Headache + Infections Flashcards
acute primary headache disorders
-migraine with or without aura: MC dx in primary care
-tension type headache: MC headache
-trigeminal autonomic cephalgias (Cluster headache) - rare and often presents to ER
tension headache (TTH) ethiology + description
Ethiology:
-Neurovascular dilation of blood vessels innervated by trigeminal nerve (CN V)
-Bilateral, tight, band-like or pressure type pain
Description:
-MC headache
-Mild-Moderate intensity
-Self-limited
-± Pericranial and nuchal muscular tenderness
-Never incapacitating
-NO nausea, vomiting or neuro symptoms
-Rarely photophobia/phonophobia
-Lasts 30 min – 7 days
-Frequency: Rarely to daily
-aggravated by stress
-goes away with distraction**
-major cause of work loss productivity
-75% of people will have at some point
-females > males
Ethiology and duration of headaches: tension, cluster, migraine
Tension:
-Neurovascular dilation of blood vessels innervated by trigeminal nerve (CN V)
-Bilateral, tight, band-like or pressure type pain
-Lasts 30 min – 7 days
Migraine:
- primary neuronal dysfunction leads to sequence of intracranial and extracranial changes
- episodic and severe POUND (4-72h) headaches with N/V and/or light/sound sensitivity
Cluster:
- unclear ethiology, subtype of trigeminal autonomic cephaligia
- frequent 0.5-8x/day for 6-8 wks that last 15 min - 2h, self resolving
MC patient demographic to have each headache:
Tension:
- F>M
- MC type of headache
Migraine:
- F>M
- MC: 30-39
- can be familial
- 15% women of childbearing age -> affects childcare and jobs
Cluster:
- predominantly middle aged males
tension headache environmental triggers
-NOT TRIGGERED BY ACTIVITY
-Stress
-Mental/emotional tension
-Bright light
-Loud noises
-Smells
-Hunger
-Ambient temperature extremes
-Caps/headbands/ponytails
-Suboptimal/improper vision correction
-Pericranial muscle tension
3 subtypes of tension headaches
-infrequent episodic tension HA: < 1 HA per month (MC)!!!
-frequent episodic tension HA: 1-14 HA per month
-chronic tension HA: >= 15 HA episodes per month
tension headache tx
Often self dx and self tx*
Acute: NSAIDs
Chronic
- amitriptyline (prophylaxis)
- massage
- Cognitive behavioral therapy
- HA clinic
migraines epidemiology
-2nd most leading cause of disability; underdiagnosed/undertreated
-as disabling as dementia, quadriplegia, and psychosis
-COMMON, DISABLING, UNPREDICTABLE
-15% women of childbearing age -> affects childcare and jobs
-Women > Men, MC: 30-39, can be familial
migraines Types
-Episodic and severe headaches associated with N/V and/or light/sound sensitivity
Types:
-Migraine w/o aura (“Common” migraine) (70%)
-Migraine w/ aura (”Classic” migraine)
-Status Migrainosus: debilitating migraine lasting >72 hours
-Menstrual Migraine: occurs closely to onset of menstruation (2d before or 3 d after onset of bleeding)
what precipitates or exacerbates migraines?
-Emotional stress (80%),
- menstruation or estrogen (65%)
- fasting (57%)
- weather changes (53%)
- alcohol (38%)
- food (27%)
4 phases of migraine headache
-know the timeline
-migraine can last a week
prodrome/premonitory phase: what signs
-Symptoms that occur 3 hours – several days BEFORE migraine headache (NOT aura symptoms)
-occurs in 60% of patients
Mood changes: Depression, euphoria, irritability, drowsiness, restlessness, difficulty concentrating
GI changes:
- Food cravings** (chocolate, cheese, alcohol), anorexia, diarrhea or constipation
Increased thirst or more frequent need to use the bathroom
Muscle stiffness (esp neck)**
Fatigue: **Yawning (dopaminergic phenomenon), fatigue, insomnia
Photophobia/phonophobia
aura symptoms description
-a group of sensory, motor and speech symptoms
-warning signs for migraine (although sometimes can occur during or even after headache)
-Commonly misinterpreted as a seizure or stroke -> you can have unilateral weakness
-An aura can last from 5 to 60 minutes*
-15-30% of people who experience migraines have auras
-Aura symptoms are reversible
-Types of auras by frequency are : VISUAL > SENSORY > LANGUAGE
-Seeing bright flashing dots, sparkles, or lights.
