Headache - Erwin Flashcards
What is the difference between primary and secondary headaches?
primary: genetic, migraines
secondary: this is what you need to worry about. this could be anything from an aneurysm to a brain tumor
When diagnosing a primary or secondary headache. What red flags will lead you to believe the patient has a secondary headache?
•SNOOP4
1. Systemic symptoms
- fever
- weight changes
- chest pain
- Cancer, HIV, immunocompromised
2. Neurologic symptoms/signs - seizures
- LOC
3. Onset is sudden
4. Older age of onset (>50)
5. Postural aggravation, 6. Precipitated by valsalva (if you haev a bowel movement, does your headache suddenly start), 7. Pregnancy (hyper-coagulable state…can cause headache), 8. Progressive
When taking an HPI for a patient who comes to your clinic for a headache, what five important pieces of info should you obtain?
LACM(MA)
- Life History
- Attack History
- Comorbidities
- Medication History
- MA (Family History)
MA - family history
Taking an HPI for headache (LACM-MA) –> Figuring out if that have SNOOP4 signs:
1. Life History:
A. ____ of 1st Headache Ever
B. ____ episodic syndromes
C. When is your headache ____/____? (during pregnancy, children, high school, college, during menarche, menopause, menses?)
D. Has it changed over time?
2. Attack History:
A. Location, onset, severity, frequency, timing, context, triggers, warnings, associated symptoms
B. ___ vs. ____
C. More than one headache ___?
D. When are your headache free days?
3. Comorbidities
A. Are any comorbidities that include __ issues, __ disorders or __ __ issues?
B. Caffeine, Sleep; snoring, ER/urgent care visits, Head/neck trauma, Abuse
4. Medication History
A. Current, past, works
B. Prescription, non-prescription (BCPs, sinus medications, herbal supplements)
C. Drug use –Cocaine, amphetamines, alcohol, marijuana, alcohol can cause ____.
5. Family History (MA)
Determine if the patient is ____ headache prone. Ask if the patient’s mother, father, sister brother ever had a headache.
A. Any family “headaches?”
B. Pro-______ conditions (MI/Stroke <50)
C. Cerebral aneurysms
Note: SINUS and SICK headache’s usually mean a recurrant ____.
1. Life History:
A. Onset of 1st Headache Ever
B. Childhood episodic syndromes
C. When is your headache better/worse? (during pregnancy, children, high school, college, during menarche, menopause, menses?)
D. Has it changed over time?
2. Attack History:
A. Location, onset, severity, frequency, timing, context, triggers, warnings, associated symptoms
B. New vs. Old
C. More than one type of headache?
D. When are your headache free days?
3. Comorbidities
A. Are any comorbidities that include medical issues, psychiatric disorders or chronic pain issues?
B. Caffeine, Sleep; snoring, ER/urgent care visits, Head/neck trauma, Abuse
4. Medication History
A. Current, past, works
B. Prescription, non-prescription (BCPs, sinus medications, herbal supplements)
C. Drug use – Cocaine, amphetamines, alcohol, marijuana. Cocaine can cause hemmorrhage
5. Family History (MA)
Determine if the patient is genetically headache prone. Ask if the patient’s mother, father, sister brother ever had a headache.
A. Any family “headaches?”
B. Pro-thrombotic conditions (MI/Stroke at <50 years of age, clotting disorders)
C. Cerebral aneurysms
Note: SINUS, aura, and SICK headache’s usually mean a recurrant migraine.
- Your patient tells you that:
- He snores every night
- He gained 30 lbs in the last yr.
What are you thinking about?
- Your other patient tells you that:
- He is diagnosed with fibromyalgia (widespread muscle pain or weakness)
- He sleeps 2-3 hrs at night
- Cries frequently
What are you thinking about now?
- Your patient tells you that:
- He snores every night
- He gained 30 lbs in the last yr.
What are you thinking about? –> Sleep Apnea
- Your other patient tells you that:
- He is diagnosed with fibromyalgia (widespread muscle pain or weakness)
- He sleeps 2-3 hrs at night
- Cries frequently
What are you thinking about now? –> Depression, Anxiety
Knowing what people ___ when they have a headache can be very useful for diagnosing what?
Knowing what people do when they have a headache can be very useful for diagnosing headache type
Nuances of Taking an HPI:
- Way ____ are phrased. Use ___ over ___ type questions
- Ask insightful questions such as, “what are you doing during the pain.” What are your fears? How has it impacted on life? Goals of care?
•Compassion
Nuances of Taking an HPI:
- Way questions are phrased. Use open over leading/closed type questions
- Ask insightful questions such as, “what are you doing during the pain.” What are your fears? How has it impacted on life? Goals of care?
•Compassion
Case #1:
- Nurse colleague
- Typical left-sided headache, can’t work
- Goes to quiet dark room, bathroom
- Eventually husband drives her home
- Misses next day of work
What could she have?
