Headaches Flashcards
Migraines
- Name comes from Greek hemi (_____) and kranion (head)
- Known for being _____lateral, but can be bilateral in about 40% of adults and 60% of children
- May occur with or without ____
- Typical duration of ____ to ____
- Typically a po_____, th_____, or p_______ pain
- Name comes from Greek hemi (half) and kranion (head)
- Known for being unilateral, but can be bilateral in about 40% of adults and 60% of children
- May occur with or without aura
- Typical duration of hours to days
- Typically a pounding, throbbing, or pulsating pain
Migraine Pathophysiology is complicated and includes
- Increased intracellular _______ – why (1) Rx helps
- Waves of __________ across the cerebral cortex
- (1) release à cause blood vessels to dilate which then causes the pain
- _____ cell activation (vasodilation and inflammation)
- Release of (3) by trigeminal neurons innervating the dural blood vessels – all neurotransmitters that increase pain perception. This causes these blood vessels to dilate and become inflamed.
- Although the brain _________ doesn’t have pain receptors, the CNS blood vessels do
- Overall, a lot of mechanisms that can cause Migraine which is why we have many medications to treat
- Increased intracellular calcium – why Ca channel blockers help
- Waves of depolarization across the cerebral cortex
- Nitric oxide (NO) release à cause blood vessels to dilate which then causes the pain
- Mast cell activation (vasodilation and inflammation)
- Release of calcitonin gene-related peptide (CGRP), substance P, and neurokinin A by trigeminal neurons innervating the dural blood vessels – all neurotransmitters that increase pain perception. This causes these blood vessels to dilate and become inflamed.
- Although the brain parenchyma doesn’t have pain receptors, the CNS blood vessels do
- Overall, a lot of mechanisms that can cause Migraine which is why we have many medications to treat
Migraine Without Aura
- At least __ attacks fulfilling criteria B through D
- Headache attacks lasting __ to ___ hours (untreated or unsuccessfully treated)
- Headache has at least 2 of the following characteristics:
- _______ location
2. ________ quality
- moderate or ______ pain intensity
- aggravation by or causing _______ of routine physical activity (eg, walking or climbing stairs)
- During headache at least 1 of the following:
- (1) and/or (1)
- (1) and (1)
- Not attributed to?
- At least 5 attacks fulfilling criteria B through D
- Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
- Headache has at least 2 of the following characteristics:
- unilateral location
2. pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
- During headache at least 1 of the following:
- nausea and/or vomiting
- photophobia and phonophobia
- Not attributed to another disorder
Migraine With Aura
- At least __ attacks fulfilling criteria B through D
- Aura consisting of at least one of the following, but no motor weakness
- Fully reversible ______ symptoms including positive features (eg, flickering lights, spots, or lines) and/or negative features (eg, loss of vision)
- Fully reversible _______ symptoms including positive features (eg, pins and needles) and/or negative features (eg, numbness)
- Fully reversible dysphasic ______ disturbance
- At least 2 of the following:
- _______ visual symptoms and/or ___lateral sensory symptoms
- At least 1 aura symptoms develops gradually over at least 5 minutes and/or different aura symptoms occur in succession over at least __ minutes
- Each symptom lasts at least __ minutes and no longer than __ minutes
- Headache fulfilling criteria B through D for “migraine without aura” (see previous slide) begins during the aura or follows aura within 60 minutes
- Not attributed to?
