Headaches

Question 1

Cluster Headache

Answer 1

• Definition:
  
  • <1% of HAs; more common in young/middle aged males
• Triggers:
  
  • Night (sleep), alcohol, stress
• Usually have 1-2 cluster periods per year (each lasting weeks to months)
• S/sxs:
  
  • severe unilateral periorbital pain, <2 hours with spontaneous remission, sharp, excruciating, searing or piercing pain
  • *Repetitive Clusters of pain
• PE:
  
  • Ipsilateral Dysautonomia:
    
    • -Ptosis (droopy eyelid)
    • -Lacrimation
    • -Conjunctival injection
    • -Rhinorrhea
    • -Nasal Congestion
    • -Restlessness
• Dx:
  
  • Clinical Dx
  • MRI: to r/o lesion
• Tx:
  
  • “Suicide Headache” because so severe
  • 100 % oxygen at 12-15L/min for 15-20 min via non-rebreather → provides relief within 15 minutes
  • -Can give in combo with sumatriptan 6mg SQ , can repeat in hour PRN(Triptan; if possible)
  • For long-term prophylaxis = verapamil, lithium, topiramate, Divalproex, or a combo
  • Anti-migraine medications: Sumatriptan, Ergotamine/dihydroergotamine (MOA: 5HT-1b/d receptor agonists)

Question 2

Red Flag Sxs in a Migraine/HA

Answer 2

• New onset in a pt ≥ 50 years of age
• -Change in established HA pattern
• -Atypical pattern
• -Unremitting/progressive neurologic sxs
• -Prolonged or bizarre aura

Question 3

Migraine: Definition, pathophys, risks, epidemiology, s/sxs

Answer 3

• Chronic Migraine:
  
  • 15+ days/month x 3 months
• Pathophys:
  
  • trigeminal nerve releases neuropeptides (CGRP)→ dural inflammation & pain that is transmitted by the same nerve;aura is an abnormal yet benign electric wave that travels slowly across the cortex to cause sxs
• Risks:
  
  • women (3x), teens, genetics, obesity, frequent HAs, head injury, med overuse (>10day/month), stress, sleep apneas
• Epidemiology:
  
  • 12% of HAs but more likely to be seen in clinic than tension-type because more severe sxs; 1-4 per month on average
• S/sxs:
  
  • Headache: unilateral, throbbing, moderate-severe, increased with exertion, 4-72 Hr duration
  • N/V
  • -Without Aura = most common 80%
  • -photophobia
  • -Phonophobia

Question 4

Migraine: Dx & Tx

Answer 4

• Dx:
  
  • Diagnosis is clinical
  • **If worrisome features:
    
    • -MRI
    • -Labs
    • -Lumbar Puncture
• Tx:
  
  • Holistic approach: regular sleep, physical activities, & meals; HA diaries, stress management
  • -Mild to moderate attacks:
    
    • → NSAIDs such as ibuprofen, naproxen, and diclofenac are generally inexpensive and effective in up to 60% of cases
    • →Excedrin Migraine (aspirin 500 mg-acetaminophen 500 mg-Caffeine 130 mg) combo is an inexpensive and FDA-approved tx for an acute migraine
  • More Severe Attacks:
    
    • Abortive: Triptans Sumatriptan 25-100 mg PO x1, may repeat dose x1 after 2 hours; 1-6mg SC x1 , may repeat dose after 1 hour. (do not use in Ischemic Heart disease), ergotamine/dihydroergotamine (do not use in pregnant women)
    • -Prophylaxis: first line agents = Divalproex, topiramate (generalized anti-seizure meds), propranolol, metoprolol, & timolol

Question 5

Migraine Attack Complex

Answer 5

Prodromes: craving, yawn, fluid retention, heightened perception

• Aura: focal neurologic sxs < 60min (ex. Flashes, tingling, vertigo)
• Headache: see sxs under Migraine flashcard
• Resolution: tired, feeling high or low, diuresis, limited food tolerance

Question 6

Tension Headache

Answer 6

• Risks:
  
