Headache Disorders Flashcards
What is our acronym for work up of secondary HA?
- S - systemic symptoms, secondary risk factors
- N - neurologic ssx, abnl signs
- O - onset
- O - older age onset (new and progressive, giant cell arteritis or CA)
- P - pattern change
HA + wide based gait + dementia + incontinence
normal pressure hydrocephalus
sudden severe HA + nuchal rigidity
subarachnoid hemorrhage
sudden HA + localized findings + HTN
Intracerebral hemorrhage
HA + pt over 50 + tender temporal arteries
temporal arteritis
Pt 50 yo + presents with jaw claudication or occipital pain. Has a thickened non-pulsatile temporal artery.
Dx? How?
Tx?
If not treated, what could be sequelae?
What other disease is this often seen with?
- Giant Cell Arteritis/Temporal Arteritis
- granulomatous (giant cell) inflammation on biopsy
- high dose corticosteroids - prednisone
- irreversible blindness
- Polymyalgia rheumatica
What is at the top of my ddx for a ‘thunderclap’ HA? When is the best time to find this on an LP and how do you know it is there?
subarachnoid hemorrhage
within 6 hours of onset - get an LP and the blood is not diluting over 4 tube draws of CSF
Pt is having recurrent thunderclap HA over 1-2 weeks. No aneurysmal SAH (but cortical SAH can be seen?), near normal CSF.
Dx?
What is happening?
Reversible Cerebral Vasoconstrictive Syndrome (RCVS)
multivessel, multifocal segmental vasoconstriction of cerebral blood vessels that reverses within 12 weeks of onset
Who normally gets RCVS? What are the HA triggered by and what are Risk Factors?
- females in 40s and 50s
- triggered by urinating, bathing, valsalva, sex
- RF: postpartum, THC, antidepressants, stimulants including cold meds and migraines
How does RCVS compare to Primary CNS Angiitis?
- RCVS
- CSF normal
- tx with CCBs
- PACNS
- CSF abnormal
- tx with steroids/immunosuppressants
If my pt is sufferring from intracranial hypotension, what would my CSF opening pressure be on LP?
When are their symptoms better or worse?
How do I tx this?
- opening pressure is <6 cm H2O
- pain is better when laying down and worse when standing d/t CSF shifts
- caffeine, rest, blood patch to stop CSF leak
What is the diagnostic criteria for Pseudotumor Cerebri?
- any HA filling criterion C
- idiopathic intracranial HTN (IIH) has been diagnosed with CSF pressure >250 mm H2O
- evidence of causation by at least two of the following
- HA developed in temporal relation to IIH or led to its discovery
- HA is relieved by reducing intracranial HTN
- HA is aggravated in temporal relation to increase in intracranial pressure
What neuroimaging would be consistent with Pseudotumor Cerebri/ IIH?
- empty sella
- orbital flattening
- tortuous optic nerves
What happens during the prodrome phase of migraine? What causes this?
- pt has fatigue, mood changes, food cravings, yawning, photophobia, muscle tenderness
- HT dysfunction with increased parasympathetic tone activating meningeal nociceptors
When does the aura phase of a migraine occur and what happens?
- 30-60 minutes prior to migraine
- consists of focal neuro ssx that persist up to one hour
- visual, sensory, language, ssx localizing brainstem
What is idiopathic recurrent moderate to severe midline abdominal pain with nausea and vomiting, lasting 2-72 hours with interval complete resolution called?
HA does not occur during these episodes
abdominal migraine
What do we call an episodic head tilt in an infant or young child a/w features such as pallor, irritability, malaise, vomiting, or ataxia?
benign paroxysmal torticollis
Migraine is a disorder of what… People with migraine lack the ability to …
brain/brainstem hyperexcitability
habituate electrically to repetitive stimuli
How is an aura prior of a migraine best described?
spreading cortical depression (SCD)
result of accumulation of extracellular K+ due to repeated depolarization and repolarization of hyperexcitable neurons
If aura occurs for the first time after the age of 40, is fast in onset, brief, purely negative in nature, a/w weakness or not followed by a migraine HA…
think TIA and refer to neurology
What is contraindicated in women with aura migraines?
synthetic estrogens
Migraine with visual aura is a/w
incidental a fib, stroke/TIA
What is the thought behind Trigeminovascular Activation?
