Headache: diagnosis and treatment-Rothrock Flashcards
When someone has a headache what is the first thing you have to determine?
primary or secondary
What are the most common causes of secondary headache?
SAH Meningitis Abnl ICP Intracranial hematoma Ischemic stroke Tumor Abscess other
What are causes of thunderclap headaches?
Aneurysmal rupture
Cerebral sinus thrombosis
Acute intracranial hypotension/CSF oligemia
Carotid artery dissection
Pituitary apoplexy
Unruptured aneurysm (?expansion,thrombosis)
Sexual headache (“explosive” type)/exertional
Crash migraine
Benign (idiopathic) thunderclap headache
What are the types of primary headache?
migraine tension cluster paroxysmal hemicrania hemicrania continua hypnic "alarm clock" headache
What is the most common cause of thunderclap headache?
Crash migraines
What is this:
19 yo Female university coed reports 10 years of episodic, left-sided, pulsatile headache often heralded by “sparkles & blind spots” in the right periphery of vision. Her previously effective abortive therapy no longer helps.
Side locked migraine
unilaterality and pain localization in long-lasting headaches
Why would a girl with persistant headaches get visual hallucinations?
headaches caused by increasing ICP caused by an astrocytoma in occipital lobe
When doing an exam for a headahce, what should you concentrate on?
BP, gait and the eyes
What is this:
pain experienced as a squeezing band aroudn the head
tension headache
What is this:
pain behinf the browbone and.or cheekbones
sinus headache
What is this:
pain is localized in one eye
cluster headache
What is this:
typica signs are pain, nausea and altered vision
5 or more attacks: unprovoked, 4-72hr duration, prohibit/significantly inhibit routine activities, nausea and/or photo/sonophobia
migraine
What is the most common diagnosis for patients presenting with a chief complaint of headache?
Migraine
If the patient’s headache history meets ICHD criteria for a dx of migraine (or another primary headache disorder), there are no (blank) (eg, “thunderclap” onset) and the neuro exam is (blank), the yield of brain imaging or other testing is virtually nil
red flags
normal
only (blank)% are “secondary” headaches
5-10
How do you identify a secondary headache in the ED?
Acute onset
Age > 55
Occipto-nuchal location
Abnormal exam
What origin must you consider with migraines?
biological
How many attacks do you have to have to be diagnosed with a migraine?
5 or more
Migraine attacks…
a) always involve severe, throbbing headache
b) usually are preceded by visual aura
c) always are accompanied by nausea
d) all of the above
e) none of the above
e) none of the above
What causes migraine?
a) stress
b) vasodilation of cranial blood vessels
c) genetically-induced neuronal hypersensitivity
d) impure thoughts
c) genetically-induced neuronal hypersensitivity
Explain the mechanism behind migraines?
the trigemincal nucleus caudalis receives afferent messages and acts as a sensory relay center of hypersensitivie cortex neurons in genetically predisoposed individuals
ie you are hypersensitive and you send too many pain signals to your trigeminal nerve via release of CGRP.
Why do you get an aura and then blindness with migraines?
Your hypersensitive neurons are activated super easily and then get super hyperpolarized because they were overstimulated so you see wavey lines and then nothing (this is called cortical spreading depression)
i.e Cortical spreading depression (CSD) is a wave of electrophysiological hyperactivity followed by a wave of inhibition, usually in the visual cortex.
What is this:
a genetically and biologically polymorphous but clinically distinct disorder resulting from the interaction of genetic predisposition and environmental stimuli
epigenetics/’’rat-licking” and childhood abuse
migraine
Migrain therapy involves acute or chronic stabilization of a (blank) sensitive system
biologically
With migraines:
if the sensitization process is allowed to advance unchecked (or worse-is assited: eg, medication overuse headache) stabilization will be increasingly (Blank) to attain
difficult
What are factors that you neeed to consider to create an effective treatment for migraines?
inherent efficacy of drug stage of attack when drug is administered drug’s T max drug’s C max drug’s ability to reach receptors drug’s affinity for those receptors
What are the acute treatments of migraine?
NSAIDS, triptans, ergotamines/dihydroergotamine, opiates/opioids
(no or minimal side effects)
What are some preventive/suppression treatments for migraines (chronic)? What is the only one that is FDA approved?
beta blockers, TCAs, AEDs, Botox
BOTOX!!!!
How shoud you treat recall sensitization?
treat early, treat hard