- At least 2 attacks fulfilling criteria B through D
- Aura consisting of at least one of the following, but no motor weakness
- Fully reversible visual symptoms including positive features (eg, flickering lights, spots, or lines) and/or negative features (eg, loss of vision)
- Fully reversible sensory symptoms including positive features (eg, pins and needles) and/or negative features (eg, numbness)
- Fully reversible dysphasic speech disturbance
- At least 2 of the following:
- Homonymous visual symptoms and/or unilateral sensory symptoms
- At least 1 aura symptoms develops gradually over at least 5 minutes and/or different aura symptoms occur in succession over at least 5 minutes
- Each symptom lasts at least 5 minutes and no longer than 60 minutes
- Headache fulfilling criteria B through D for “migraine without aura” (see previous slide) begins during the aura or follows aura within 60 minutes
- Not attributed to another disorder
Acute Treatment of Migraines
TEN SEE V
Triptans, Ergots, NSAIDs
Steroids, Esgic, Excedrin/Acetaminophen
Valproate IV
Triptans
- _____stay*
- ____ line/most common: ______ (Imitrex)*
- Mainstay*
- First line/most common: Sumitriptan (Imitrex)*
Triptans
MOA (4)
Causes constriction of blood vessels, inhibit neurons transmission, and enhance inhibitory pain pathways – which is why it can precipitate (2)– ideal patient is someone young and with no (1)
Selective Serotonin 5-hydroxytriptamine 1B and 1D agonists
- Constriction of intracranial vessels (5-HT 1B)
- Peripheral neuronal inhibition (5-HT-1D)
- Brainstem neuronal inhibition (5-HT-1D)
- Enhancement of descending inhibitory pain pathways
Causes constriction of blood vessels, inhibit neurons transmission, and enhance inhibitory pain pathways – which is why it can precipitate heart attack and stroke– ideal patient is someone young and with no CVD
Triptans Admin Considerations
- When should the patient take the medication?
- (1) formulations take effect within 20-60min. (2) work faster
- Depending on dose and type of triptan, often may repeat dose in __-__ hours if the first does doesn’t work well enough
- Patient should take at first sign of migraine and/or migraine aura
- Oral formulations take effect within 20-60min. SC and intranasal work faster
- Depending on dose and type of triptan, often may repeat dose in 2-4 hours if the first does doesn’t work well enough
Triptans CI
- Not for _____ use
- CI in patients with or risk factors of (1)
- Should not use within 2 weeks of an (1) Rx – can precipitate serotonin syndrome (although triptan use in patients on SSRIs may be safe)
- Not for daily use
- CI in patients with CAD or risk factors of CAD
- Should not use within 2 weeks of an MAOI – can precipitate serotonin syndrome (although triptan use in patients on SSRIs may be safe)
Ergots
MOA
Serotonin agonism, but less selective than triptans
Triptans more selective and constrict cerebral blood vessels, ergots constrict all vessels
Ergots Admin Considerations
Comes in what types of formulations?
Sublingual, intransal spray, IM, SC, IV
Ergots CI
(5)-(1)**
Vascular disease
HTN
Renal failure
Hepatic failure
Pregnancy* (ergots are class D) (whereas sumatriptan is pregnancy class C)
Ergots SE
_____ SE than triptans
(1) is common
More SE than triptans (less selective)
Nausea is common
NSAIDs
Rx such as (7)
Efficacy for acute migraine tx?
Aspirin, Ibuprofen, Naproxen, Indomethacin, Diclofenac, Ketoprofen, Ketorolac
Generally good efficacy for acute migraine tx
NSAIDs Admin Considerations
In the outpatient setting, NSAIDs are a _____ expensive alternative to triptans and ergots
In the inpatient/ER setting, Rx (1) 15-60mg IV or IM often works well for acute migraine tx
In the outpatient setting, NSAIDs are a less expensive alternative to triptans and ergots
In the inpatient/ER setting, ketorolac 15-60mg IV or IM often works well for acute migraine tx
Other Analgesics
- A_______
- (1) Combination of acetaminophen, butalbital, and caffeine
- (1) Combination of acetaminophen, aspirin, caffeine
- Acetaminophen
- Esgic
- Excedrin
Acetaminophen Admin Consideration
Acetaminophen vs. other NSAIDs efficacy?
Acetaminophen often less effective than NSAIDs
Other Analgesics SE
All of these can lead to ______ (medication overuse) headaches- causes a vicious cycle, need to get off these meds
The ________ (can cause barbiturate w/drawal when getting off) in Esgic can be s______
All of these can lead to rebound (medication overuse) headaches- causes a vicious cycle, need to get off these meds
The butalbital (can cause barbiturate w/drawal when getting off) in Esgic can be sedating
Steroids
Rx (1) Dose Pack
Used for migraines that?
