headaches Flashcards
what are primary headaches
headache syndromes unto themselves:
migraine
tension headache
cluster headache
what are secondary headaches
symptoms of other illnesses such as:
meningitis
intracranial mass
what are the 2 important questions to ask about hx for headaches
- Is this headache new or old?
- If old, is the headache typical?
also should ask:
-Onset
-Location, Quality/ Severity, Radiation
-Duration, Frequency, Intensity
-How often and how long they last
-Associated symptoms
-Aggravating or Alleviating Factors
-Presence or absence of aura or prodrome
-Response to previous treatment
what chronic medical conditions should be assessed for during hx
HIV
Cancer
Pregnancy
HTN
Anxiety/depression
what are the danger signs for headaches
- systemic symptoms, illness, or condition (fever, weight loss, cancer, pregnancy, immunocomp)
- Neurologic symptoms or abnormal signs (confusion, altered consciousness, papilledema, meningismus, focal neuro signs, seizures)
- Onset is new or sudden (Age >40 years or “thunderclap”)
- Other associated conditions or features (Head trauma, illicit drug use, awakens from sleep, worse with Valsalva, precipitated by cough, exertion, or sexual activity)
- Previous headache history with progression (Change in frequency, severity, or clinical features)
Acronym “SNOOP”
what features could suggest secondary HA source
- Impaired vision: halos around lights
- Visual fields defect
- Sudden, severe, unilateral vision loss
- Blurring of vision on forward bending or headache when awakening
8 Nausea, vomiting, worsening of headaches with changes in body position, an abnormal neurologic exam, changes in headache pattern
when is neuroimaging indicated in headaches
- Age of onset >40
- Focal neurologic signs or symptoms
- Onset of headache with exertion, cough, or sexual activity
- Change in pattern of headaches
- Frequency or severity
- In a patient with cancer, Lyme disease, or HIV
- Progressively worsening of headache despite adequate therapy
what is the most sensitive and preferred imaging study in HA
MRI
what imaging is often used in ED setting to r/o sinusitis or head injury
CT
when is LP consiered
must be considered in patient with signs of meningitis or subarachnoid hemorrhage
(Measure opening pressures with suspected subarachnoid hemorrhage)
what are common misconceptions of causations for HA
- Acute and chronic sinusitis is an uncommon cause of recurrent headaches
- Poor vision, or eye strain, is also rarely a cause of chronic headaches
- Hypertension is not a likely cause of headache, unless the patient is in a hypertensive crisis
when is hospitalization indicated in HA patients
- repeated doses of parenteral pain meds
- work-up requiring sequences of imaging/procedures
- monitor progression of symptoms if initial presentation is inconclusive
- pain severe enough to impair activities of daily living or limit participation in follow up
what is the pathophysiology of migraines
Thought to be a neuronal dysfunction in the trigeminal system resulting in the release of vasoactive neuropeptides such as calcitonin gene-related peptide leading to neurogenic inflammation, sensitization, and headache (not the vasodilation/vasoconstriction theory)
what is the epidemiology of migraines
- Affects up to 12% of the general population
- About 10% of school aged children suffer from migraines
- Women > men (3 times more)
- 25 – 55 years old most common
- 90% have a family history
what is the MC type of migraine
Migraine w/o aura (75%)
what are the triggers for migraines
Triggers: stress, menstruation, visual stimuli, weather changes, nitrates, fasting, wine, sleep disturbances, aspartame
what are the four phases of classic migraine attack
- prodrome
- aura
- HA
- postdrome
what is the prodrome and how common is this in migraines?
- this is affective symptoms 24-48 hours prior to headache beginning. this can include: Euphoria, depression, irritability, food cravings, constipation, neck stiffness, and increased yawning
- 60% of migraines report prodrome
what is aura and how common is it in migraines
- transient neurologic symptoms (MC visual but can be sensory, verbal or motor)
- develope gradually and last no longer than an hour
- occurs in 25% of migraine suffereers
what is the classic presentation of the headache phase of a migraine
- unilateral, throbbing or pulsatile in quality
- assocaited s/s of NV, photophobia, phonophobia, cog impair, blurry vision, hyperalgesia, cutaneous allodynia
- lasts several hours to days
- aggravated w/ routine physical activity
what is the postdrome phase of a migraine
Patient often feels drained or exhausted, but some report a feeling of mild euphoria
what is the criteria for migraine without aura
what are the two aspects of management for migraines
- preventative strategies (meds, trigger avoidance)
- abortive (symptomatic) treatment (NSAIDS, triptans, argotamines, antiemetics)
what are the NSAID options for migraine
- tylenol, ASA, ibuprofen (OTC and inexpensive)
- ketorolac (toradol)
- naproxen (naprosyn, anaprox)
- if one does not work, may try the other
