Headaches Flashcards
Primary HA v Secondary HA
Primary HA: asring from a HA
- tension
- migraines
- idopathic stabbing
- exertional
- cluster
Secondary HA: arising from another issue
- systemic infection
- head injury
- vascualr disorder
- SAH
- tumor
Thunderclap Headache
- most concerning ddx
- other ddx for the “thunderclap” HA
most concerning ddx is a subarachnoid hemorrhage
Other DDX.
Hemorrhagic in nature:
- SAH or other intercranial hemorhage
- sintinel aneurysmal headache
- spontaneous intercranial hemorrhage
Vascual
- coritd or vertbrobasilar dissection
- reversible cerebral vasoconstrction syndrome
- cerebral vein thrombosis
- posterior reversible enceph.
other causes
-coital HA, valsalva assocaited, spontaneous intercranial hypotension, hydrocephlul, pitutiray apoplexy, acute angle closure glacoma
what are some symptoms that may clue you into a high risk serious cause of a HA
Onset that is
- sudden
- tramatic
- exertional (when you exert force gets worse: think ICP)
Associated Symptoms….
- AMS
- seiure
- fever
- neurologic changes
- visual changes
Medication use of..
- anticoags/antiplatelets
- recent abx use
- immunosuppressants
Hisotyr of…
- no prior headache
- a change in the quality of HA
- progressive worsening voer weeks/months
Associated Conditions…
- pregnant up to 6 weeks pp
- SLE
- Behcets disease
- vasculitis
- sarcoidosis
- cancer
PE
- AMS
- Fever
- neck stiffness
- papilledema
- focal neurologic signs
Headache Evaluation
things to ask and think about associated reasons for the HA
changes in pattern, frequency, quality and intensity of the HA = you need to dig deeper
- fever? think infection (meningitis/encephalitis, systemic infection)
- HIV status of pt? if CD4 < 200 = risk of CNS toxo or lymphoma
Pst Mhx. (for secondary HA causes)
- immunocomp.
- malignancy?
- trauma?
- pregnant?
Medications
- OCPs
- analgesias
- rx. migraines
- all these can cause med. overuse HA
- abx.
- immunosupressants
- these can increase risk of infection
- ASA
- antiplatlets
- coumadin/DOACS
- these can inc. bleed risk
History of HA?
- type?
- is this same/different
Substance use
- amphetamines, cocaine = increase risk of IC hemorrhage
Alcohol Abuse
- risk for IC bleed
HA Physical Exam Findings that might point toward something
Vitals
Fever
- persistant HA after normalization of a fever = suggests infection in cranium
Classic triad: HA + fever, neck stiffness & AMS = MENINGITIS
BP
- severe HTN = HA & AMS – think hypertensive crisis and encephalopathy syndrome
assess head and neck
- meningismus = think infection/hemorrhage
- ENT = look for infection source
- papate temporal: temporal arteritis
assess eye
- visual acuity
- pupillary exam: for glaucoma
- photophobia
- cornea steamy, haxzy? = acute angle glacoma
- Funduscopic Exam = papilledema (increased ICP) * hemorrhages with hypertensive crisis
- do baseline neuro exam
- **kernig’s sign = knee unable to extend due to increase ICP
- Brudzinskis sign = flex hips when you flex neck due to meningitis and inc. ICP**
HA Red Flags- reason for
SNOOP-10
S = systemic symptoms (fever, rahs, WL), seizure
N = neoplasm (known), neuro defict
O = onset is abrupt
O = onsent after 50
P x 10
P = painful eyes and automonic features
P = painkiller use/overuse
P = papilledema
P = pathology of immune system
P = Pattern: new HA, or change
P = Position: exacerbates or relieves
P = posttraumatic onset
P = pregnancy
P = porgressive/atypical
Diagnosic Testing for HA
Labs
Imagings
Labs (if you see necessary)
- CBC/Blood culutres
- CBC/ESR/CRP
- test for preeclampsia (BP + protein in urine)
Imaging
- if pt. presents with typical HA and symptoms and Hx. and neuro exam normal: no imaging is needed
- if neede: NON CONTRAST CT is most sensitive for hemorrhage
- remeber avoid contrast in pregnant
when to get noncontrast CT
- trauma
- thunderclap HA
- new HA + deficts on neuro exam or papilledema
- chronic HA + change sin physical features
- before an LP (to avoid herination if possible)
- age > 50 with new onset HA
the role of a Lumbar Puncture
LP = Lumbar Puncture
- not needed for every HA case
- but can be used as a diagnostic tool and therapeduic for some to find = meningitins, subarach hemorrage, carcenoumaous meningitis
LP should be preformed in teh LLD position to determine opening pressure
CT before LP in some cases (because if ICP is elevated that can lead to herniation of the brain) for….
