Headache Lecture Flashcards
what type of headaches can have a genetic disposition
Primary Headaches
type of headache
90% of reported headaches
Primary Headaches
You wouldn’t have this headache if it wasn’t for a catalyst or a reason
Secondary Headaches
rebound headaches are what type of headache
secondary
timeline to define status migrainosus
migraine that is unremitting for over 72 hours
episodic syndromes that may be associated with migraine
cyclical vomiting syndrome
abdominal migraine
cluster headache symptoms
one sided tearing rhinorrhea ptosis conjunctival injection
rare in kids
definition of a concussion
neurologic symptoms that develop min, hours or even a few days after a head injury
no obvious signs of trauma needed
Cervicogenic headache stems from
stems from neck - tight muscles, knots, ect
most common primary headache disorder that people get world wide
tension headache
second most common primary headache disorder
migraine
nausea and or vomiting
sensitive to noise (phonophobia) or light (photophobia)
what type of headache
migraine
tension does not have n/v
location characteristic of migraine vs tension
tension - circumferential
migraine (unilateral or bilateral (frontal) location
tension headaches last from
30 min to 7 days
migraine attacks last at least
2 hours
Auras
most are visual
some can be sensory such as parasthesias
Brainstem auras are rare (refer to neuro)
- Dysarthria
- Vertigo
- Tinnitus
- diplopia
- motor weakness= hemiplegic migraine
women who have migraine with aura are at greater risk for
stroke
no estrogen containing meds due to increased risk
common migraine triggers
stress food additives: MSG, dyes, aspartame Cheese (dairy) chocolate citrus nitroglycerine change in barometric pressure caffeine withdrawal fasting/skipping meals dehydration menstruation acute illness wine/alcohol
when is the worst time of year for adolescence and migraine occurrence
April and May
comorbid conditions r/t migraines
Acute or chronic disease processes (DM, Sickle cell, chronic pain disorder)
Orthostatic hypotension/intolerance (POTS or dysautonomia)
Epilepsy
Anxiety, depression, ADHD and/or other psychiatric diagnosis
IBS
Back Pain
TMJ
Concussion history
Thyroid disease
Sleep disorders
Inflammatory disorders such as asthma
Pertinent history for headache presentation
Age of onset (when was very first headache)
Family history
headache frequency and severity)
Are the headaches escalating in frequency/severity, unchanged over time or improving?
Pain location/and or radiation
Duration (include time during sleep, is it constant/unremitting?)
Pain description (sharp, throbbing, pounding, squeezing, ect)
Warning signs (prodrome or aura)
Associated symptoms ( n/v/sensitivity to light/noise, dizziness/lightheadedness, sensory changes or motor weakness
Triggers
Do headaches worsen with physical activity?
Considerations for females (pregnancy, menstruation, menopause)
when do boys usually develop migraines
5/6 years old ,usually when they reach puberty they get better
when do girls usually develop migraines
puberty (menarche)
phases of episodic migraines
Prodrome (moody, chocolate or maybe sleepy) - few hours to days
Aura - 5-60 min
Migraine attack - 4-72 hours
Postdrome - 24-48 hours (sluggish, hangover like feeling)
the key brain structure involved in the production of migraine pain and symptoms
brainstem
Vital signs part of the focused neurologic exam
potential red flag items
BP
HR
Mental Status
others-
Temp
BMI
Head/neck part of the focused neurologic exam
Potential red flag items
Neck ROM
Carotid bruits (MRA of head and neck)
others
tenderness
pericranial tenderness
Cranial nerves part of neurologic exam
Fundoscopic exam - looking at margins of the optic disc- if they are blurred that would indicate ICP (optic nerve sheet swelling)
Sensation/coordination
other Visual acuity and visual fields Extraocular movements facial symmetry and sensation intact palate elevation symmetric and tongue protrudes midline
Motor part of neurologic exam
Potential red flag
Sensation/coordination
Gait
other
strength/tone
Deep tendon reflexes
what is the pneumonic for neurologic red flags
SNOOP 5
S - symmetric symptoms or secondary risk factors
N- neurologic signs or symptoms (confusion)
O - onset sudden, abrupt, peak < 1 min (thunderclap, SAH, CVST, dissection)
O - older, greater than age 50 (Giant cell arteritis, glaucoma, cardiac cephalgia)
P- Previous headache history (change in character, severity, frequency or pattern)
P- Postural (intracranial hypertension or low pressure HA/CSF leak)
P - Precipitated by valsalva, exertion - like cough or sneeze (Chiari, space occupying lesion)
P - Pulsatile tinnitus (with diplopia + transient visual changes = intracranial HTN)
P - Pregnancy or post partum (preeclampsia, eclampsia, apoplexy)
Neuro Diagnostic imaging
can accurately detect acute SAH or focal bleed
Head CT - can accurately detect acute SAH or focal bleed
- without contrast to detect blood
- with contract to detect lesions or AVM
Neuro Diagnostic imaging
to detect blood
CT with or without contrast?
without
Neuro Diagnostic imaging
to detect lesions or AVM
CT with or without contrast?
With
what is the best neuro diagnostic imaging for looking at lesions
MRI (Mass or demyelinating)
What diagnostic imaging to look for demyelination
MRI
what neuro diagnostic imaging to look for arterial dissection, AVM or aneurysm
MRA head
What neuro diagnostic imaging to look for venous sinus thrombosis
MRV head
what can you order to evaluate for low or high CSF pressure headache, SAH, meningitis
Lumbar puncture
can also look for other CSF pathologies
what labs for neuro diagnostic
Markers of inflammation (ESR and sed rate)
thyroid panel
If you have a neg CT, can you still have a concussion
yes
what labs to order for LP
cell count
glucose
protein
cultures
which of the following symptoms reported by a pt with acute headache warrants a need for urgent neuroimaging?
a. limited neck flexion on exam with a fever
b. Witnessed LOC
c. Head pain onset with exertion
d. All of the above
D. All of the above
How do we know this is a primary headache? by characteristics
Characteristics of the headache or headache pattern fit classification
Complete resolution of symptoms in between headaches
Not attributed to another disorder
normal neurologic exam
Treatment protocol for migraines
With Hydration/fluid bolus
1) NSAIDS
- ibuprofen 10mg/kg/dose q 8 hrs
- naproxen 10mg/kg/dose q 12 hrs
- acetaminophen 15mg/kg/dose q 6 hours
- ketorolac 10mg po or 30mg IV q 6-8 hrs
2) Triptans (Serotogeneric agonist selective activity on 5-HT1B, 5-HT1D)
- Sumatriptan, rizatriptan, zolmitriptan, ect.
- available in tablets, ODT, and nasal spray
- Dosed q 2 hrs with max daily dosing of 2-3 tabs in 24 hrs
3) antiemetics/dopamine receptor antagonists
- promethazine
- prochlorperazine
- metoclopramide
- ondansetron
* *beware of extrapyramidal side effects**
4) Magnesium sulfate 1000mg IV over 30 min
5) Sodium valproate 20mg/kg (max 1000mg) IV
6) DHE IV (per protocol)
