Headache: diagnosis and treatment-Rothrock

Question 1

When someone has a headache what is the first thing you have to determine?

Answer 1

primary or secondary

Question 2

What are the most common causes of secondary headache?

Answer 2

SAH
Meningitis
Abnl ICP
Intracranial hematoma
Ischemic stroke
Tumor
Abscess
other

Question 3

What are causes of thunderclap headaches?

Answer 3

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

Question 4

What are the types of primary headache?

Answer 4

migraine
tension
cluster
paroxysmal hemicrania
hemicrania continua
hypnic "alarm clock" headache

Question 5

What is the most common cause of thunderclap headache?

Answer 5

Crash migraines

Question 6

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.

Answer 6

Side locked migraine

unilaterality and pain localization in long-lasting headaches

Question 7

Why would a girl with persistant headaches get visual hallucinations?

Answer 7

headaches caused by increasing ICP caused by an astrocytoma in occipital lobe

Question 8

When doing an exam for a headahce, what should you concentrate on?

Answer 8

BP, gait and the eyes

Question 9

What is this:

pain experienced as a squeezing band aroudn the head

Answer 9

tension headache

Question 10

What is this:

pain behinf the browbone and.or cheekbones

Answer 10

sinus headache

Question 11

What is this:

pain is localized in one eye

Answer 11

cluster headache

Question 12

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

Answer 12

migraine

Question 13

What is the most common diagnosis for patients presenting with a chief complaint of headache?

Answer 13

Migraine

Question 14

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

Answer 14

red flags

normal

Question 15

only (blank)% are “secondary” headaches

Answer 15

5-10

Question 16

How do you identify a secondary headache in the ED?

Answer 16

Acute onset
Age > 55
Occipto-nuchal location
Abnormal exam

Question 17

What origin must you consider with migraines?

Answer 17

biological

Question 18

How many attacks do you have to have to be diagnosed with a migraine?

Answer 18

5 or more

Question 19

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

Answer 19

e) none of the above

Question 20

What causes migraine?

a) stress
b) vasodilation of cranial blood vessels
c) genetically-induced neuronal hypersensitivity
d) impure thoughts

Answer 20

c) genetically-induced neuronal hypersensitivity

Question 21

Explain the mechanism behind migraines?

Answer 21

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.

Question 22

Why do you get an aura and then blindness with migraines?

Answer 22

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.

Question 23

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

Answer 23

migraine

Question 24

Migrain therapy involves acute or chronic stabilization of a (blank) sensitive system

Answer 24

biologically

Question 25

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

Answer 25

difficult

Question 26

What are factors that you neeed to consider to create an effective treatment for migraines?

Answer 26

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

Question 27

What are the acute treatments of migraine?

Answer 27

NSAIDS, triptans, ergotamines/dihydroergotamine, opiates/opioids
(no or minimal side effects)

Question 28

What are some preventive/suppression treatments for migraines (chronic)? What is the only one that is FDA approved?

Answer 28

beta blockers, TCAs, AEDs, Botox

BOTOX!!!!

Question 29

How shoud you treat recall sensitization?

Answer 29

treat early, treat hard