Headache (Hon)

Question 1

What are primary headaches?

Answer 1

Benign HA disorders
Migraine (with or without aura)
Chronic migraine
Tension type
Cluster HA
Post-traumatic HA
Drug rebound HA

Question 2

What are secondary headaches?

Answer 2

Sign of organic disease

Question 3

Describe headache history

Answer 3

How many types of HA?
Frequency: previous, current, mode of increase (gradual or sudden)
Prodrome
Associated symptoms
Triggers
Current and previous medications tried

Question 4

Describe prodrome of headaches

Answer 4

Changes in energy levels, mood, appetite
Fatigue
Muscle aches
Aura

Question 5

Describe associated symptoms of HA

Answer 5

Nausea
Vomiting
Anorexia
Photophobia
Phonophobia
Diarrhea
Stuffy/runny nose
Watery eyes
Ptosis/Miosis
Dizziness
Behavior: retreats to dark room, paces, rock

Question 6

What are triggers of HA?

Answer 6

Hormones (menstrual cycle, OC’s, HRT)
Diet: alcohold (esp beer, red wine), chocolate, aged cheese, MSG, aspartame, caffeien, nuts, nitrates/nitrites, citrus fruits, others
Stress: let down periods, times of intense activity, major life changes
Environmental changes: weather, seasons, altitude
Sensory stimuli: bright or flickering lights, odors
Others: travel, sleep pattern (too little, too much, or changes from usual pattern), skipping meals

Question 7

Describe history of current and previous medications tried for HA

Answer 7

For both prophylactic and abortive therapy
Dosages
Effectiveness
Side effects

Question 8

Describe good medical/surgery history and family/social hx

Answer 8

Co-morbidities: sleep disturbances, mood disturbances
Other medications
Head trauma
Previous LOC
Seizure D/O
Allergies

Family illnesses including HAs
Habits
Occupation

Question 9

Describe good general exam for HA

Answer 9

Vital signs (BP/pulse)
Cardiac status
Extracranial structures
ROM & presence of pain in C-spine

Question 10

Describe neuro exam for HA

Answer 10

Neck flexion
Presence of bruits over head and neck
Optic fundi, pupils, visual fields
Thorough cranial nerve exam
Motor power in limbs
Muscle reflexes
Plantar responses
Sensory exam
Coordination
Gait

Question 11

What are the worrisome signs that may indicate HA of pathological origin (secondary HA)

Answer 11

"Worst HA"
Onset of HA after age 50
Atypical HA for pt
HA with fever
Abrupt onset (max. Intensity in sec. To min)
Subacute HA with progressive worsening over time
Drowsiness, confusion, memory impairment
Weakness, ataxia, loss of coordination
Paresthesia/sensory loss/ paralysis
Abnormal medical or neuro exam

Question 12

Describe diagnostic evaluation

Answer 12

Lab testing (appropriate for variant or atypical forms)
Neurodiagnostic tests
Other: WSR, TSH, CBC, glucose
CT, MRI/MRA, EEG, LP, arteriogram
Dental, ENT, allergy evaluation

As a general rule, many physicians (including neurologists) believe that any person with HA should have a one-time thorough neuroimaging study (CT head with and without contrast or MRI of head)

*Clearly, any pt with a worrisome history or abnormal examination needs urgent imaging study and perhaps even an LP and possibly arteriogram. (CT can miss 5-10% of subarachnoid hemorrhages, and an LP may be needed if CT is normal)

Question 13

What are primary HA disorders?

Answer 13

Common migraine (without aura)
Classic migraine (with aura, consider chronic migraine)
Tension-type HA
Cluster HA

Question 14

Describe common migraine

Answer 14

Intensity: moderate to severe
Disability: inhibits or prohibits daily activities. Pain aggravated by activity
Age of onset: late teens to early 20’s. Prevalence peaks between 35-40 years
Gender ratio F:M: = 3:1
Frequency: 1-4 attacks per mo. (Occ infreq) but 14 days or fewer per month
Duration: 4-72 hr, usually 12-24 hr
Location: *unilateral or bilateral
Description: throbbing/sharp/pressure
Prodrome: mood changes, myalgias, food cravings, sluggishness, excessive yawning
Postdrome: fatigue, irritability, “fog”
Behavior: retreat to dark, quiet room
Aura: None
80-90% of migraine sufferers do not experience aura

