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
Migraine Subtype: Vestibular migraine
Vestibular Migraine
- episodic vertigo in a pt. with hisotry of migraine
- episodic vertigo with other steriotypical auras + hx. of migraine
this is a diagnosis of exclusion: look to Brainstem and vestibualr disease first
Migraine Subtype: Mestrual Migraine
Menstrual Migraine
- a pure menstrual migraine: the migraine will occur exclusively in a cose relationship to menses like 2 days before or into 3 days of the bleeding
a menstrually related migraine: migraine occurs in relatin with the cycle at times, but occurs outside the cycle time point also
Clinical signs
- typical migraine symptoms: but usually longer and less responsive to treatment
- commonly no aura with these!
Migraine Subtype: Chronic Migraine
headaches for 15+ days of the month for 3 or more months, with features of a MIGRAINE HA for at least 8 days (with or without aura)
can be related or a type of medication overuse HA
treatment mostly with botox
Treatment of Migraine HA
abortive treatment
education is so important: about what it is and how treatment works
- if NSAIDS arent helpful -> migraine meds can be used
- can use self-admin meds for rescue in those with severe migraines that are refractory to other treatments
- always be on the watch for medication overuse HA to arise!!! councel and educate
Abortive treatment (getting rid of HA)
simple analgesics
- acetamin/asprin/caffeine (excedrine)
- NSAID
migrain specific meds (serotonin = constrict vessels)
- 5HT (serotonin) receptor agonist: Ergotamine, “triptans” & triptam/nsaid combo
- CRGP antagonists (the protein)
- lasmiditan (selective serotonin agonist)
can do adjunct therapy with dopamine receptor antagonists for nausea
Treatment of Migraines
Other options (outside of the abortpive treatment)
-acetamin./dichoralphenazone/opmetheptene
- butorphanol
- parenteral opioids (caution)
- magnesium slufide??
- neuromod: TENS, celphaic
Neuromodualtion
- transcut. nerve stimulation and others
what is the classic ED treatment for Migraine
- a dopamine receptor antagonist
- benadryl to counteract akathisias from the dop. receptor antagonsits
- dextamethasone can be given to reduce the recurrence/rebound HA
Specifics of the 5-HT Receptor Agonists for Migraine meds
- how do they work
- side effects
Serotonin Receptor Agonists: work on the blood vessels to constrict and decrease migraine
- Ergotamine + dihydroergotamine
they arent often usedin PCP care; used in the inpatient or ED setting via injection
SE
- higher risk of nausea than the triptans; but lower migraine recurrence = give with antiemic
specifics of the Triptans for migraine treatment
“Triptans” = selective 5 HT receptor agonists
- the standard of care for treatment usually = more widely used than ergotamine
how they work
- stimulate serotonin receptors in IC vessels & with trigeminal system nerves to vasoconstrict & reduce inflammaion
- since they are constricting: can cause angina!!
Side Effects
- vasoconstrict elsewhere: contraindicated in vascualr disease pts
- nausea
- jaw,neck,, chest tightness
- increase HR
- fatigue
- numb/tingle
- burning of face (trigem. nerve)
How to use
- should be given ASAP when the HA starts but NOT DURING AURA
- rebound HA is a concern
- can be dosed at inervals but there is a daily max
Names
- sumatriptan
- almotriptan
- rizatriptan
- eletriptan
- zolmitriptan
Triptans to use with…
- pt. with SE’s
- pt with migraine + aura
- pt. with early nausea
- pt. with vomiting
- pt. with menstrual migraine
pt with side effects of tripans
- naratriptan or frovatriptan = less SE
pt. with migraine + aura
- any triptan, taken after aura
pt. with early nausea
- nasal spray prep or oral dispersible tablet
pt. with vomiting
- SQ or nasal prep
pt. with menstrual migraine
- any, frovatriptan could be best
sumatriptan comes in combo with NSAID but expensive; just take together
contraindications of triptans for migraines
- those with CAD
- history of stroke or TIA
- PVD
- uncontrolled HTN
- pregnancy cat C
- hemipalegic or basilar migraine
CGRP inhibitors: Migraine medications
- they modulate calcitonin gene related peptide activity- impacting the trigeminal nerve pain transmission
Names
injectables: erenumab, eptinezumab, fremanazeumab, galcanezeumab
oral: atogepant, rimegepant, urbrogepant
nasal: zavegepant
erenumab, fremanezumab, galcanezumab, ramegipant
- CAN be used for prophylatic migraine relief as well
whats the deal with Lasmiditan for migraine treatment
Lasmiditan
- serotnin receptor agonist
- can only tkae 1 dose / 24 hours
- if it didnt work, up the dose next day with next attack
how to combat the N/V of migraine; treatment
- metoclopramide: in the ED perferred agent
- ondansetron : oral
- Promethazine
- Prochlorperazine - QTC prolong.
- chlorpromazine (typical antipsych.)