-Seeing wavy or jagged lines.
-Blind spots in your vision.
-Temporary vision loss
-Numbness or tingling skin, pins and needles
-Ringing in your ears (tinnitus).
-Changes in smell or taste.
-Vertigo, dizziness
-Aphasia, dysarthria- least common
scintillating scotoma
-AKA visual migraine
-MC visual aura preceding migraine
-positive and negative symptoms mixed
auras: visual, auditory, somatosensory, motor
-strokes are ONLY negative symptoms
-migraines can have positive and neg
migraine with aura vs TIA
Migraine:
-No CVS risk factors
-GRADUAL ONSET, slow, spreading,
-If more than one type of aura, its often sequential (one after another)
-Often positive THEN negative sxs!!!**
-“tingling THEN numbness”
-“shimmering lights and zigzag vision THEN loss of vision”
-scintillating scotomas- both positive + negative
-Long duration 15-60 minutes in 75%
STROKE/TIA:
-CVS risk factors
-older people
-Acute/abrupt onset, simultaneous
-Negative symptoms only “loss of function”
-Shorter duration <10 minutes
POUND mneunomic
-Pulsatile
-One day duration (4-72h)*
-unilateral- less important
-nausea*
-!debilitating- photophobia, phonophobia
-92% if 4 POUND
-64% if 3 POUND
-17% if <3 POUND
Billy Baker is a 30-year-old man with a history of migraine who presents for his annual physical examination. He reports that he has had about three migraine attacks in the past month, and he is able to treat them effectively with sumatriptan. He does note, however, that the day before he gets an attack, he is unusually tired and irritable and has difficulty focusing at work. What phase of migraine is Mr. Baker describing?
Headache
Ictal
Postdrome
Prodrome*** -> you can take meds during the prodromal phase
migraine PE
-Although a thorough neurological examination is essential, most exams will be NORMAL
Normal vitals
Normal neurologic exam:
-Cranial nerves
-Motor
-Sense
-Gait and coordination
-Mental status
Eye exam:
-Check: Funduscopic, Visual Acuity, Visual Fields, EOM
-May have cranial or cervical tenderness , conjunctival injection, Horner’s syndrome
Head and neck:
- ± Temporal tenderness, Muscle tenderness
ENT (Nose for mucus sometimes, teeth for tenderness)
complicated migraines can have:
-Hemisensory or hemiparetic neurologic deficits
-Aphasia, syncope, balance problems (Basilar type migraines)
-CN3 palsy (Ophthalmoplegic migraine)
migraine tx
-assess disability
-Educate that its incurable (“migraine brain”)-> can give treatment and prophylaxis drugs
-acute episodes -> abortive therapy!!
-Medicate
-1. Non-specific treatments
-2. Migraine specific
-Consider non-PO routes for N/V
-Avoid rebound headaches -> educate on meds overuse
-Nonpharmacologic measures
-Cognitive-behavioral therapy
-once pts are taking meds everyday for migraines -> can cause medication overuse headaches -> start prophylaxis therapy
lifestyle modifications for migraine
-Prevention of triggers
-Avoid irregular lifestyle
-Eat and sleep regularly
-↓ Alcohol / caffeine intake
-Hydration
-Regular moderate exercise
-Try and reduce stress
-PEARL: Start a HEADACHE diary (frequency, intensity, triggers, medications used, success rates)
Select the factor that greatly increase risk of ischemic stroke in females with migraines with visual aura
Diabetes mellitus
Oral contraceptives*** -> alternative is progestin only BC or IUD
Hyperlipidemia
Hypertension
migraine tx flow chart
acute migraine specific: triptans description
-for severe migraines
Serotonin agonists - Bind to 5HT-1b/d receptors, reduce levels of CGRP
-induce vasoconstriction of extracerebral, cranial blood vessels -> dont give to stroke pts
-Suma-, Riza-, Ele-, Almo-, Zolmi-, Nara-, Frova- triptans- None proven to be superior to another -> trial them all if not working
-Forms: PO, IN, SQ, ODT -> If giving intranasal, give opposite rhinorrhea/congestion
-Clarify limits: 1 tab PRN, may repeat in 2 hours, limit 2 tabs/24 hours, and no more than 8d/mo -> too much can cause sensitization
-Eliminate pain within 2 hours for ~30% of patients
-Triptans are generally VERY WELL TOLERATED
acute migraines: triptans ADRs and CI
(Triptans are generally VERY WELL TOLERATED)
ADR:
- Nausea*
- fatigue*
- flushing*
- dizziness, dry mouth, headache, sleepiness, hot/cold sensations, chest pain
Less common side effects:
- chest tightness (from vasoconstriction)**
-tingling*
throat discomfort!