Question 15

Describe the most and least common associated symptoms of common migraine

Answer 15

Most common:
Nausea (90%)
Vomiting (30%)
Photophobia
Phonophobia

Least common:
Diarrhea
Conjunctival injection
Stuffy nose
Lacrimation
Miosis
Ptosis

Question 16

Describe classic migraine aura

Answer 16

Usually lasts 15-30 min but sometimes longer

Commonly visual symptoms (scintillations, scotoma, often hemianopic) but can be anything neurological

Question 17

Describe chronic migraine

Answer 17

Many patients with episodic migraine will ultimately develop chronic migraine
History of headaches consistent with migraine, now with HA 15 or more days per month, HA lasting 4 hrs or longer for a period of at least 3 months, not attributed to another disorder

Question 18

What causes migraine?

Answer 18

Theory is “neurogenic inflammation”
Trigeminal nerve becomes activated, releasing neuropeptides, causing painful neurogenic inflammation within meninges, with subsequent effect on dural vasculature (vasodilation, plasma protein extravasation, and mast cell degranulation)

Question 19

Describe tension-type HA

Answer 19

Intensity: mild to moderate
Disability: may inhibit but does not prohibit daily activities
Age of onset: variable. Generally peak incidence 20-40 yr
Gender ratio F:M = 3:2
Frequency: episodic type = 15 days/month
?Analgesic rebound HA’s
Duration: episodic = several hours. Chronic type = all day, waxing and waning
Location: bifrontal, bioccipital, neck, shoulders, band-like
Description: dull, aching, squeezing, pressure
No prodrome or aura
Behavior generally not affected

Question 20

Describe cluster HA

Answer 20

Intensity: severe, excruciating
Disability: prohibits daily activities
Age of onset: 20’s to 50’s
Gender ratio F:M = 1:6
Recent association with obstructive sleep apnea
Monthly frequency: episodic = 1 or more attacks/day for 6-8 wks. Chronic = several attacks per week without remission
Duration: 30 min to 2 hr
Location: 100% unilateral, generally orbitotemporal
Description: nonthrobbing, excruciating, sharp, boring, penetrating
Prodrome: may include brief mild burning in ipsilateral inner canthus or internal nares
No aura
Behavior: Frenetic, pacing, rocking
Associated symptoms: ipsilateral ptosis, miosis, conjunctival injection, lacrimation, stuffed or runny nose

Question 21

Describe acute treatment of migraine

Answer 21

OTC analgesics
NSAID's: Naproxen, Ketorolac, Diclofenac
Isometheptene (Midrin)
Butalbital (Fiorinal, FIoricet)
Opioids: demerol, morphine, codeine, oxycodone, hydrocodone
DHE nasal spray
Triptans (5HT1 agonists):
-Sumatriptan (Imitrex)
-Zolmitriptan (Zomig)
-Naratriptan (Amerge)
-Rizatriptan (Maxalt)
-Almotriptan (Axert)
-Frovotriptan (Frova)

Question 22

Describe contraindications to Triptan usage

Answer 22

Documented or strong risk factors for ischemic heart disease, other CV, cerebrovascular, or peripheral vascular disease, Raynaud’s syndrome, uncontrolled HTN, hemiplegic or basilar migraine, severe renal or hepatic impairment, use within 24 hr of tx with ergotamines, MAOI’s, or other 5HT1 agonists

Question 23

Describe DHE protocol (Raskin protocol)

Answer 23

Metoclopromide or prochloperazien 10 mg IV over 60 sec. Wait 5 min to allow distribution
Give DHE 0.5 mg IV over 60 sec. Wait 3-5 min
May repeat 0.5 mg IV if no relief. May repeast every 8 hr for short-term use
Same general contraindication as triptans
Side effects: chest pressure, anxiety, speeding or dissociation of thoughts, nausea

