Headache & Facial Pain 2

Question 1

What is Cefaly Device?

Answer 1

1. TMS
2. ACUTE: works at trigeminal nucleus caudalis
3. CHRONIC: slows modulation of cortical areas

(FDA approved, not covered by insurance. $500)

Question 2

How is the cephaly device used?

Answer 2

• Prophylaxis: daily 20 minute sessions
• Acute treatment: 60 Minutes session

Question 3

How does Gamma Corps/VNS device work?

Answer 3

1. Prophylaxis: 2 treatments daily (3 consecutive 2-minute stimulations)
2. Acute tx: 3 consecutive 2-minute stimulations, repeat 3 min up to 4 attacks or 8 tx/dy

($7k, FDA approved, hard to get insurance to cover it)

Question 4

Mechanism of action for single pulse transcranial magnetic stimulation (sTMS) (2)

Answer 4

1. Blocks cortical spreading depression
2. Inhibits firing rate of vpm neurons

Question 5

Criteria for cluster headache diagnosis

Answer 5

At least five attacks with the following:

1. Severe (“suicide headache”)
2. Unilateral orbital, supraorbital or temporal
3. Last 15 to 180 minutes

Either or both:

• conjunctival injection and or lacrimation
• nasal congestion and or rhinorrhea
• Eyelid edema
• Forehead or facial sweating
• Meiosis and or ptosis
• Sense of restlessness or agitation

Question 6

What is the main precipitating factor for cluster headache?

Answer 6

Alcohol triggers it

(nocturnal, occurs more in men age 20-40)

Question 7

Cluster headache is relieved by

Answer 7

• 100% oxygen
• Activity
• Medication: supatriptan or triptan

Question 8

Cluster headache abortive treatment

Answer 8

1. Oxygen is very successful w/n minutes - unique to these headaches
2. Sumatriptan
3. Ergotamines
4. Midrin

Question 9

Medication overuse headache diagnostic criteria (2)

Answer 9

1. Headache occurring on 15 days out of the month and a patient with a pre-existing headache disorder
2. Regular overuse greater than three months of one or more drug

(not accounted for by another diagnosis)

Question 10

Medication overuse headache treatment

Answer 10

1. Discontinue overuse medication
2. Behavioral changes
3. Physical therapy

Question 11

How do you remove a patient from a medication that is causing overuse headache?

Answer 11

1. Abrupt withdrawal: for OTC analgesics & triptans
2. Tapered withdraw: for BZD, opioid & barbiturates

Question 12

Epidemiology of migraine headache and Pregnant patients

Answer 12

1. 30% of patients will have primary headaches
2. Migraines will not affect outcome measure of pregnancy

(mostly migraine & tension)

Question 13

Occurrence of migraine is most common in what trimester of pregnancy?

Answer 13

First trimester

(hormonal changes, lack of sleep, low blood glucose, hunger, dehydration, caffeine and sugar withdrawal)

Question 14

Possible causes of migraine in the second trimester of pregnancy

Answer 14

1. Strong smells
2. Poor posture
3. Muscle tension from excess weight
4. Preeclampsia

Question 15

Nonpharmacologic therapies for migraine and pregnancy

Answer 15

Hyperbaric oxygen

(and other non-pharmalogic therapies that are normally given for migraine)

Question 16

Short-term treatment for migraine in pregnant patients

Answer 16

1. Acetaminophen
2. Metoclopramide
3. Small doses of caffeine
4. NSAIDs (must stop at 32 weeks)
5. Antiemetic
6. Prednisone (Category B)
7. Triptans (Category C)

(severe HA: codein or meperidone is category B)

Question 17

Prophylactic treatment for migraine in pregnant patients (for frequent or disabling attacks) (4)

Answer 17

1. Beta blockers (Category C0
2. Magnesium
3. Riboflavin
4. Fluoxetine