- Head, jaw, arm discomfort/tightening ,cramps,
Contraindications:
- Ischemic CVD/CVA**
- Prinzmetal angina*
- uncontrolled HTN
- pregnancy (relative, new evidence might be safe)*
triptans: contraindications
-DONT NEED TO KNOW
-DONT NEED TO KNOW
-Contraindications for triptan use are due to its ability to constrict blood vessels (~10%)
-Known or suspected ischemic coronary artery disease (e.g. angina pectoris, documented silent ischemia, myocardial infarction, vasospastic “Prinzmetal” angina)
-History of stroke or transient ischemic attack
-Uncontrolled hypertension
-Peripheral vascular disease
-Ischemic bowel disease
-Wolff-Parkinson-White or other cardiac accessory conduction pathway-associated dysrhythmias
-Use of ergot agents (e.g., dihydroergotamine [DHE]) or triptans in the previous 24 hours
-Use of monoamine oxidase inhibitors in the previous 2 weeks
-Severe hepatic impairment
-In addition, triptans are usually avoided in hemiplegic migraine or migraine with brainstem aura.
-Currently available evidence does not support limiting the use of triptans with serotonin-specific reuptake inhibitors (SSRIs) or serotonin–norepinephrine reuptake inhibitors (SNRIs), or the use of triptan monotherapy, due to concerns for serotonin syndrome.
medications chart
-ALWAYS check pregnancy and lactation status
-start with NSAID, if not working do triptans, then do gepants and antiemetics
-can take 6 meds for one migraine
gepants, antiemetics
-abortive and prophylactic
-ergots too
a pt with hx of stomach ulcers may NOT be a good candidate for
NSAIDS
migraine prophylaxis chart
-WEAK EVIDENCE FOR CCBs -> IGNORE THAT
- beta-blockers: most used drug class
- anticonvolusants/antiepiletics
- amitriptyline: highest risk of adverse events
headaches area of pain photo
red flag symptoms chart: what are the red flags
worrisome headache red flags SNOOP4
S: systemic signs or secondary risk factors:
-fever, weight loss, malignancy, uncontrolled or new HIV
N: Neurologic sx
-confusion, impaired alertness, consciousness
Onset:
- sudden/thunderclap
-precipitated by exercise or valsalva
Older:
-new onset and progressive headaches, especially >50 years old
Papilledema, pulsatile tinnitus, positional/postural, precipitated by exercise
-first headache OR different from normal (change in attack frequency, severity, clinical features)
Pregnancy, painful eye
ethiologies of meningitis by age
know this chart
-ampicillin treats the listeria -> really given to neonates and elderly
meningitis PE
-+Kernig’s sign = after hip flexion, cannot straighten the knee
-+Brudzinski’s sign = neck flexion produces knee/hip bending
-Petechiae or palpable purpura often seen in n. meningococcal -> non blanching
classic csf findings in meningitis chart: normal, bacterial, viral, fungal/tb
CSF should not have WBCs-> over 100 = meningitis concern
brain abscess
-Often follows surgery or trauma
-Common causes: !Toxoplasmosis, !fungal infections (cryptococcus, histoplasmosis, candidiasis, Coccidioides etc) and !bacterial causes (strep, staph)
Brain abscesses often appear as “ring enhancing lesions”
Note there are a wide number of non-infectious causes of ring enhancing lesions such as brain metastases
-LP contraindicated
-Management: Surgical drainage, antibiotics