Question 24

Describe adjunctive agents in migraine

Answer 24

If nausea/vomiting are a major feature of migraine, consider using antiemetic (often before analgesic medication): metoclopramide, prochlorperazine
If insomnia is a major feature of migraine, consider a sedative/hypnotic (diazepam or temazepam) or major tranquilizer (thorazine) to help pt sleep off migraine
Prednisone taper can sometimes be used to break cycle of prolonged migraine or several weeks of frequent migraines

Question 25

Describe preventative treatment of migraine

Answer 25

In general, if pt is experiencing one or more HA’s per week, consider preventative medication in attempt to decrease frequency and severity
Antidepressants: TCA’s (amitriptyline, nortriptyline), SSRI’s (fluoxetine, sertraline, escitalopram), MAOI’s (phenelzine)
Beta-blockers: propranolol
Calcium channel blockers (verapamil)
Anticonvulsants (topiramate, valproic acid, gabapentin)
Ergot alkaloids (ergotomine+phenobarbital)
NSAIDs (ASA, naproxen)
Muscle relaxants (tizanidine)
Methysergide (Sansert)

Question 26

Describe preventative treatment of chronic migraine

Answer 26

Many used to prevent episodic migraine will also work for chronic (propranolol, amitriptyline, topiramate, valproic acid)

BOTOX injections: only FDA approved treatment for chronic migraine
155 units injected into 31 different sties, repeated every 3 months
May see some improvement after 1st treatment but need multiple treatments over 9-12 months to determine if working. 70-80% improvement
Minimal side effects: typically mild, temporary ptosis. Rarely can see widespread effect, ineffectiveness d/t antibody formation

Question 27

Describe nonprescription tx of migraine

Answer 27

Exercise
Stop smoking
HA education
Riboflavin (400 mg daily)
Magnesium (325 mg daily for menstrual migraine)
Biofeedback/relaxation/stress management (one of best preventative tx of migraine and tension-type HAs)

Question 28

Describe acute tx of tension HA

Answer 28

OTC analgesics
NSAID (ibuprofen, naproxen)
Opioids (codeine, hydrocodone)
Midrin

Question 29

Describe preventative tx for tension HA

Answer 29

Antidepressants (TCA’s, SSRI’s, MAOI’s)
Muscle relaxants (Tizanidine)
Anticonvulsants (valproic acid, gabapentin)
BOTOX injections
Ergot alkaloids (DHE sometimes used to break cycle of chronic daily HA)

Question 30

Describe acute tx of cluster HA

Answer 30

DHE 1 mg IM or ergotamine 2 mg SL
Lidocaine 4% - 1 ml intranasal
Narcotics (meperdine, morphine)
Oxygen 100% 8 L/min by mask
Sumatriptan 6 mg SQ

Question 31

Describe preventive tx for cluster HA

Answer 31

Calcium channel blocker (Verapamil)
Anticonvulsant (valproic acid)
Lithium
Indomethacin
Prednisone x 10-14 days
Capsaicin 0.025% intranasal tid x 1 wk
Ergotamine tartrate

Question 32

Describe trigeminal neuralgia

Answer 32

Excruciating sharp, shooting, electrical quality pain occurring in paroxysms in one or more distributions of trigeminal nerve, often frequent throughout day.
Treatment is usually carbamazepine or oxcarbamazepine. Other anticonvulsants or rarely surgery can be considered

Question 33

Trigeminal autonomic cephalgias (TAC’s)

Answer 33

Group of headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features
Include: cluster headache, paroxysmal hemicrania, hemicrania continua, SUNCT syndrome

Question 34

Describe SUNCT syndrome

Answer 34

Shortlasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing
Excruciating, burning, stabbing electrical HA in periorbital area lasting seconds to a few minutes, occurring frequently throughout the day
Onset typically over 50 in men
Treatments usually anticonvulsants (particularly lamotrigine)

Question 35

Describe paroxysmal hemicrania

Answer 35

Very similar to cluster headache (unilateral, periorbital, severe, excruciating, often with lacrimation, conjunctival irritation) but shorter duration (often only a few minutes) and increased frequency (usually > 5 times per day)
Exquisitely responsive to indomethacin