Medrol (Methylprednisolone) Dose Pack
Used for migraines that just won’t go away
Steroids Admin Considerations
- Dosing
- Day 1: __mg
- Day 2: __mg
- Day 3: __mg
- Day 4: __mg
- Day 5: __mg
- Day 6: __mg
- A large (but non-blinded and non-randomized) study showed benefit to a short course of oral prednisone for (1) in medication overuse HA
- Dosing
- Day 1: 24mg
- Day 2: 20mg
- Day 3: 16mg
- Day 4: 12mg
- Day 5: 8mg
- Day 6: 4mg
- A large (but non-blinded and non-randomized) study showed benefit to a short course of oral prednisone for analgesic detoxification in medication overuse HA
- Pts were instructed to gradually taper off of their analgesic over a 7d period.
- Days 1-2: pred 60mg/day, Days 3-4: pred 40mg/day, Days 5-6: pred 60mg/day
- Ranitidine 300mg/day for all 6 days of steroids
- Start of the headache prophylactic medication on day 7
IV Valproate
_____ opinions/evidence. Some studies have shown IV valproate to be more effective than DHE plus metoclopramide for acute migraine, while other studies have not shown this.
HA relief has been shown to take effect anywhere from __ hour to ___ hours after infusion
Mixed opinions/evidence. Some studies have shown IV valproate to be more effective than DHE (ergotamine) plus metoclopramide for acute migraine, while other studies have not shown this.
HA relief has been shown to take effect anywhere from one hour to 24 hours after infusion
IV Valproate Admin Considerations
Dosing =
Typically used for (2) but used commonly in _______ settings/as _____ medication
500mg IV once (Diluted in 5mL of NS, given over 15-30min)
Typically a antiepileptic/mood stabilizer but used commonly in emergency settings/as rescue medication
IV Valproate
SE
Generally well tolerated
However has many SE (decreased bone density (fracture risk), liver dysfunction, etc)
Acute Treatment of Migraines
First line is usually at (1) - but if the patient has CAD then use (2)
Triptan -> Analgesics/Esgic
Migraine Prophylaxis Treatment
Gi_VVV_ TPA Before _C_risis
Gabapentin
Verapamil
Venlafaxine XR
Valproate
Topiramate (Topamax)
Propranolol
Amitriptyline
Botox
CGRP Inhibitors (Erenumab (Aimovag), Galcanezumab (Emgality))
Topiramate (Topamax) Dosing
=
Target dose =
Start with 25mg once daily, and increase weekly by 25 mg/day up to a target dose of 50mg twice a day
Topiramate SE
(4) - (1)*
Weight loss – avoid in thin pts
Word finding difficulties
Paresthesias
Kidney stones*
Topiramate Efficacy
Efficacy?
Often can help with other comorbidities (3)
Highly efficacious at preventing migraines
- Obesity
- Epilepsty
- Essential tremor
Propranolol Dosing
(1)
- Start with 80 mg/day divided every 6-8 hours.
- Increase by 20-40 mg/dose every 3-4 weeks to effective dose.
- Maximum dose for migraine prophylaxis is 240 mg/day given in divided doses every 6-8 hours.
(1)
- Start with 80 mg once daily.
- Maximum dose for migraine prophylaxis is 240 mg once daily
Regular Release
- Start with 80 mg/day divided every 6-8 hours.
- Increase by 20-40 mg/dose every 3-4 weeks to effective dose.
- Maximum dose for migraine prophylaxis is 240 mg/day given in divided doses every 6-8 hours.
Long Acting Formulation
- Start with 80 mg once daily.
- Maximum dose for migraine prophylaxis is 240 mg once daily
Propranolol
Efficacy?
Vs other beta blockers?
