Headaches Flashcards
what are the major 3 types of primary headaches?
- migraine
- tension headache
- trigeminal autonomic cephalalgias
entirely diagnosed by history
what are the clinically features of migraines? (7)
- unilateral but not side-locked (could occur on either side)
- pounding/throbbing
- photophobia, phonophobia, osmophobia
- nausea w/wo vomiting
- typically 4-24 hours
- classic migraines preceded by auras lasting 15-30mins (scotomata = flashing lights)
- worsened by activity
acephalgic migraine
independent aura without a migraine following
scotomata (flashing lights), sometimes somatosensory
classic vs common migraine
classic = preceded by aura
common = NOT preceded by aura (more common)
what are migraines caused by?
electrochemical processes triggering the trigeminal system
“neurovascular theory”: neuronal hyperexcitability causes release of CGRP (calcitonin gene-related peptide), a potent vasodilator
CGRP —> MMP (matrix metalloproteinase) —> inflammatory mediators (serotonin, bradykinin, substance P, neurokinin P/Y, prostaglandins) —> pain
what are 3 dietary supplements that may be beneficial for patients with frequent migraines?
- vitamin B2
- magnesium
- coenzyme Q10
what defines status migrainosus
migraine lasting >72 hours
initial options: ketorolac, metoclopramide, IV fluids
secondary options: sumatriptan, DHE, methylprednisolone, valproic acid, MgSO4
what are transformed migraines
migraines that transform into chronic daily headache
what is the most common type of headache, and how do they present? (4)
tension headache
- typically bilateral
- pressing/tightening in band-like squeezing sensation
- lasting 30 mins to days
- pericranial tenderness to palpation
how do trigeminal autonomic cephalalgias present?
type of primary headache which trigger pronounced autonomic features - dilated/constricted pupils, ptosis, lacrimation, facial sweating (Horner’s syndrome - occurs ipsilateral to headache)
SUNCT vs SUNA
SUNCT = short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing
SUNA = short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms
both moderate/severe unilateral head pains lasting for short durations and occurring as single stabs in series or sawtooth pattern
how do cluster headaches present?
1-8 attacks per day, occurring in series lasting for weeks of months, separated by remission periods (months or years)
excruciating drilling pain supraorbitally/temporally, restlessness
last 15mins-hours (usually shorter), classically awake patients in the middle of the night, higher risk in 1st degree relatives
may be treated acutely with high-flow O2, prevented with verapamil
what does fMRI show in patients with cluster headaches?
activation of ipsilateral posterior hypothalamic grey matter —> triggers activation of trigeminal nerve/ release of inflammatory mediators
what is the inherited form of cluster headaches?
autosomal dominant mutation in hypocretin receptor 2 gene (HCRTR2)
hemicrania continua
non-stop headache >3 months, sometimes with severe side-locked headache that will only respond to indomethacin
paroxysmal hemicrania
severe, strictly unilateral head pain which is orbital, supraorbital, or temporal lasting 2-30 mins and occurring several/many times a day
rank/differentiate cluster, paroxysmal hemicrania, and SUNCT headaches by the following features:
a. daily attack frequency
b. duration of attack
c. pain quality
d. pain intensity
a. cluster (1-8) < paroxysmal hemicrania (1-40) «< SUNCT (3-200)
b. SUNCT (5-250s) «< paroxysmal hemicrania (2-30mins) < cluster (15-180mins)
c. cluster = sharp/throb, paroxysmal hemicrania = sharp/throb, SUNCT = stab/burn
d. all very severe
which of the following types of primary headaches is most likely to present bilaterally?
a. cluster
b. migraine
c. paroxysmal hemicrania
d. SUNCT
e. tension
e. tension: gradual, constant, bilateral, dull, aching, squeezing
patients with which of the following types of primary headaches often can be treated with indomethacin?
a. cluster
b. migraine
c. paroxysmal hemicrania
d. SUNCT
e. tension
c. paroxysmal hemicrania
indomethacin = NSAID
patients with which of the following types of primary headaches are very restless and may be treated with high-flow O2?
a. cluster
b. migraine
c. paroxysmal hemicrania
d. SUNCT
e. tension
a. cluster - extremely intense pain
what is the most effective intervention for headaches caused by idiopathic intracranial HTN?
aka pseudotumor cerebri
losing weight to help decrease the elevated intracranial pressure
how do headaches associated with Chiari I malformations present?
Chiari I = downward displacement of cerebellar tonsils into upper cervical canal —> compression of nearby structures:
—> occipital/upper cervical headache with Valsalva maneuvers (bending over, laughing, coughing, sneezing - increase intracranial pressure)
—> neck/shoulder pain
—> down-beating nystagmus, other visual symptoms
—> ataxia (cerebellar)
—> diminished gag reflex
—> tinnitus, vertigo, fluctuating hearing loss
how does temporal arteritis present, and what is a serious possible consequence?
inflammatory arteritis of temporal artery, presents in older patients with headache + jaw claudication (pain with chewing), loss of temporal artery pulse (artery is thick and rigid)
may cause irreversible monocular visual loss