IV dexamethasone is given to reduce recurrance
Migraine Headaches
Prophylatic Treatment
indications & general appraoch
Indications
- 2+ migraines per month with 3 days of disability per month
- contraindications or significant ADR to abortive treatments (analgeics, serotinins)
- using abortive meds more than 2x weekly
- debailitating attacks despite use of abortive meds
- medication oversue headaches
Aprroach
- avodi triggers
- start with med of higehst efficacy
- choose med to treat comorbid conditions
- start low and uptitrate to therapedudic dose
- can consider to taper off 6-12 months of controlled HA
First Line meds for Migrain prophalxis
First Line
- divalproex (depakote) = eatch liver and thrombocytopenia
- frovatriptan (menstrual migraines)
- metoprolol
- propranolol
- timolol
- toperiamate
beta blockers: goof if concomant htn, angina, heart diesase
non-first line prophylatic treatment for migraine
- butterburplant (not recommended)
- botox: for chronic migraines prophylatically : given as special clinics
menstraul migraines: specific treatments and algorithim
abortive treatment = triptan at the start of the HA
prophylatic
- naproxen (nsaid)
- scheduled use of frovatriptan (2 days before period, for 5 days)
- magnesium at day 15 of cycle until bleed
if NO aura present prophylatic use
- progesteroneestrogone OCP
- combo OCP
- progest. only OCP
if aura with visual present= OCP cannot be used
Status Migraninosus
what is it
treatment
debilitating migraine > 72 hours long
treatment
- metoclopromide (DA agonist) + dihydroergotatine
- lidocaine
- steroids
treating migraines in pregnancy
in peds??
Pregnancy
acute migraine: acetominophen, opioids or corticosteroids
N/V assocaited = metoclopramide
CANNOT USE
- triptans
- ergotamines
- CGRP
Peds
- auras are rare; migraine is simialr in nature
- start with NSAIDs
- can use triptans (suma or ele)
Trigeminal Autonomic Cephalgias (Cluster HA)
etiology
symptoms
Etiology
- HA with short, lasting attack of pain assocaited with CN autonomic symtpoms of tearing, conj. injection, or nasal congestion
- pain = ice pick like behind the eye multiple times of dday
Types of TAC
- clusters
- SUNCT
- SUNA
Cluster HA
Etiology
Symptoms
triggers
treatment
Etiology
- men > women
- sever pain + autonomic symptoms and activation of parasympathetic fibers around the carotid artery as its dilated/inflammed
- can have daily 1-2 attacks in short time of unilateral pain for 8-10 weeks an year, then pain free for some time
Triggers
- nothing brings on the cluster
- when in a cluster - alchol makes it worse
Symptoms
- abrupt and rapidly severe
- O2 helps
- stabbing sensation with no radiation
- severe pain behind the eye or temporal lobe
- occurs every 8-10 days over some weeks then disappears for a while
- unable to sit still!!
- tearing, conj injection, congestion, ptosis all can happen
Treatment
- early treatment is imperative : supplemental O2!!!
- sumatriptan parentral formation!!! (not oral)
- prophylatic: prednisone during a cluster, lithium (side effects!)
- longer term prophylatic: verapimil (CCB)
Subarachnoid Hemorrahge : seondary HA
Etiology
- an anyuresum usaully causes, can be tramatic
Symptoms
-acute onset of sever HA THUNDERCLAP: SAH untile proven otherwise
- worst headache of life
- meningismus (stiffeneing)
- can have family hx. of anyuresum, or dominant PCKD
Diagnosis
- CT:
- if negative CT but still sus = LP for yellow, blood or billirubin
Treatment
- surgery
Subdural Hematoma: secondary HA
etiolgoy
- with or without trauma
Symptoms
- new or progressive HA with neuro deficts
- ct: CRESENT SHAPE
who
- elderyl
- alcholotics
- antiplatelet or anticoags. (CT ALWAYS regardless of neruo exam for risk of bleed is too high)
Epidural Hematoma : seondary HA
etiology
- bleeding between dura and the skull
- urually trauma: fx or tear of the middle meningeal artery
symptoms
- h/o trauma, transient LOC, lucid then detereorate
Diagnosis
CT
Brain Tumors ;secondayr HA
- presentaion varies based on location
- early morning HA
- worse iwth coughing, better to stand
- seizures, N/V, speech, weakness and imbalance iare signs
acute angle glacoma
- abrupt rise in intraoccular pressure
- severe HA, halos around lights and profound vision loss
- red eye cloudy cornea
- dilated pupil
- firm globe
Diangosis
- IOP measure (normal < 22) this will be > 50
treat
- occular emergency
- IV acetazolamide
Medication Overuse HA
etiology
diagnosis
what meds
symptoms
treatment
etiology & dx.
- a headache occuring 15+ days per month in a pt. with pre-exisitng HA disorder and taking those meds
- central sensitzation, downregulation of serotonin receptors and inhibitory pathways— thus increased level of pain more than other people becuase less receptors more sensive
- additions, anxiety and compusive
Meds
- butalbital
- asprin/acetominophin/caffeine med
- opioids
- triptans
- ergotamines
- aspring
Symptoms
- develop after dx. of primary HA disorder
- transiet relief from meds
- usually comes on shortly after waking and lasts all day
Treatment
- patienet eduation and d/c medication
- get worse before better
- withdrawl quickly (except barb or benzo)
- bridge with NSAID and begin prophalytic med?
- if its opioid, barb or benzo consider inpt. managment
