Headache (Hon) Flashcards
What are primary headaches?
Benign HA disorders Migraine (with or without aura) Chronic migraine Tension type Cluster HA Post-traumatic HA Drug rebound HA
What are secondary headaches?
Sign of organic disease
Describe headache history
How many types of HA? Frequency: previous, current, mode of increase (gradual or sudden) Prodrome Associated symptoms Triggers Current and previous medications tried
Describe prodrome of headaches
Changes in energy levels, mood, appetite
Fatigue
Muscle aches
Aura
Describe associated symptoms of HA
Nausea Vomiting Anorexia Photophobia Phonophobia Diarrhea Stuffy/runny nose Watery eyes Ptosis/Miosis Dizziness Behavior: retreats to dark room, paces, rock
What are triggers of HA?
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
Describe history of current and previous medications tried for HA
For both prophylactic and abortive therapy
Dosages
Effectiveness
Side effects
Describe good medical/surgery history and family/social hx
Co-morbidities: sleep disturbances, mood disturbances Other medications Head trauma Previous LOC Seizure D/O Allergies
Family illnesses including HAs
Habits
Occupation
Describe good general exam for HA
Vital signs (BP/pulse)
Cardiac status
Extracranial structures
ROM & presence of pain in C-spine
Describe neuro exam for HA
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
What are the worrisome signs that may indicate HA of pathological origin (secondary HA)
"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
Describe diagnostic evaluation
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)
What are primary HA disorders?
Common migraine (without aura) Classic migraine (with aura, consider chronic migraine) Tension-type HA Cluster HA
Describe common migraine
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
Describe the most and least common associated symptoms of common migraine
Most common: Nausea (90%) Vomiting (30%) Photophobia Phonophobia
Least common: Diarrhea Conjunctival injection Stuffy nose Lacrimation Miosis Ptosis
Describe classic migraine aura
Usually lasts 15-30 min but sometimes longer
Commonly visual symptoms (scintillations, scotoma, often hemianopic) but can be anything neurological
Describe chronic migraine
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
What causes migraine?
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)
Describe tension-type HA
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
Describe cluster HA
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
Describe acute treatment of migraine
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)
Describe contraindications to Triptan usage
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
Describe DHE protocol (Raskin protocol)
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
Describe adjunctive agents in migraine
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
Describe preventative treatment of migraine
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)
Describe preventative treatment of chronic migraine
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
Describe nonprescription tx of migraine
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)
Describe acute tx of tension HA
OTC analgesics
NSAID (ibuprofen, naproxen)
Opioids (codeine, hydrocodone)
Midrin
Describe preventative tx for tension HA
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)
Describe acute tx of cluster HA
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
Describe preventive tx for cluster HA
Calcium channel blocker (Verapamil) Anticonvulsant (valproic acid) Lithium Indomethacin Prednisone x 10-14 days Capsaicin 0.025% intranasal tid x 1 wk Ergotamine tartrate
Describe trigeminal neuralgia
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
Trigeminal autonomic cephalgias (TAC’s)
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
Describe SUNCT syndrome
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)
Describe paroxysmal hemicrania
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