Highly efficacious at preventing migraines, and propranolol is more efficacious than other beta blockers
If pt has migraines and already on a BB for heart disease – try to switch to propranolol
Amitriptyline
MOA
Blocks neuronal uptake of serotonin and norepinephrine
Amitriptyline Dosing
- Start with 10-25 at (1) time bc ______, and increase (if needed and tolerated) gradually up to 150mg
- If 10mg QHS is not tolerated, there are reports of patients experiencing relief at doses as small as __-__mg QHS
- Start with 10-25 at QHS time bc sedating, and increase (if needed and tolerated) gradually up to 150mg
- If 10mg QHS is not tolerated, there are reports of patients experiencing relief at doses as small as 2.5-5mg QHS
Amitriptyline
SE (1)*
Sedating*
AmiTRIPtyline (you’re sedated so you trip)
Amitriptyline Efficacy
Also good for treating (3)-(1)*
- comorbid insomnia* (which can further improve migraine control, as sleep deprivation often triggers migraines)
- neuropathy
- fibromyalgia
Gabapentin
MOA
Mechanism of pain control not well understood, but may relate to binding to voltage dependent Ca channels, thereby inhibiting the release of excitatory neurotransmitters
Gabapentin Dosing
Start w _____mg/day and increase (if needed and tolerated) gradually, up to 2400mg/day
(1) reduces the chance of (2)
Start w 300mg/day and increase (if needed and tolerated) gradually, up to 2400mg/day
Gradual titration reduces the chance of dizziness and somnolence
Gabapentin
SE (1)
Peripheral Edema (maybe) “ive seen it once”
Gabapentin Efficacy
Good choice for patients with impaired? Why?
Good choice for patients with impaired liver function, cleared by kidneys with no hepatic metabolism
Verapamil MOA and Dosing
MOA
Typical target dose?
Antihypertensive and Ca channel blocker
120-480mg/day divided Q6-12hrs
Verapamil
SE (5)-(3)*
Dizziness
Hypotension
Constipation
Cardiac conduction blocks (heart blocks)
CYP3A inhibition may cause drug-drug interactions
Venlafaxine XR
MOA
Blocks reuptake of serotonin and norepinephrine (SNRI)
Venlafaxine XR Dosing
Very ____ results seen with __mg daily, and ___mg daily
___mg more effective than __mg daily
Start with ____mg daily and then increase
Very good results seen with 75mg daily, and 150mg daily
150mg more effective than 75mg daily
Start with 37.5mg daily and then increase
Valproate Dosing
Regular release
- Start with ____mg 2x/day
- ______ (if needed and tolerated, may increase after one week to 1000mg once daily)
Regular release
- Start with 250mg 2x/day
- Titrate (if needed and tolerated, may increase after one week to 1000mg once daily)
Valproate Efficacy
______ efficacious at preventing migraines, but has many _______ (t________, ____ density loss, weight _____, _____cytopenia, ______toxicity, possible acceleration of (1) disease, (1) enzyme inhibition causing ___-___ interactions etc.) – therefore we don’t really use it for HA, more so for seizures (antiquated)
Highly efficacious at preventing migraines, but has many drawbacks (teratogenicity, bone density loss, weight gain, thrombocytopenia, hepatotoxicity, possible acceleration of carotid artery disease, liver enzyme inhibition causing drug-drug interactions etc.) – therefore we don’t really use it for HA, more so for seizures (antiquated)
Valproate Other Uses
Can also treat other comorbidities (2)
But Rx (1) also treats the same disorders w/o bad SE
Bipolar disorder, Epilepsy
Lamotrigine also treats the same disorders w/o bad SE
Botulinum Toxin (Botox)
Now FDA approved for migrain prevention
Typically repeated every ___ months
Efficacy? (PREEMPT trial) However?
Q3 months
Highly efficacious However recently, medicare has been pushing back on approving it for migraines bc new CGRP inhibitors (below) are the new tx for prevention of migraines
CGRP Inhibitors
(2)
Also worth mentioning why?
Dosing frequency?
Efficacy? Only drawback is?
Erenumab (Aimovag), Galcanezumab (Emgality)
Newest medication on the block
- Injections once a month*
- Works very very well, only drawback is before insurance companies will approve will show that pt has been trialed on many other meds first*
Menstrual Migraines
Caused by?
