (daily headache with pain free periods) or hemicrania continua (daily headache without pain free periods).
need to treat with indomethacin!
progressive diffuse, severe headache, bitemporal visual field deficits, and paresis of the oculomotor nerve 3. See hypotension
pituitary apoplexy - hemorrhage into pituitary gland or adenoma
can have acute secondary adrenal insufficiency
needs immediate IV steroids to prevent refractory hypotension.
differential for meningeal signs (neck stiffness)
meningitis subarachnoid head bleed pituitary apoplexy get CT head, MRI and LP
Definition of chronic migraine headache:
unilateral headache (with or without aura) that is worsened with physical activity seen with photophobia and phonophobia and osmophobia, nausea, or vomiting
OCCURS >15 days/month for 3 consecutive months in absence of secondary causes
Medication overuse headache (MOH) is
can occur in the primary headache (migraine) when a pt takes daily analgesics (NSAIDS, butabital + aspirin + caffeine, tylenol, triptan, opioids) >15 days a month
most common causes of medication overuse headache (MOH)
highest incidence: opioids, butalbital containing compounds tylenol/caffeine combinations intermediate to high incidence: triptans, aspirin, ergotamine lowest incidence: NSAIDS other than aspirin
how to treat medication overuse headache (MOH)
very difficult but needs immediate discontinuation of offending analgesic agent (including tylenol)
pts will have significant worsening of headache shortly after discontinuing their analgesic agent will need a bridging agent (1-2 week course of oral steroids) to help control headache
In addition, if the pt has an underlying chronic migraine headache they need to be started on a migraine preventative agent _ topiramate
potential MRI findings in someone with idiopathic intracranial HTN (pseudotumor cerebri)
flattening of posterior scleral, empty sella see elevated CSF pressure
when to order a MRV
exclude cerebral sinus venous thrombosis
signs suggestive of cerebral sinus thrombosis?
increased cranial pressure (papilledema, transient visual obscurations, worsening of headaches with cough, valsalva maneuver or lying flat)
post dural puncture headache or post lumbar headache is
head from persistent CSF leakage where needle penetrated the subarachnoid space. Results from intracranial hypotension after LP - 10-30% and described as mild headache but can be severe and typically worse with standing and better with lying flat. see sniffness, blurred vision and tinnitus and vertigo post LP. Resolves within days but can last weeks to months.
most common complication of lumbar puncture
post dural puncture headache or post LP headache
headache worsens with standing and improves with lying flat see sniffness, blurred vision and tinnitus and vertigo post LP. Resolves within days but can last weeks to months.
presentation of post dural puncture headache or post LP headache. “headache worsens with standing and improves with lying flat” is characteristic
post dural puncture headache or post LP headache treatment
conservative therapy with bed rest, oral or IV caffeine can be done for first 24-48 hrs pain relief agents opioids can be used if >24 hrs of pain then can do epidural blood patch if needed - inject 15 ML of whole blood into epidural space where initial LP was done.
rare complication of lumbar puncture
cerebral venous thrombosis
presentation of cerebral venous thrombosis
headache is unilateral and gradual. Sometimes can be severe worsens with lying flat and can see associated encephalopathy, hemiparesis and seizures if severe need MR V to diagnosis. CT scan of head is normal.
what is a primary stabbing headache
transient localized stabs of head pain that occur spontaneously in absence of organic disease and lasts several seconds. seen commonly in migraine heaches
characteristics of stabbing headache:
ice pick headache transient localized stabs of head pain that occur spontaneously in absence of organic dx and lasts seconds some lingers for 1-3 minutes and soreness may last minutes can occur anhwerhe on head including the eye but face is generally spared no cranial autonomic signs - differentiates between cluster headache.
treatment of primary stabbing headache?
indomethacin may be helpful but often necessary.
Red flag symptoms of headache?
first or worse headache abrupt onset or thunderclap attack progression or fundamental change in headache pattern abnormal physical exam findings neurological symptoms that last >1 hr new headache in persons younger than 5 years or older than 50 yrs new headache in pt with cancer, coagulopathy, immunosuppression or pregnant association with alteration in or loss of consciousness headache triggered by exertion, sexual activity or valsalva maneuver
headache associated with medication withdrawal
nitrates (adverse event) ETOH caffeine withdrawal medication overuse
what to be done for a thunderclap headache?
needs evaluation and this is a medical emergency needs CT head non contrast needs LP with opening pressure checked need to rule out SAH
Cavernous sinus thrombosis presentation:
-headache is most common symptom and maybe only symptom abrupt onset and unremitting. - can see headache worsens with valsalva movement and see pulsatile tinnitus -can see ICP and papilledema, decreased mentation, seizures and can see a cranial nerve 6 (abducens) palsy
cavernous sinus thrombosis is often associated with a
bacterial sinus infection that is a n acute onset headache, proptosis and periorbital edema and opthalmoplegia - needs to get immediate antibiotics and surgical drainage.
what is reversible cerebral vasoconstriction syndrome?
recurrent thunderclap headache and multifocal constriction of intracranial vessels normalizing within 3 months of onset
intracranial hypotension presentation:
postural change headache headache is weeks to months see either thunderclap or subacute headache see falsely localizing cranial nerve 6 palsy
treatment of intracranial hypotension is
epidural blood patch. if don’t respond get a CT myelography for potential detection of site of CSF leak.
causes of intracranial hypotension
seen in females and middle age and connective tissue disorders results from CSF leakage from LP, surgery, trauma or spontaneously.
MRI findings of intracranial hypotension
see diffuse non nodular pachyemingeal enhancement and cerebellar tonsillar abnormalities and subdural fluid collections
in diagnosing a secondary headache what is the best initial imaging study?
MRI brain not the CT head. that is mean for acutely emerging changes like acute severe headache or history of trauma.
when do we use verapamil for headache?
can use with migraine with basilar aura
meant for prophylaxis for cluster headache not really used in migraine prophylaxis except in women of childbearing or pregnant due to safety in pregnancy.
if pt has eyes that look funny and a headache for past 3 days. Exam shows both eyes are slightly inward when she tries to look straight.
what to order?
If this exam is negative, what to order next?
what is causing this eye problem?
order a CT head to rule out bleeding or structural abnormality.
If negative order a MRV. Could have a DVT
The increased intracranial pressure from blockage of veins causes CN6 compression.
FIRST neuroimaging study for headache should be
BUT if headache, stroke, hemorrhage or head trauma is suspected, neuroimaging that should be done FIRST
MRI, not CT head
CT head non contrast, if neg then get MRI.
don’t pick EEG ever