- CGRP and other vasoactive neuropeptides activate the trigeminal ganglion
- afferents from here converge at the Trigeminal cervical complex (TCC) (extracranial structures also converge here)
- TCC activates the Superior Salivatory Nuc. and other structures projecting to the cortices
What features will a migraine without aura have?
- unilateral
- pulsating
- at least one of
- N/V
- photophobia or phonophobia
What are features of tension type HA?
- bilateral
- pressing or tightening (nonpulsating)
- not aggravated by routine physical activity
- BOTH
- NO Nausea or Vomiting
- NO more than 1 of photophobia or phonophobia
What rx should I avoid in pts with a typical aura but without HA?
avoid triptans or vasoconstrictors
Preventative rx tx should be for those pts who …
experience more than 1-2 HA/week or one severe prolonged episode monthly
My pt has a migraine HA for longer than 72 hours.
Dx?
Tx?
Status Migrainous
- IV fluids
- valproic acid IV
- Magnesium sulfate IV
- Diphenhydramine IV
- Metoclopromide IV
- Solumedrol IV
- DHE IV (Raskin Protocol)
What is the Rasking Protocol?
- Metoclopramide or prochlorperazine 10 mg IV over 60 seconds
- wait 5 min
- DHE 0.5 mg IV over 60 s
- wait 3-5 min
- may repeat 0.5 mg IV if no relief
follow with dexamethasone 4-12 mg IV
Who is DHE contraindicated in?
pts at risk for MI
What are examples of migraines with atypical auras?
What is contraindicated in these pts?
- hemiplegic Migraine - CL motor paralysis
- migraine with brainstem aura
- TIAs must be excluded
repeated attacks of monocular visual disturbance, including scintillations, scotoma or blindness, a/w migraine HA
dx?
What else must be ruled out?
retinal migraine
amaurosis fugax
What are four types of trigeminal autonomic cephalgias?
- cluster
- paroxysmal hemicrania
- hemicrania continua
- SUNA/SUNCT
What is usually a trigger of a cluster HA and what is the primary symptom?
etoh
orbital/temporal stabbing, boring pain; rapid, severe onset
What is the acute tx for cluster HA?
What rx could prevent cluster HA?
sumatriptan SC with O2
verapamil
How is Paroxysmal Hemicrania different from a cluster HA
- more in females
- shorter attack, but higher daily frequency
- tends to be chronic (lasting about a year)
- always unilateral
- completely responsive to indomethacin
What is unique to Hemicrania Continua?
- unremitting pain lasting 30 minutes to 3 days
- unilateral HA
- pain not as bad as cluster or paroxysmal
- complete response to indomethacin
What is unique to SUNA/SUNCT? How do I tx it?
- Short-lasting Unilateral Neuralgiform
- attacks only 1-600 seconds, occur up to 100x /day
- tx - Iamotrigine
What should I be thinking clinically with trigeminal autonomic cephalgias?
- r/o other with MRI and pituitary testing
- cluster responds to short acting verapamil
- avoid PO in acute cluster
- if clusterlike without trigger in a female, think paroxysmal hemicrania
What are three causes for medication overuse HA?
- butalbital >5 d/mo
- opioids >8 d/mo
- triptans/NSAIDs/analgesics >10 d/mo
How can you differentiate Trigeminal neuralgia from cluster HA?
Trigeminal neuralgia will likely include V2/3 while cluster is mostly V1
Eagle’s syndrome is a calcified stylohyoid ligament that could cause …
glossopharyngeal neuralgia