What is priority?
- Thought to be caused by the sudden drop of estrogen levels at the beginning of the menstrual cycle (estrogen withdrawal)
- Can be treated acutely (triptans, NSAIDs, etc), but the predictable timing of these headaches provides a unique opportunity for successful PREVENTION, which should be the priority.
Menstrual Migraine Prevention
(4)
Triptans
NSAIDs
Magnesium
Hormonal Prophylaxis
Triptans
- ______triptan 2.5mg daily or BID (BID shown to be more effective) for __ days_, starting __days before expected onset of headache_
- _____triptan 1 mg BID for __ days, starting __ days before anticipated menses
- ______triptan (PO) 2.5 mg BID or TID (TID shown to be more effective) for __ days, starting __ days before anticipated menses
So even though used for treatment can be used for prevention if used for a _____ period of time
- Frovatriptan 2.5mg daily or BID (BID shown to be more effective) for 6 days_, starting 2 days before expected onset of headache_
- Naratriptan 1 mg BID for 5 days, starting 2 days before anticipated menses
- Zolmitriptan (PO) 2.5 mg BID or TID (TID shown to be more effective) for 7 days, starting 2 days before anticipated menses
So even though used for treatment can be used for prevention if used for a short period of time
NSAIDs
(1) Rx (550 mg BID for 13 days, starting 7 days before onset of menses) shown to be effective, BUT THIS IS A ____ DOSE AND A _____ DURATION, WITH POTENTIAL FOR ADVERSE EFFECTS SUCH AS ___.
Naproxen (550 mg BID for 13 days, starting 7 days before onset of menses) shown to be effective, BUT THIS IS A HIGH DOSE AND A LONG DURATION, WITH POTENTIAL FOR ADVERSE EFFECTS SUCH AS GI.
Magnesium
- Based on the idea that migraine patients may have (1) magnesium levels despite normal serum magnesium levels.
- One study found magnesium pyrrolidone carboxylic acid 120mg PO TID (starting on the 15th day of the cycle and continuing until the next menses) to be effective.
- Class __ during pregnancy “we give magnesium like _____ during pregnancy for migraine prevention”
- Why it works so well?
- Based on the idea that migraine patients may have low intracellular magnesium levels despite normal serum magnesium levels.
- One study found magnesium pyrrolidone carboxylic acid 120mg PO TID (starting on the 15th day of the cycle and continuing until the next menses) to be effective.
- Class B during pregnancy “we give magnesium like candy during pregnancy for migraine prevention”
- Why it works so well bc it competes with Ca, knocks Ca off and prevents the neuron from firing
Hormonal Prophylaxis
To prevent abrupt?
- Transdermal estradiol gel
- Transcutaneous estradiol patches
- Extended-cycle estrogen-progestin contraceptives
- Cyclic estrogen-progestin contraception with supplemental estrogen
First thing to do is ______ the contraceptive that the pt is already on
prevents abrupt decline of estrogen levels that occur at the beginning of the menstrual cycle
- Transdermal estradiol gel
- Transcutaneous estradiol patches
- Extended-cycle estrogen-progestin contraceptives
- Cyclic estrogen-progestin contraception with supplemental estrogen
First thing to do is switch the contraceptive that the pt is already on
Tension Headache Classification Criteria
- Pretty much _____ intense, always there, th_____ d____ ache, but ____ go about their day*
- Tension headache pts usually disappointed when they leave bc there’s not really a good med to fix it acutely besides nsaids and ice*
- Pretty much less intense, always there, throbbing dull ache, but can go about their day*
- Tension headache pts usually disappointed when they leave bc there’s not really a good med to fix it acutely besides nsaids and ice*
Acute Treatment of Tension Headache
(3)
Simple Analgesics
Caffeine Combinations
Triptans
Simple Analgesics
- Ac_______ 1000mg
- As_____ 500mg
- I______ 200-800mg
- Ke_____ 12.5-50mg
- Na______ 375-550mg
- Dic_______ 12.5-100mg
Studies comparing have these to each other shown widely ______ results
- Acetaminophen 1000mg
- Aspirin 500mg
- Ibuprofen 200-800mg
- Ketoprofen 12.5-50mg
- Naproxen 375-550mg
- Diclofenac 12.5-100mg
Studies comparing have these to each other shown widely variable results
Caffeine Combinations
(1) + Caffeine
(1) + Caffeine
(1) + (1) + Caffeine
Aspirin 1000mg and Caffeine 64mg
Ibuprofen 400mg and Caffeine 200mg
Aspirin 500mg, Acetaminophen 400mg, and Caffeine 100mg
Triptans
Evidence on efficacy for tension headaches?