Case #1:
- Nurse colleague
- Typical left-sided headache, can’t work (typical left sided…she could be left-sided dominant)
- Goes to quiet dark room, bathroom (she goes to a bathroom to maybe throw up? nausea is common in migraines)
- Eventually husband drives her home (maybe from vision problems)
- Misses next day of work
What constitutes a migraine?
- At least __ attacks
- Attacks lasting __-___ hours (average __-___)
•At least 2 of the following:
- ____ pain
- Headache is __ to ___ pain
- ___ pain
- Headaches ___with activity
•At least one of the following:
- ___ and/or ___
- ___phobia AND ___phobia
•Must NOT be attributed to another ____–> this means, you must make sure nothing else is going before you diagnose is as a migraine!
What constitutes a migraine?
- At least 5 attacks
- Attacks lasting 4-72 hours (average 12-48 hrs)
•At least 2 of the following:
- unilateral pain
- Headache is moderate to severe in pain
- throbbing pain
- Headaches worsen with activity
•At least one of the following:
- nausea and/or vomiting
- photophobia AND phonophobia
•Must NOT be attributed to another condition –> this means, you must make sure nothing else is going before you diagnose is as a migraine!
What is the prevalence of migraine headaches as far as age and sex?
Migraine affecs both female and males, but affects females more.
The peak prevalence is at 40 years old.
The greatest impact is 25-55 years old.
Migraine with Aura
What is an aura? –> symptoms such as ___, sensory, speech, or motor that fully ____.
Aura’s develops gradually over ___ minutes (spreads ___)
They last no more than ___ minutes
The pain follows the attack in < ___
An aura is NOT always followed by ___.
Migraine with Aura
What is an aura? –> symptoms such as vision, sensory, speech, or motor that fully reverse.
Aura’s develops gradually over 4 minutes (spreads slowly)
They last no more than 60 minutes
The pain follows the attack in < 1 hour
An aura is NOT always followed by pain
Patient comes in with a see’s a crescent type shape of image that looks like a kalaidascope and then goes away. They also have a central loss of vision.
What could they have?
Migraine with aura
How can you tell the difference between a TIA and a migraine headache?
Migraine
_____ visual symptoms
_____ onset/evolution
_____ progression
Flurry of attacks at __-life (peaked at age 40)
Duration ~ ___ minutes
Headache follows in ___%
TIA
Visual ____
___ onset
_____ occurrence
Occurs ____ life
Duration < ___ minutes
Headache ___
How can you tell the difference between a TIA and a migraine headache?
Migraine
Positive visual symptoms
Slow (4 mintes) onset/evolution
Gradual progression
Flurry of attacks at mid-life (peaked at age 40)
Duration ~ 20 minutes
Headache follows in 50%
TIA
Visual loss
Abrupt occurrence
Occurs later life
Duration is < 15 minutes
Headache uncommon in people who have TIA
What is considered a chronic migraine?
Individuals who have a migraine more than 15x a month.
Treatment-Migraine Medications (3 groups)
1. Abortive drugs
__
__
__
2. Prophylactic drugs
____
____
____
____
•3. Chronic migraine drugs
____
Treatment-Migraine Medications (3 groups)
1. Abortive drugs
Triptan (7)
NSAID
Anti-emetics
Trippin’ Nuwan said, “I am anti-embryo!”
2. Prophylactic drugs
Beta-blockers
Anti-epileptics
Anti-depressants
Calcium-channel inhibitors
“Better be prepared for epically depressed ants from CalCutta!”
•3. Chronic migraine drugs
–Onabotulinumtoxin A (Botox)
“Migraines may give you headaches, but they’ll take your fine-grain wrinkles away! Try BOTOX today!!!!”
Triptans (7)
Used for migraines as ____ drug:
Under Triptans, there are two categories:
- Fast Acting, recurrence:
____ (generic)
____(generic)
____
_____
_____ (for __-__ y.o.’s)
2. Long half-life, less recurrence:
____ (generic)
____ (___ hours!)
Triptan Contraindications: You don’t want to use Triptan if you have:
- Poorly controlled _____
- Can cause ____ migraine
- Can cause ____ Disease
–_____ heart disease
–Multiple ____ risk factors, unless workup is fully (-)
–Coronary ____ (including _____’s)
Triptans (7)
Used for migraines as abortive drug:
Under Triptans, there are two categories:
- Fast Acting, recurrence:
- Sumatriptan (generic)
- Zolmitriptan (generic)
- Eletriptan
- Rizatriptan
- Almotriptan (12-17yo)
“A sumowrestler zooming on his eletric razor almost tripped.”
2. Long half-life, less recurrence:
- Naratriptan (generic)
- Frovatriptan (26 hours!)
