Headache Phys and Pharm

Question 1

What are the only head-things that carry pain fibers?

Answer 1

• Meninges
• Vessels
○ Dural veins or sinuses, meningeal arteries, extracranial and proximal intracranial arteries
• Dermis
○ Trigeminal sensory systema nd cervical sensory system C2-4

Question 2

Of primary and secondary headaches, which are the more common?

Answer 2

• Primary make up over 90% of headache complaints
  
  • Tension-type headaches
  • Migraine
  • Trigeminal autonomic cephalagias

Question 3

you expect to find trigeminal neuralgia mostly in what patient population?

Answer 3

elderly

Question 4

History is all important in headache examination. What questions are super important?

Answer 4

• Onset
	• Duration
	• Location of pain
	• Relation to position (lying vs. sitting vs. moving)
	• Frequency
	• Time of day or cyclical events
	• Triggers
	• Quality of pain
		○ Throbbing, pounding, burning, dull, achy, thunderclap

Question 5

What are the IHS criteria for migraine headache?

Answer 5

• 5 recurring headaches that last 4-72 hours
	• Characterized by at least 2 of:
		○ Unilateral in location
		○ Pulsating in character
		○ Moderate or severe in intensity
		○ Pain that increases with physical activity
	• Must have one of:
		○ Nausea and/or vomiting
		○ Photophobia AND phonophobia

Question 6

What are the 4 phases of a migrane attack?

Answer 6

• Premonitory
		○ Alterations in mood, alertness and appetite up to 24 hours in advance
	• Aura
		○ Various neurologic symptoms preceding headache
			§ 30% of patients
	• Headache and associated symptoms
	• Postdrome
		○ Post event lethargy and exhuastion

Question 7

What are some triggers for migraine attacks?

Answer 7

• Relief of stress
  
  • Caffeine withdrawal
  • Perimenstruation
  • Lack of sleep
  • Alcohol consumption
  • Skipping a meal

Question 8

What is the treatment paradigm of migraines?

Answer 8

• Abortive, prophylactic
• Combo of caffeine, NSAIDs and acetaminophen
• Specific serotonin receptor agonists
○ Triptans or ergotamine derivatives

Question 9

What are the abortive treatments of migraines?

Answer 9

• Nonspecific and specific
• Nonspecific
○ Aspirin, acetaminophen, NSAIDs, caffeine
○ Combos of these
• Specific for migraines are serotonin receptor agonists either direct or indirect
○ Direct - triptans - sumatriptan, naratriptan, rizatriptan, eletriptan
○ Indirect - ergotamine derivatives

Question 10

What are some prophylactic treatments for migraine?

Answer 10

• Beta blockers
	• Calcium channel blockers
	• Tricyclic antidepressants
	• Anti-epileptics
		○ Effective in 30-70%

Question 11

What is a migraine aura?

Answer 11

• Criteria include 2 episodes with reversible symptoms of:
○ Visual, sensory, language, motor, brainstem, retinal changes
• AND 2 of:
○ Unilateral symptoms, gradual development over 5 minutes or greater, symptom lasting 5-60 minutes, accompanied or followed by headache
• Most are visual

Question 12

Most likely, the pathophys of migraines entails…

Answer 12

• Depends both on activation of the trigeminovascular pathway by pain signals that originate in peripheral intracranial nociceptors and on dysfunction of CNS structures involved in the modulation of neuronal excitability and pain
• Glial wave in non-aura with messenger molecules being involved
○ 5-HT, NO, calcitonin gene related peptide
• Vascular involvement with depression of blood flow in affected area

Question 13

How do you know if a headache is a tension-type

Answer 13

headache?
• Must include at least 10 episodes of headache that last 30 minutes to 7 days
• Each episode must be characterized by pressing or tightening sensation, mild to moderate severity, bilateral and not aggrevated by phsyical activity
• NO nasea/vomiting
• NO photophobia or phonophobia
○ Essentially, featurless and non-migraine headache

Question 14

What is abortive therapy for cluster headaches?

Answer 14

• Oxygen, triptans, ergotamine derivatives, lidocaine, corticosteroids, nerve blocks
  
  • Prophylactic - CCBs, lithium and anti-epileptics

Question 15

What must go down to be a cluster headache?

Answer 15

• At least 5 episodes of severe, unilateral, periorbital and or temporal pain that lasts 15-180 minutes
  
  • Pain should recur at least every other day up to 8x/day
  • Ipsilateral - conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, ptosis, miosis, facial swelling, ear fullness
  • Restlessness and agitation is a MUST
  • Men predominance
  • Triggers - alcohol or vasodilatory drugs

Question 16

What is treatment of tension-type headaches?

Answer 16

• Abortive OTCs
		○ NSAIDS, aspirin and acetaminophen
		○ Prophylactic
			§ Tricyclic antidepressants
			§ SSRIs - prozac
			§ Psychotherapy
			§ Physical therapy

Question 17

What are IHS criteria for Trigeminal neuralgia?

Answer 17

• Very brief pain in the trigeminal nerve distribution lasting less than 1 second to 2min
• Pain must be:
○ Sharp, intense, superficial, stabbing
• Triggered by sensory stimulation of a particular area within the trigeminal sensory innervation or by a factor such as chewing or brushing teeth
• Pain must be stereotyped
• Primary or secondary due to vascular compression or demyelination within the pons
○ MS can cause the demyelination

Question 18

What is treatment for trigeminal neuralgia?

Answer 18

• Not all that successful
  
  • Anti-epileptics
  • Baclofen
  • Can surgically free up the compressed nerve

Question 19

CT is how sensitive for SAH?

Answer 19

• Depends on how close to onset
  
  • 100% inside of 12 hours
  • 93% for 12-24
  • Less after 24 hours
  • Abnormal LP if you are super suspicious and CT is negative is xanthochromia in CSF and RBCs
  • Angiography is done STAT after abnormal CSF findings

Question 20

What is giant cell arteritis?

Answer 20

• Affecting elderly, potentially devastaating
  
  • 95% of patientw will have headache and it will be the presenting complaint
  • Women and men equally
  • Blindness can occur
  • Jaw claudication, temporal artery region scalp tenderness, joint pain, constitutional symptoms such as fever, malaise and weight loss
  • Sed rate and CRP are elevated usually
  • Biopsy temporal artery is diagnostic confirmation
  • Treatment is steroids long term

Question 21

Describe the headache associated with ICP

Answer 21

• Worsens with exertion
  
  • Retro orbital pain
  • Associated nausea/vomiting
  • Pulsatile intracranial noises
  • Transient visual obscurations
  • Photopsias (flashes of light)
  • Diplopia
  • Vision loss
  • Awakens from sleep
  • CN palsies
  • Papilledema
  • Focal deficits