One study showed triptans to work for tension headache in migraine patients, but this raises the question of whether these were really tension headaches as opposed to migraine headaches
NOT RECOMMENDED for Tension HA
(3)
All have the abuse potential and increase the risk of medication overuse for headaches
Muscle Relaxants
Barbiturates (Butalbital, Fiorinal)
Opiates
Tension Headache Prophylaxis
(2) Rx
(2) Non-Rx
Amitriptyline, SNRI’s (mirtazaine, venlafaxine)
Non-pharm: Relaxation techniques, Cognitive behavioral therapy
Amitriptyline for Tension HA Prophylaxis
Start with __-__mg at (1), and increase (if needed and tolerated) gradually up to ____mg
Start with 10-25mg QHS, and increase (if needed and tolerated) gradually up to 150mg QHS
SNRI’s
What about SSRIs?
SNRIs have shown benefit
- (1) 30mg/day
- (1) 150mg/day
SSRI’s have not shown to be beneficial
SNRI’s have shown benefit
- Mirtazapine 30mg/day
- Venlafaxine XR 150mg/day
Other Headache Types Worth Mentioning
(3)
Occipital Neuralgia
Cluster Headaches
Hemicrania continua
Occipital Neuralgia
Diagnostic Test =
Treatment =
Occipital nerve block – diagnostic test - if the HA go away for a few days when blocked (numbed)/ can also be tested by reproducing pain radiation pattern by pressing on occipital notch
Radiofrequency ablation – not an important nerve so it can be killed, just controls sensation to the scalp
Cluster Headaches
Prevalence =
Symptoms =
More frequently seen in what population?
Treatment (2)
Rare
VERY SEVERE, comes in clusters, usually with other sx of the eye, usually unilateral
More frequent in young males
- Sumatriptan 6mg SC or 20mg intranasal
- Inhaled O2 (100% 12L/min, delivered by face mask, for 15 min at the start of an attack of cluster headache)
Hemicrania Continua
IHC criteria require at least a 3 months of constant pain but may have fluctuating severity
Unilateral, with ipsilateral _________ symptoms (ie: rhinorrhea, lacrimation, conjunctival injection, nasal congestion, ptosis, miosis) but ____ prominent than in cluster headache
IHC criteria require a + response to (1) Rx (suggested trial)
- 50mg BID x3d then
- 50mg TID x3d then
- 50mg QID x3d
IHC criteria require at least a 3 months of constant pain but may have fluctuating severity
Unilateral, with ipsilateral autonomic symptoms (ie: rhinorrhea, lacrimation, conjunctival injection, nasal congestion, ptosis, miosis) but less prominent than in cluster headache
IHC criteria require a + response to indomethacin (suggested indomethacin trial)
- 50mg BID x3d then
- 50mg TID x3d then
- 50mg QID x3d
Headaches in Pregnancy
- Migraine headaches often improve during pregnancy, why?