“A narrative of Frovo’s long Trip”
Triptan Contraindications: You don’t want to use this if you have:
- Poorly controlled hypertension
- Causes Hemiplegic migraine
•Heart Disease
–Ischemic heart disease
–Multiple CAD risk factors, unless workup is fully (-)
–Coronary vasospasm (including Prinzmetal’s)
Tryptophan Contraindications:
- Poorly controlled ____
- ____ migraine
____ Disease
–Ischemic heart disease
–Multiple ____ risk factors, unless workup is fully (-)
–Coronary vasospasm (including Prinzmetal’s)
•Poorly controlled hypertension
•Hemiplegic migraine
•Heart Disease
–Ischemic heart disease
–Multiple CAD risk factors, unless workup is fully (-)
–Coronary vasospasm (including Prinzmetal’s)
Cluster Headache:
- Severe, ___ (on one side) ____/____/____ pain
- ____ onset
- Excruciating
- ___-___ minutes (whereas migraines can last up to 72 hours)
- ____/day to one every other day in a “____”
- _____ facial autonomic symptoms
- A sense of ___ or ___ (key component!) In migraine patients, they want to sit still and not move. People with cluster headache’s want to move.
Treatment:
•Abortive:
–____
–____
•Stop the cluster bout:
–___/___
–____
Cluster Headache:
- Severe, unilateral orbital/supraorbital/temporal pain
- Abrupt onset
- Excruciating
- 15-180 minutes
- 8/day to one every other day in a “cluster”
- Ipsilateral facial autonomic symptoms
- A sense of restlessness or agitation
United Supramarket in Temple City
A man with the hook in his eye is waiting in line at the grocery store. There is a long line so he is restless and agitated.
On one side, there are apples (8 for 1 dollar)
On his other side, there are bunches of grape clulsters for 2.00
Behind him there is a sign for Au bon Pain pastries ranging from 15 cents to 1.80. Behind his right side of his face, theres an automobile shop.
•Abortive:
–SQ Sumatriptan
–Oxygen
The headache man was the size of a sumowrestler when he was a baby, so his mom almost had an abortion because he wasn’t getting enough oxygen.
•Stop the cluster bout:
–Verapamil/Lithium
–Prednisone
The Vera Wang Pret-A-Porter show displayed a dress made out of grape clusters that lit up (lithium battery). It was a cluster fuck at the show.
Cluster Headaches are often ____.
•1st attack to diagnosis
–Range: 1 wk to 48 yrs!
–Average: 7 Years!
•>4 doctors seen prior to diagnosis
–Dentist (34%) or ENT (33%) 1st
•16% underwent tooth extraction
Cluster Headaches are often Misdiagnosed
•1st attack to diagnosis
–Range: 1 wk to 48 yrs!
–Average: 7 Years!
•>4 doctors seen prior to diagnosis
–Dentist (34%) or ENT (33%) 1st
•16% underwent tooth extraction
Tension Type Headache:
- Length: Lasting _ min to __ days
- Location: ___
- Quality: ___, ____ (non-___)
- Intensity: ___ to ____
–Not aggravated by ___ activity
•Associated symptoms
–NO ___ OR ___
–Only 1: of ___phobia or ___phobia
Tension Type Headache:
- Length: Lasting 7 min to 30 days
- Location: bilateral
- Quality: steady, pressing (non-pulsating)
- Intensity: mild to moderate
–Not aggravated by routine activity
•Associated symptoms
–NO nausea OR vomiting
–Only 1: of photophobia or phonophobia
Giant Cell (Temporal) Arteritis
- ____- of medium, large vessels head
- Age of onset > ___ yo, ____
- Symptoms:
–____
–_____ tenderness
–Pain with ____
- ____
- ESR, CRP, CBC, biopsy of temporal artery
- Treatment: ____
Giant Cell (Temporal) Arteritis
- Vasculitis- of medium, large vessels head
- Age>55yo, women
- Symptoms:
–Headache
–Bitemporal tenderness
–Pain with chewing
- Blindness
- ESR, CRP, CBC, biopsy of temporal artery
- Treatment: Steroids
.Increased Intracranial Pressure
- Signs:
- ___dema
- Awakens in the ____
- Projectile ___
- Cough ____
- Causes:
–__ __
–High ___ pressure headache
Increased Intracranial Pressure
•Signs:
- Pappiladema
- Awakens in the night
- Projectile vomiting
- Cough headache
- Causes:
–brain tumor
–High CSF pressure headache
Man in bed next to his pappilon named Ed. Ed has those ring around the eye which resembles papillodema and his head is swollen.
Man is awake in bed, has a brain brain tumor on his forhead, he is vomiting projectiles and cough headache. Outside his window is a view of the SF bridge at night time and his waterbed is swollen and filled with CSF pressure. The dog is barking “IIP! IIP! IIP!”