  • stress, sleep deprivation, eye strain
• Epidemiology:
  
  • 38% of headaches (most common) but less likely to be seen in clinic than migraine
• s/sxs:
  
  • Headache: diffuse, dull, “band-like”, non-throbbing
  • No accompanying symptoms like N/V, and photophobia/phonia
  • Bilateral, squeezing sensation, mild to moderate with dull pain
• PE:
  
  • normal
• Dx:
  
  • Dx is based on characteristic sxs and a normal physical exam → normal Neuro
• Tx:
  
  • 1st line - NSAIDs: ibuprofen (400mg PO q 4-6hrs PRN) , naproxen (250-500mg PO q 12 hours, max dose: 1250mg)
  • 2nd line: caffeine-containing agents (Excedrin alone can be very effective)
  • Opiates should be avoided
  • Prevention: Tricyclic antidepressants (TCAs) (particularly amitriptyline - 10-100mg PO qhs (at bed time) )

Question 7

Trigeminal Neuralgia

Answer 7

• Pathophys:
  
  • compression of the trigeminal nerve (CN V) root by the superior cerebral artery or vein. Also known as tic douloureux
• Epidemiology:
  
  • Uncommon; most common in middle-aged women
• Etiology:
  
  • compression of CN V by a blood vessel
• S/sxs:
  
  • Facial Pain: brief (<1-2 minutes), episodicstabbing, lancinating
  • Distribution of trigeminal branches (lips, gums, cheek, chin)
  • Triggered by touching, chewing, brushing teeth
• PE:
  
  • Light palpation of “trigger zones” may trigger attack (face, lips, tongue)
  • Absence of signs of sensory loss of exam
• Dx:
  
  • Clinical Dx
• Tx:
  
  • Antiepileptic drugs: carbamazepine 100mg PO QD (maintenance dose is 200mg QID), oxcarbazepine, lamotrigine, phenytoin, baclofen
  • Surgery: microvascular decompression to relieve pressure, gamma knife radiosurgery

Question 8

Idiopathic Intracranial HTN

Answer 8

• Definition:
  
  • idiopathic increased intracranial (CSF) pressure with no clear cause evidenced on neuroimaging
• Pseudotumor cerebri: mimics a brain tumor with N/V & visual disturbances but isn’t focal
• Risks:
  
  • Obesity, acne treatment (Vit A), pregnant women
• S/sxs:
  
  • HA: pulsatile, worse with straining
  • Pulsatile tinnitus
  • Transient visual Obscurities
  • -N/V
• PE:
  
  • Papilledema: usually bilateral & symmetric
  • No focal deficit (b/c there is no mass)
• Dx:
  
  • CT scan: to r/o intracranial mass
  • LP: increased CSF pressure & otherwise normal CSF
• Tx:
  
  • Weight loss
  • -Diuretics: Acetazolamide

Question 9

Intracranial Neoplasms (General Info)

Answer 9

• Headache is heralding symptom in ⅓ of all cases
• Hints:
  
  • -Focal Headache: worse when decubitus or early AM, lingers or worsens
  • Pulsatile tinnitus
  • Transient Visual Obscuration
  • N/V

Question 10

Subarachnoid Hemorrhage

Answer 10

• Definition:
  
  • bleeding between the arachnoid membranes & the pia mater (The meninges PAD the brain; skull, dura, arachnoid, pia → brain )
• S/sxs:
  
  • -Thunderclap headache: brutally severe, “Worst of life”
  • -N/V
  • -Decreased LOC
  • -Neck stiffness
  • -Sentinel HA
• PE:
  
  • Meningeal Signs: Nuchal rigidity (neck stiffness)
  • -+/- deficits
• Dx:
  
  • -CT scan without contrast:initial study of choice, subarachnoid bleeding
  • -Lumbar Puncture: if CT negative & no papilledema, xanthochromia (presence of bili in CSF)
  • -Angiography: performed after confirmed SAH to identify bleeding source
• Tx:
  
  • Up to 10% mortality & high morbidity
  • -Surgery
  • -Admit to ICU to monitor vasospasms