Headache Active Learning

Question 1

What are the 3 main types of primary headache?

Answer 1

tension

cluster

migraine

Question 2

What is hte most common type of primary headache? What is the most common one you’ll see in a primary care office?

Answer 2

tension headaches are most common overall, but migraines will predominate in-office

Question 3

FOr tension headaches… age of onset? gender difference? other social factors?

Answer 3

under 40 yrs of age

women

increased with higher educational attainment

Question 4

When do you consider tension headaches chronic?

Answer 4

when they happen every other day or more often

Question 5

What is the pathophysiology behind tension headaches?

Answer 5

muscle contraction of neck and upper back

greater occipital nerve compression

irritation of nerve causing pain that starts in back and wraps around the sides like a headband

Question 6

How will tension headahces present?

Answer 6

• last 30 min to a week
• pressing/tighening/constant pain (not throbbing)
• mild to moderate intensity
• bilateral
• not aggreavated by routine physical activity
• NO nausa or vomiting
• can hav ephono or photphobia but not both

Question 7

True or false: physical therapy is very effective at eliminating tension headaches.

Answer 7

false

Question 8

Who is at higher risk for cluster headaches?

Answer 8

young males

male: female is 4:1

mean age of onset is 27-31

Question 9

What do they think causes cluster headache?

Answer 9

posibly hypothalamic activation of the trigeminovascular autonomic system, innervating the dura and cerebral vasculature and other targets

Question 10

What is the clinical presentation for a cluster headache?

Answer 10

severe, unliteral orbital/supraorbital/temporal pain lasting 15-180 minutes

circadian periodicity

frequency is every other day to 8/day during a cluster

associated with autonomic symptoms: lacrimation, nasal congestion, rhinorrhea, forehad sweating, miosis, ptosis, eyelid edema, conjunctival injection

Question 11

What is the treatment for cluster headches?

Answer 11

Oxygen at high levels thorugh a nonrebreathing mask for 15 minutes

triptan medications - SUBQ OR NASAL - oral won’t reach high enough plasma levels to be effective in the amount of time the headache lasts

Question 12

WHo gets migraines most often?

Answer 12

females (3 to 1)

onset before 40 yrs of age

prevalence is 18% in women and general lifetime prevalence is 25%

Question 13

What are some theories as to the cause of migraines?

Answer 13

spreading cortical depressoin

possible neurotransmitter dysfunction (NO or CGRP)

Dorsal pontine activation

Question 14

What is the typical clinical presentation for a migraine headache?

Answer 14

gradual onset..

can be associated with aura first, sometimes photophobia, and phonophobia

intermittent, unilateral throbbing headache lasting hours to days. Can generalize to both sides if not treated

nausea and vomiting often

exacerbated by activity - typically makes normal daily life impossible

Question 15

True or false: there is no genetic component to migraines.

Answer 15

false

Question 16

What should you really thinking about in a young sexually active women with migraines + aura?

Answer 16

If they’re on an estrogen-containing birth control, they’re at higher risk for stroke

Question 17

What affect might Viagra have on migraines?

Answer 17

if a guy already has migraines, taking viagara may increase the risk of a migraine attack occurring

Question 18

What is the first line of drugs for the treatment of migraine attacks?

Answer 18

triptans or DHE if those don’t work

also antiemetics - perchlorperaxine or metoclopramide

aspirin, ibuprofen and naproxen may be helpful

desamethasone

Question 19

What is the counterintuitive effect over extensive medication use in migraine treatment?

Answer 19

frequent use of OTC analgeis, triptans, and opioids significantly increase the risk for medication overuse headache

Question 20

What medications are best for prophylactic medications in migraine headache treatment?

Answer 20

amitriptyline

divalproex sodium

propanalol beta blockers

timolol

Question 21

What neurotransmitter is largely targetted in treatment of migraine headaches?

Answer 21

serotonin

Question 22

How is 5HT synthesized, stored and metabolized?

Answer 22

made from tryptophan

stored in vesicles at pre-synaptic terminal

brought back in thorugh a reuptake transporter and broken down by MAO

Question 23

WHere else does 5HT work esides the CNS?

Answer 23

in the GI tract

its produced and stored in enterochromaffin cells of gastric mucosa and will be released in response to mechanical stretch from eating

metabolized by MOA in the liver

Question 24

In the vascular system, what does 5HT do?

Answer 24

it produces vascoconstriction of the cerebral vasculature and splanchnic/renal/pulmonary vasculature

Question 25

Which 5HT receptors are targeted for migraine treatment?

Answer 25

5HT 1B and 1D

Question 26

What happens to 5HT levels as a trigger for migraine?

Answer 26

increases - so it starts with vasoconstriction

Question 27

Are migraine treatments 5HT receptor agonists or antagonists? Why is this weird?

Answer 27

agoanists - weird because a spike in sterotonin was the trigger for the migraine

Question 28

What ion channels are affected by 5HT 1Ba nd D receptors and what does this mean for the membrane?

Answer 28

activates K+ channels

inhibits Ca2+ channels

this means the membrane becomes hyperpolarized

Question 29

If Tritans are 5HT 1b and 1d receptor agonists, what do they do?

Answer 29

they cause vasoconstriction

autoregulation

and decreased release of pro-inflammatory neuropeptides

Question 30

What are the general pharmacokinetics of triptans?

Answer 30

metabolized by MOA

1-3 hour half-life

urinary and fecal excretion

Question 31

When woul dyou NOT want to prescribe triptans and why?

Answer 31

In cariovascular disease, uncontrolled HTN, current use of Ergots, liver disease

vascular stuff because it increases risk of stroke or heart attack due to the vasoconstrictive/vasospasmic effects

Question 32

How does Ergot work in treatment of migraines? Why are they given less often?

Answer 32

same way as the triptans - agonist for the 5HT 1B and 1D receptors

not used as often because they can cause severe nausea and vomiting

Question 33

Why do you need to be careful about drug interactions with Ergots like DHE?

Answer 33

It is metabolized by the CYP3A4 pathway in the liver, so if they’r eon drugs that reduce this, ergot iwll build up to dangerous levels quickly

Question 34

What are the headache red flags for life threatening underlying causes?

Answer 34

sudden onset of severe thunderclap headache = subarachnoid

headache with exercise = ruptured aneurysm

new HA onset after age 50 = temporal arteritis or mass

HA with fever, nucla rigidity, etc = meningitis

HA onset hours to weeks after trauma = subdural

HA with focal neurological signs, papilledema = tumor, subdural, epidural

multiple people with similar new onset HA = environmental exposure like CO

Question 35

Wheen do you order neuroimaging in headche?

Answer 35

with focal neuro exam findings

abrupt onset of headaches

change in character/intensity/frequency

Tx failure