- Medication choices are significantly _______
- Acetaminophen is pregnancy class __
- (1) is sometimes used for migraines (class B, used the most, Rx (1) has less diarrhea than (1))
- Pregnancy is the time for optimization of ___-pharm measures
- Pregnancy class C medications sometimes used in _____ circumstances
- Breast-_____ issues
- Increased and more steady estrogen levels (opposite of menstrual HA, estrogen is protective aganst migraines)
- limited
- Tylenol = Class B
- Magnesium - Magnesium Oxide 400mg daily has less diarrhea than mag sulfate
- extreme
- breast-feeding issues
Dangerous Headaches
(3)
Temporal Arteritis
Pseudotumor Cerebri
Thunderclap Headache
Temporal Arteritis Features
- age older than ___ , _____ onset HA
- tender t_____(s)
- ____ claudication
- weight _____, malaise, fa_____, fe____, night _____
- poly______ rheumatica
- v_____ problems
- CHECK* (2)
- age older than 50 , new onset HA
- tender temple(s)
- jaw claudication
- weight loss, malaise, fatigue, fever, night sweats
- polymyalgia rheumatica
- vision problems
- elevated ESR (sed rate), elevated CRP CHECK*
Temporal Arteritis Dg/Tx
- Diagnosis =
- Treatment =
- Diagnosis = Temporal artery biopsy (DO NOT miss this dg, can cause permanent blindness)
- Treatment = Steroids (start tx before biopsy results, send to ophthalmologist)
Pseudotumor Cerebri Features
- Also called (1)
- Increased _____ pressure causing headache and can cause vision problems and visual field problems
- Strongly associated with ______
- CN 6 palsy possible =
- (2) if not sufficiently treated
- Over_____ pt with HA
- Also called “idiopathic intracranial hypertension”
- Increased CSF pressure causing headache and can cause vision problems and visual field problems
- Strongly associated with obesity
- CN 6 palsy possible = abducens: responsible for EOM
- Permanent vision problems or blindness if not sufficiently treated
- Overweight pt with HA
Pseudotumor Cerebri Diagnosis
- Opthalmoscopic exam may see (1)
- Visual _____ and visual ______
- Diagnostic Test =
- Opthalmoscopic exam (papilledema) optic disc margins less crisp
- Visual fields and visual acuity
- LP (elevated CSF opening pressure) – spinal tap right away
Pseudotumor Cerebri Treatment
- _____ removal
- Weight ____
- (1) Rx
- Optic nerve fenestration
- (1) placement
- CSF removal
- Weight loss
- Carbonic anhydrase inhibitors
- Optic nerve fenestration
- VP shunt placement
Thunderclap Headache
Described as?
Differential Diagnosis
- Vascular =
- Non Vascular =
- Primary headache disorders =
“Worst headache of my life”
- Subarachnoid hemorrhage, Cerebral venous sinus thrombosis, carotid or vertebral artery dissection, reversible cerebral vasoconstriction syndrome, acute hypertensive crisis, ischemic stroke, pituitary apoplexy
- Spontaneous csf leak, colloid cyst of the third ventricle
- Primary cough, exertional, sexual headache
Thunderclap Headache
Work up =
CT head, LP, MRI, MRA, CTA
Case #1
- 42 –year-old female with 3-year history of R-sided headaches
- pulsating
- lasting 4-24 apiece, occurring 2-3 times a week
- associated with nausea, vomiting, phonophobia, photophobia.
- debilitating
- OTC analgesics only help slightly.
- PMHx of kidney stones, asthma, and tubal ligation.
- What type of headaches are these?
- How would you treat them?
Migraines
- NO Topiramate (kidney stones)
- NO Propranolol (asthma)
- Amitriptyline
- Gabapentin
- Verapamil
- Venlafaxine XR
- Valproate
- Botox
Case #2
- 51 –year-old male with 2-year history of bifrontal headaches “bandlike sensation)
- tightening/pressure sensation
- lasting 30 minutes to an entire day, occurring 6-7 times a month
- no photophobia, phonophobia, nausea, or vomiting
- pain is 6/10
- OTC analgesics only help slightly.
- PMHx of insomnia.
- What type of headaches are these?
- How would you treat them?
Tension headaches
- Tension HA Prophylaxis
- Amitriptyline (good for insomnia, and also for superimposed migraines)
- Mirtazapine
- Venlafaxine XR (good for superimposed migraines)
- Nonpharmacologic (cognitive behavioral therapy, relaxation techniques)
**** Each of these may also help with coexisting depression
