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

Headache Lecture Flashcards by Brittany Blackston

what type of headaches can have a genetic disposition

Primary Headaches

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type of headache

90% of reported headaches

Primary Headaches

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You wouldn’t have this headache if it wasn’t for a catalyst or a reason

Secondary Headaches

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rebound headaches are what type of headache

secondary

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timeline to define status migrainosus

migraine that is unremitting for over 72 hours

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episodic syndromes that may be associated with migraine

cyclical vomiting syndrome

abdominal migraine

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cluster headache symptoms

one sided
tearing
rhinorrhea
ptosis
conjunctival injection

rare in kids

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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

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Cervicogenic headache stems from

stems from neck - tight muscles, knots, ect

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most common primary headache disorder that people get world wide

tension headache

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second most common primary headache disorder

migraine

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nausea and or vomiting
sensitive to noise (phonophobia) or light (photophobia)

what type of headache

migraine

tension does not have n/v

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location characteristic of migraine vs tension

tension - circumferential

migraine (unilateral or bilateral (frontal) location

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tension headaches last from

30 min to 7 days

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migraine attacks last at least

2 hours

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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

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women who have migraine with aura are at greater risk for

stroke

no estrogen containing meds due to increased risk

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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)