Headaches

Question 1

ED Refer Headaches

Answer 1

Any abrupt-onset “thunderclap” headaches, head injury. or headache with neuro abnormalities

Question 2

Secondary Headaches

Answer 2

Less common and result of underlying disease process such as aneurysm, tumor, bleeding, temporal arteritis, meningitis

Question 3

Primary Headaches

Answer 3

Common, not symptomatic of underlying disease

Migraines, tension-headaches, trigeminal autonomic cephalagias, rebound headache

Question 4

Migraine Types

Answer 4

Without aura (more common)
With aure

Question 5

Migraine Presenation

Answer 5

ipsilateral headache pain - pounding or throbbing
aggravated by physical activity
episodic
May have N/V, photophobia, phonobia
Prefer dark quiet room
Preceding aura such as jagged lines in vision, spots, lights, tingling, others

Question 6

Aura criteria

Answer 6

Visual and somatosensory disturbances last at least 5 minutes but less than 60 minutes and the patient experiences a migraine

Question 7

Tension Headache

Answer 7

Feeling of tight band around head
No N/V
Nagging headache that occurs less than 15 days per month, present most of the day
Chronic = last more than 15 days

Question 8

Triggers for Migraines

Answer 8

Individual to patient

Common - medication overuse, obesity, stress, weather, foods, alcohol, skipping a meal, hormones

Question 9

Trigeminal Autonomic Cephalalgias (TAC)

Answer 9

group of headache syndromes that are differentiated by duration and frequency but all have unilateral autonomic symptoms.
Cluster headaches

Question 10

TAC Presentation

Answer 10

Usually awakes from sleep with severe unilateral retro-orbital pain
Maximum pain in 15 minutes, lasta about 90 minutes
Occurs several times per day
Lacrimation, rhinorrhea, restlessness can occur

Question 11

Headache Assessment

Answer 11

Medication profile
History and Exam including fundoscopic / pupils, neck muscles, temporal artery exam, gait
CBC, CRP, ESR, Thyrod panel to rule out other issues
Consider CT

Question 12

Dangerous Headache Signs

Answer 12

Systemic symptoms, Neuro signs, Acute onset, Older patient, previous headache history, decreased reflexes

“Worst headache ever” is a significant red flag

Question 13

Headache Management

Answer 13

Lifestyle / Behavior changes
Headache journal to identify triggers
Medications

Question 14

Preventive Therapy

Answer 14

More than 4 per month or attacks refractory to medicine
Anticonvulsants - depakote, gabapentin, toprimate
CCBs for patient with Raynaud or hypertension - amlodipine or diltiazem
Beta blockers - propranolol
TCAs / SSRI if sleep or chronic pain related

Question 15

Abortive Therapy

Answer 15

patient with a severe migraine or cluster attack that peaks to full intensity within 15 minutes will most likely benefit from parenteral or nasal therapy rather than oral medication

Acetaminophen or Aspirin / NSAIDs should be tried first as abortive
Ergot derivatives but high overuse and rebound risks
Triptans - each brand is slightly different so try different ones
CCBs - verapamil for cluster headaches - lithium may be used but bigger risk
Oxygen may be effective for cluster (75%)
Muscle relaxers for tension headaches may work

More than 4 uses of abortives in a month = preventive therapy needed and refer

Question 16

What is an effective abortive therapy for a majority of patients with cluster headaches?

Oxygen
Lithium
NSAIDs
Verapamil

Answer 16

Oxygen works as abortive therapy for cluster headaches in 75% of patients and should be inhaled at the start of an attack.

Question 17

What is an effective abortive therapy for patients with long-lasting migraine headaches?

Frovatriptan

Rizatriptan

Sumatriptan

Eletriptan

Answer 17

Frovatriptan and naratriptan are the preferred abortive migraine treatments for long-lasting migraine headache sufferers.