Headache & Facial Pain Flashcards
Classification of headaches
- Primary headaches
- Secondary headache
- Painful cranial neuropathies and Facial Pain
Examples of primary headaches (4)
- Migraine with or without aura
- Tension-type
- Trigeminal autonomic cephalalgia (TAC)
- Other causes: cough, exercise, sexual activity, thunderclap)
Examples of secondary headaches (7)
- Trauma
- Infection
- Vascular disorder
- Intracranial disorder
- Substance withdrawal
- Psychiatric disorder
- Structural head and neck disorder
(disorders that cause the HA)
Examples of painful cranial neuropathies and Facial Pain (3)
- Involving cranial nerves V, IX, X, VII
- Occipital neuralgia
- Optic neuritis
Prevalence of migraine
- Lifetime: 25% of women and 8% of men
- Peaks in adolescence and early adulthood (25-50)
- Most have a relative with headaches
Non-sinister causes of headache (6)
- Errors of _refraction_ (not going to optometrist)
- _TMJ_ dysfunction (teeth grinding & chewing)
- _Occipital_ neuralgia
- Hypertension
- Post trauma without skull fracture
- Medication overuse headache
If a patient has a headache and an abnormal neurologic exam, what does this indicate?
Sign of a sinister headache, send to ER (cannot miss)
If a patient states that their headache is the worst headache of their life, first severe headache or that it has been worsening over days, what does this indicate?
Signs of sinister headache (cannot-miss, send to ER)
If a patient has a headache that increases with the ______ (special test), this is a sign of a sinister headache and they need to go to the ER.
valsalva maneuver
A headache that is accompanied by _____ or _____ is a sign of a sinister headache and you should send the patient to the ER.
- fever
- systemic illness
A headache that is preceded by ______, wakes a patient from their sleep or is seen in a patient over the age of ______ is a sign of a sinister headache, and they should be sent to the ER.
- vomiting
- 55
Acute glaucoma is a cause of a _______ headache
sinister
A headache caused by ____ poisoning is a major causes of sinister headache.
CO poisoning
Vascular causes of sinister headaches (6)
- Thunderclap
- Dissection (Carotid or vertebral)
- Acute or chronic subdural hematoma
- Giant cell arteritis
- Hypertension (Acute severe)
- Thrombosis
Headache pathophysiology: which structures have pain receptors?
Dura, meninges, veins, arteries, CN V, VII, IX, X
(NOT THE PARENCHYMA)
Atopic allergies can cause ______
headache
Which respiratory condition can cause a headache?
Asthma
Which neurologic condition can cause a headache?
Epilepsy
Which GI condition can cause a headache?
Irritable bowel syndrome
Which cardiac conditions can cause a headache (2)?
- Mitral valve prolapse
- Patent foramen ovale
Which psychiatric conditions can cause a headache (4)?
- Depression
- Bipolar disease
- Anxiety
- Panic attacks
Complications of migraine
Infarct
(increased risk w/migraine with aura & smoking, also increased in young females)
Characteristics of migraine (5)
- Unilateral pain
- Recurrence
- Episodic
- Neuro and autonomic changes
- Visual aura
Phases of migraine (4)
- Prodrome
- Aura
- Headache
- Postdrome
Migraine Aura starts gradually and can last no longer than_____,
1 hour
Symptoms of migraine headache (6)
- Usually unilateral (frontotemporal region)
- Throbbing or pulsatile
- N/V
- Photophobia
- Worse w/movement or activity
(with or without aura)
Describe the aura of a migraine (3)
- Focal neurological sx
- Visual phenomena: resembles being close to a flash camera
Migraine headache pathophysiology
Vasodilation of dural arteries → release of CGRP → peripheral sensitization of the trigeminal ganglion → central sensitization → headache
Criteria for migraine (4)
- 5 attacks & including the following :
- Headache for at least 4-72 hours
- N/V
- photophobia & phonophobia
- 2 of the following: unilateral, pulsing, severe or moderate pain & aggravated by physical activity
Behavioral modifications patients can use to avoid migraines (3)
- Avoid triggers (alcohol, caffeine, chocolate, odors, nitrates)
- Regular meals and sleep
- Minimize environmental stress & stimuli (if sensitive)
Migraine: non-pharmacologic treatment (6)
- Ice and/or heat
- Massage
- Regular exercise
- Meditation
- Stress reduction
- Cognitive behavioral therapy/psychotherapy
Migraines: abortive therapies (7 medications)
- NSAIDs
- Tylenol
- Parenterals
- Non-triptans
- Antiemetics
- Rescue therapy
- electronic device
OTC migraine meds (4)
- Migraine OTCs (acetaminophen/ASA/Caffeine)
- Motrin migraine
- Anacin (ASA/caffeine)
- Migralex (ASA/Magnesium Oxide)
(migraine OTC brands: excedrin, bayer, Tylenol, Advil)
Migraine: rescue therapies (abortive Rx) (3)
- Corticosteroid
- Neuroleptic
- Opioids (lastly)
Side effects of neuroleptics (8)
- Extra pyramidal (tardive dystonia)
- Hyperprolactinemia
- Anticholinergic symptoms
- Weight gain, metabolic syndrome
- Hypertension
- Sedation
- QTc prolongation (if overdosed)
- Lowered seizure threshold
(this is why rescue therapies are not first line)
Migraine: When to use prophylaxis (4)
- Greater than 2 per month
- Severe
- Attacks lasting several days per week
- Abortive therapies are contraindicated ineffective or overused
- Uncommon migraine type: hemiplegic, basilar, prolonged aura
Migraine treatments: classes of prophylactics (4)
- Antiepileptic (topiramate, valproate)
- Antihypertensive (propranolol)
- Antidepressant
- Calcitonin gene-related peptide (CGRP) MAB (monoclonal antibody)
2 Migraine prophylactic tx (other than meds)
- Electric devices
- Subcutaneous medication: Botox
Migraine treatment: antihypertensives (2)
- Propranolol
- Timolol
(these are FDA approved, the others can be prescribed, but insuracne co. will push back)
- Topiramate (topamax)
- Valproic Acid (Depakote)
What are these used for?
Migraine treatment: prophylactic, antihypertensive
Topiramate side effects (3)
- Weight loss
- Neuralgia
- Kidney stones
Valproic acid (Depakote) side effects (5)
- Hair loss
- Low PLT
- Hepatic dyfunction
- Weight gain
- Cognitive problems
(must monitor CBC & LFT’s - liver fxn tests)
Migraine treatment: prophylactic antidepressants (3)
- SSRIs
- SNRIs
- MAOI’s (must avoid w/tyramine and all alcohol to avoid blood pressure crisis)
(in this order; none are FDA approved; sometimes TCAs)
Migraine prophylactic treatments: CGRP antagonists (5)
- Erenumab (Aimovig)
- Fremanezumab (Ajovy)
- Galcanezumab (Emgality)
- Eptinezumab (Vyepti)
- Rimegepant (Nurtec ODT; abortive or preventive)
- Ubrogepant (Ubrelvy)
(Migraine prophylactics = “numab”, “zumab” and “pant”)
What are cyproheptadine, gabapentin and cadesartan used for?
Migrain prophylactic treatment
(less used outside of the other 4 classes: anti-epileptic, anti-depressant, CGRP antagonists (MC used))
Cyproheptadine MOA
serotonin antagonist (5-HT1a & 5-HT2 receptors)
(side effects: dry mouth and lightheadedness)
Gabapentin side effects (4)
- somnolence
- weight gain
- edema
- lightheadedness
(out of it, fat, swollen, dizzy)
