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Block 8 week 4 > Headache - Rockroth > Flashcards

Headache - Rockroth Flashcards

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1
Q

What is one of the first things to think about when a patient presents with a headache?

A

Is it primary or secondary?

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2
Q

What are some causes of secondary headaches?

A
  1. SAH
  2. meningitis
  3. abnormal ICP - too low or too high can cause headache
  4. intracranial hematoma
  5. ischemic stroke
  6. tumor
  7. abscess
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3
Q

When a patient presents with a thunderclap headache what are some potential causes?

A
  1. aneurysmal rupture
  2. cerebral sinus thrombosis
  3. acute intracranial hypotension/CSF oligemia
  4. carotid artery dissection
  5. pituitary apoplexy
  6. unruptured aneurysm/expanded thrombosis
  7. sexual headache
  8. exertional headache
  9. crash migraine
  10. benign, idiopathic thunderclap headache
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4
Q

What is the most common cause of thunderclap headache?

A

Crash migraine - this is because migraines themselves are very common in our population.

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5
Q

What type of headache can acute intracranial hypotension cause?

A

Positional. It is worse when lying flat and better when upright.

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6
Q

Carotid artery dissections commonly occur at what level?

A

C1-C2

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7
Q

Primary sexual headaches have what characteristic that is good for prognosis?

A

If you suppress them for a period of time they tend to go away.

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8
Q

What is one reason why it is so important not to miss burst aneurysms when evaluating a thunderclap headache?

A

After bursting and bleeding, the risk of re-bleeds are high and the re-bleeds are also often very heavy bleeding.

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9
Q

Even in patients with a history of migraines you should do what?

A

Always do an exam, focus on BP, gait and especially on the eyes as this is where ICP can show up. Pay attention to history and if things are changing - ie. did their meds stop working. Just because they have migraines does not mean that they do not have other pathologies too.

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10
Q

What is the most common diagnosis for patients presenting with a chief complaint of headache?

A

Migraine. 94% of elective visits for chief complaint of headache end up with diagnosis of migraine. 10% of the population has migraines.

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11
Q

When would brain imaging not be indicated with a person presenting with a headache?

A

If the patient’s headache history meets ICHD criteria for a dx of migraine (or another primary headache disorder), there are no “red flags” (eg, “thunderclap” onset) and the neuro exam is normal, the yield of brain imaging or other testing is virtually nil.

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12
Q

What are the types of primary headaches?

A
  1. tension- type headache
  2. migraine
  3. cluster
  4. paroxysmal hemicrania
  5. hemicrania continua
  6. hypnic or alarm clock headache
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13
Q

What is at the top of the differential diagnosis if a patient presents with recurrent attacks of disabling headache?

A

Migraine.

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14
Q

Headaches comprise 2% of all ED visits but most end up being what?

A

Migraine - about 65%. Only about 5-10% are secondary headaches caused by an underlying pathology.

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15
Q

What are some things to look for in the ED to determine if a headache is secondary?

A
  1. acute onset
  2. age greater than 55
  3. occipito-nuchal location
  4. abnormal exam
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16
Q

What is the clinical definition/ICHD criteria for migraine?

A

5 or more unprovoked attacks, 4-72 hour in duration that prohibit or significantly inhibit routine actives. They also present with nausea and/or photophobia and sonophobia or both.

17
Q

Do migraines always present with nausea?

A

No. In fact they are variable and may not be preceded by visual aura and do not always involve severe, throbbing headache.

18
Q

What causes migraine?

A

Genetically induced neuronal hypersensitivity.

19
Q

Describe a pathway for migraine.

A
  1. vasodilation of dural blood vessels (where pain receptors in the brain are located)
  2. local release of CGRP - calcitonin gene related peptide
  3. activation of primary afferent neurons of the trigeminal nerve
  4. involvement of the trigeminal nucleus caudalis which acts as a sensory relay center
20
Q

What is another way to think about migraine?

A

a genetically and biologically polymorphous but clinically distinct disorder resulting from the interaction of genetic predisposition and environmental stimuli

21
Q

What does migraine therapy involve?

A

Acute or chronic stabilization of a biologically sensitized system. If sensitization is allowed to advance unchecked then stabilization will be increasingly difficult to attain.

22
Q

Why is taking too much medication for migraine a risk?

A

It can cause medication overuse headache and further help to sensitize the system to promote migraine.

23
Q

What types of receptors are located in the trigeminal nucleus caudal is?

A

1D and 1B 5HT receptors. These are an ideal target for migraine and headache therapy.

24
Q

Migraine is often comorbid with what condition?

A

Epilepsy.

25
Q

Cluster headaches also involve what structure?

A

The thalamus.

26
Q

Successful treatment of acute migraine is a function of what?

A

inherent efficacy of drug
stage of attack when drug is administered
drug’s T max - want this to be short so can treat migraine already underway
drug’s C max
drug’s ability to reach receptors
drug’s affinity for those receptors

27
Q

Ideally, therapy for acute migraine should be rapid and have no or minimal side effects. What are some drugs used to treat migraine?

A
  1. NSAIDs
  2. triptans
  3. ergotamines
  4. dihydroergotamines
  5. opiates/opioids
28
Q

Describe therapy for chronic migraines.

A
  1. want to achieve headache-free…or nearly so
  2. no or minimal side effects
  3. ability (eventually) to discontinue Rx
  4. examples - [beta blockers, TCAs, AEDs, Botox]
29
Q

What is the only FDA approved preventative treatment for chronic migraine?

A

Botox

Block 8 week 4 (5 decks)

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