- altered mentation (GCS < 11)
- focal neurologic signs
- papilledema
- seizure within 1 week
- impaired cellular immunity
Tension Type HA
- etiology
- symptoms
Etiology
- a primary HA
- described as a band-like HA with chronic or episodic syndrome
- pathophsy. = unclear; pain modualation disorder, possible muscle contration
- not due to psychological tension
Symptoms
- gradual onset
- provoked by = sustained muscle tension (driing, typing)
- palliative with = massage, strech
- described as band-like pain, a pressure but not throbbing
- bilateral, whole head, temporal/occiptial & can radiate to neck
- severity is mid-moderate
Tension Type HA
treatment
Treatment
Non-Pharm
- relaxation, massage, stretching
Pharm
- acute attacks = simple analgesics (asprin, NSAID, acetaminophen)
- chronic prophylaxis = only treatment is amitriptyline (TCA)
no other TCA, SSRI, benzo, botox or acupuncture is effective
Migraine HA
- etiology
- pathology
Etiology
- priamry headache class
- episodic, throbbing HA with sterotypical features
Pathology
- trigemnovascualr impulse from menigeal vessels got to TG tract to the brain = brain interprets the bain
- its a neurovascular issue in the brain surroudnings
- possibele relation to CGRP protein which when released around the brain causes inflammation in the meninges and then migraine (MAB treatment target this protein)
Migraine HA
- symptoms
- diagnosis via the IHS
Diagnosis Criteria
- repeateed attacks of a HA lasting 4-72 hours in those with a normal PE and no other cause of the HA PLUS…..
- 2 of : unilateral pain, throbbing pain, aggrevation of pain via moving, moderate/severe intensity
PLUS…
- 1 of: nausea/vomiting, photophobia/phonophobia
can be classified further as with or without aura
Symptoms
- pulsitile/throbbing
- 4-72 hours long (peakin first 1-2 then can linger)
- unilateral in nature (some can be bitemproal or global)
- N/V
- disabling in its intensity
- rapid onset (usually, but not a thunderclap)
- lots of triggers
- quiet and dark make it better
more of these symptoms = more liekly to be
Types of Auras
- symptoms (visual or auditory usually) which arise and then spread over 5 mintues, or two of these symptoms which are one after the other in occurance
- the aura is unilateral
- and the aura is accompanied by a headache within 60mints.
Symptoms of Migrain (Specific Detials)
what are some common triggers of a migraine HA to occur
explain the timing of a migraine & what a prodrome is
- afferent stimuli (glare, bright light, sounds)
- coming DOWN from stress
- physical activity
- rainy weather/change in baropressure
- hormonal flux (menses)
- lack of sleep or too much sleep
- alcohol
- foods (cheese, salty and processed)
- additives in food
- skipped meals (low BS)
Timing
- 4-72 hours, peak 1-2 hours first
- rapid in timing
- can have a prodrome, the aura, the headache & then a postdrome (sometimes have all these)
whats a prodrome
- 24-48 hours before people can have symtpoms of….
- euphoria
- depression/irritable
- food cravings
- constipation
- stiffness
- yawning
- dont need a prodrome for dx.
Migraine HA
specifics about the aura
postive v negative
who do you need to rule out a TIA in?? why
Aura
- focal neurological symptoms in approx. 25%
- can preceed or be in combo with HA
- gradual onset of the aura, lasts < 1 hr.
- mostly visual, sensory can follow can be sensory, motor or verbal
Positive Symptoms
- Visual Auras: bright lights, shapes
- Auditory: tinnitus, nosies
- Somatosense: buring, paresthesias
- Motor: jerks
Negative symptoms
- loss of function:vision, hearing, feeling or ability to move
TIA v Aura?? (since TIA is a return to baseline)
- for anyone with an aura for the first time > 40 y/o = need to rule out TIA
- for anyone with only negative auras (like loss of vision or movement)
- for anyone with aura prolonged or super short
Associated Migraine Symptoms
- N/V
- photophobia/phonophobia/osmophobia
- scalp tenderness
- visual disturbances
- vertigo
- paresthesias
- confusion
Migraine Subtype: Migraine with Brainstem Aura
- aura symptoms that are related to the BS capibilities WITHOUT WEAKNESS
symptoms that would be present
- vertigo
- dysarthia
- tinnitus
- diplopia
- ataxia
- hypo-acussis
- decrease LOC
Migraine Subtypes: Hemiplegic migraine
- presence of motor weakness (usually unilateral) as a manifestaion of the aura in some attacks
other manifestations of the aura (assoicated with the weakness)
- scotoma
- visual field defect
- numbness
- paresthesias
- aphasia
- fever
- lethargy
- coma
- seizure
can be familial
similar to TIA and stroke = ensure you are ruling it out
Migraine Subtype: Retinal Migraine
a rare condition: ocular migraine
- repeated attacks of monocular blindness or monocular scotoma > 1 hour during or right before a HA arises
rarely perminent blindness