What does this patient have?
IIP
Idiopathic Intracranial Hypertension “Pseudotumor Cerebri”
Who’s at risk?
___ ____
Signs?
___+ ___ changes + ___
Diagnosis:
MRI (exclude __ __ and __ __)
CSF: Increased __
Treatment:
__ __
___
Idiopathic Intracranial Hypertension “Pseudotumor Cerebri”
Who’s at risk?
Obese women
Signs?
Pappildema + visual changes + headache
Diagnosis:
MRI (exclude out brain tumors and venous thrombosis)
CSF: Increased pressure
Treatment:
weight loss
diuretics
Low Pressure Headache
- Patients they feel better __ __ than __-___
- Most common cause is __ __
- On MRI, the edges will __ up (meningeal _____), low-lying cerebellar tonsils, ____ brain
Treatment:
__ __
Low Pressure Headache
- Patients they feel better lying down than up-right
- Most common cause is LP
- On MRI, the edges will light up (meningeal enhancement), low-lying cerebellar tonsils, saggy brain
Treatment:
Blood patch
Women is lying down, very droopy. Next her is her LP and therapeutic blood red tomato patch. She has a halo around her head (meningeal enhacement.
Thunderclap Headache:
comes on very ____, ____ triggers it (bowel mvmts, coughing, throwing up, sexual activity)
Begin with looking at a __ __. Here, you are looking for ___. If negative (you don’t see blood), do a __ __ and look for ___, __ and make note of opening ___.
If that is all negative, look for other causes!
MS. VV. PARC
Thunderclap Headache:
comes on very suddenly, vasovalvas triggers it (bowel mvmts, coughing, throwing up, sexual activity)
Begin with looking at a head CT. Here, you are looking for blood. If negative (you don’t see blood), do a lumbar puncture and look for blood or infection, and make note of opening pressure
If that is all negative, look for other causes!
MS. VV. PARC
Thunder from down under stripper man (can be trigger by sexual activity) from viva las vegas (Valsalva) is clapping. His legs are the start of a flow chart. On one leg, there is a spider crawling up his leg (could be some subarachnoid hemmorhage). There is an LP next to his other leg. In the audience, a very special guest named MS. VV. PARC is watching him.
- Meningitis
- Subarachnoid
- Vasculitis
- Venous thrombosis
- Pituitary apoplexy
- Arterial dissection
- RCVS (reversible cerebral vasoconstricting syndrome)
- CSF leak
A patient comes to you with a thunder clap headache. You do an MRI and you see this.
What could have caused it?
Reversible Cerebral Vasoconstriction Syndrome (RCVS)
- Recurrent thunderclap headaches
- Segmental constriction of cerebral arteries
–Must resolve within 3 months
- Normal CSF protein
- Must rule out the following:
–Subarachnoid blood
–CNS Vasculitis
–Cerebral venous thrombosis
–Cervical artery dissection
•ALso consider Precipitants that can trigger RCVS (postpartum, drugs, catecholamine tumors)
In vasculitis, you would see elevated ___ levels in the CSF after doing a spinal tap.
Protein
Reversible Cerebral Vasoconstriction Syndrome (RCVS)
- Recurrent ___ headaches
- Segmental ____ of cerebral arteries
–Must resolve within __ months
- Normal __ protein levels after doing a spinal tap.
- Must rule out the following in order to diagnose RCVS:
–Subarachnoid blood
–CNS Vasculitis
–Cerebral venous thrombosis
–Cervical artery dissection
•Must also consider ____that can trigger RCVS (postpartum, ___ drugs, ____ tumors)
Reversible Cerebral Vasoconstriction Syndrome (RCVS)
- Recurrent thunderclap headaches
- Segmental constriction of cerebral arteries
–Must resolve within 3 months
- Normal CSF protein
- Must rule out the following:
–Subarachnoid blood
–CNS Vasculitis
–Cerebral venous thrombosis
–Cervical artery dissection
•Also consider Precipitants that can trigger RCVS (postpartum, vasoactive drugs, catecholamine tumors)
Trigeminal Neuralgia
- ___ ___ bursts of pain
- ____ distribution:
–___ is the most common
–If a young women’s V1 is most affected, what disease should you consider?
•Can be triggered by ___ ___, ___ or nothing at all.
Trigeminal Neuralgia
- Frequent short bursts of pain
- Trigeminal distribution:
–V2 is the most common
–If a young women’s V1 is most affected, what disease should you consider? –> MS
•Can be triggered by light touch, air or nothing at all.
Trigeminal mountains. Three peaks V1, V2, and V3.
V2 level is the most common because it medium level, so most people are looking for gems on that peak.
A very weak woman with MS is on V1 because it is easiest and she cannot get to the second level.
It is breezy on the mountain, and the air touches their face lightly.
