Headaches Flashcards
Migraine Pathophysiology (7)
- Not well understood
- Related to neurovascular dysfunction
- Dilation of bv’s innervated by CN5
- Change in brainstem sensory nuclei
- Initially: cerebral blood flow decreases
- Later: cerebral blood flow increases, hyperemia
- Cortical spreading depression of leao (starts in occipital region and spreads forward)
Migraine Clinical Presentation
- Lateralized, throbbing headache
- Onset: adolescents, early adulthood
- Gradual onset with aura
- Visual field defects
- Scintillating scotoma (flashing lights)
Migraine S/S (14)
- Anorexia
- N/V
- Photobia
- Phonophobia
- osmophobia
- cognitive impairement
- blurred vision
- aphasia
- numbness
- paresthesia
- clumsiness
- dysarthria
- dysequilibrium
- weakness
What are some triggers for migraines? (7)
- Stress
- sleep disturbance
- missed meals or specific foods
- alcohol
- bright lights
- loud noise
- menstruation or OC
Atypical Migraines (3)
- Basilar artery migraine
- opthalmoplegic migraine
- Familial hemiplegic migraine
Basilar Artery Migraine (4)
- Blindness or bilateral visual disturbances
- accompanied by dysarthria, dysequilibrium, tinnitus, perioral or distal paresthias
- Loss of consciousness or confused state sometimes
- followed by a throbbing occipital headache and N/V
Opthalmoplegic Migraine (5)
- Lateralized pain around eye
- Accompanied by N/V and diplopia
- Diplopia may outlast headache for days
- CN5 opthalmic division may be involved
- Rare
Familial Hemiplegic Migraine (2)
- Autosomal Dominant
- Attacks of lateralized weakness on one side
Overview of Tx for Migraines (3)
- avoidance of precipitating factor
- symptomatic tx
- prophylactic pharmacologics
Symptomatic Tx of Migraines (7)
- Rest, quiet dark room
- OTC analgesics
- Cafergot
- Antiemetics
- Sumatriptan/ Zolmatriptan
- Opioids
- propofol
Preventative Tx of Migraines
- If headaches occur more than 2-3x per month
- If headaches are very severe
- Try in succession
- Continue for several months then slowly taper
Prophylactic Drugs for Migraines
- Topiramate
- Valporic acid
- candesartan
- propanolol
- timolol
- verapamil
- amitriptyline
- Botulinum toxin A
Cluster Headaches (5)
- M>F 10:1
- No FmHx
- Episodic, severe retro-orbital or periorbital pain or Horner’s syndrome
- Occur daily for several weeks and then remit
- Pts are restless and agitated
Cluster Headache Clinical Presentation (7)
- Unilateral nasal congestion (may happen)
- lacrimation (may happen)
- rhinorrhea (may happen)
- redness of the eye (may happen)
- Often occur at night, waking the pt
- Last 30mins-3hrs
- Last 4-8 wks and recur 3-4x per yr
- EtOH, certain foods, bright lights, stress are all triggers
Symptomatic Tx for Cluster Headaches (6)
- oral drugs don’t really work
- SQ or intranasal sumatriptan
- intranasal zolmatriptan
- O2 NRB mask high flow (12-15L)x15mins
- Dihydroergotamine
- Viscous lidocaine intranasal
Prophylaxis Tx of Cluster Headaches (8)
- Lithium
- Verapamil
- Topiramate
- Valproate
- Suboccipital corticosteroid injection
- ergotamine
- prednisone
- occipital nerve stimulation
Hemicrania Continua (3)
- Unilateral head pain a/w autonomic symptoms
- Not episodic
- Completely treated with indomethacin
What is the most common type of headache?
Tension Headache
Tension Headache Clinical Presentation (7)
- pericranial tenderness
- Occiptal region radiating to the forehead
- “vise like” not pulsatile
- daily
- poor concentration
- No focal neurological symptoms
- Exacerbated by: emotional stress, fatigue, noise, bright light
Tx of Tension Headaches (6)
- Similar to migraine
- Triptans don’t help
- Tx associated anxiety or depression
- massage
- hot baths
- biofeedback
Depression Headache (4)
- Worse when you wake up in am
- A/w other symptoms of depression
- antidepressant drugs
- psychiatric consultation
Posttraumatic Headaches
- Follow a closed head injury
- independent of loss of consciousness
- Variety of non-specific symptoms
- Common
- Appear within a day or two of injury
- Worsens then subsides over weeks
- Constant dull ache with throbbing
- May be localized
Posttraumatic Headache Clinical Presentation (8)
- N/V
- Scintillating scotomas (flashing lights)
- If they start 2 weeks after injury, may be something else
- dysequilibrium enhanced by movement
- impaired memory
- poor concentration
- emotional instability
- increased irritability
Post Traumatic Headache Tx (8)
- CT/MRI to r/o focal symptoms
- encouragement
- NSAIDs
- Tylenol
- Amitriptyline
- Propanolol
- ergotamines
- antiseizure meds
Cough Headache
- Last several minutes
- 10% have chiari malformations (part of cerebellum through the foramen magnum)
- Brain tumors may present this way
- CT/MRI is indicated
- Should repeat imaging for 3 yrs to r/o lesion
Cough Headache Tx
- Self limited, may last several years
- May be relieved by LP (decrease ICP)
- Indomethacin
What arteries are affected by Temporal Arteritis?
Arteries affected:
- temporal
- vertebral
- opthalmic
- posterior ciliary
Temporal Arteritis (7)
- Affects elderly
- Headache= major symptom
May be a/w: - myalgia
- malaise
- anorexia
- wt loss
- non-specific complaints
Temporal Arteritis PE (4)
- Scalp tenderness over temporal arteries
- Jaw claudication
- Increased sed rate
- Can cause monocular blindness if untreated
Temporal Arteritis Tx (2)
- Prednisone
- Biopsy promptly
Intracranial Mass Lesions (6)
- Displacement of vasculature/tissue causes headaches
- Headaches range from mild to severe
- Non-specific
- Worsened with exertion or postural change
- N/V
- Progressive headaches/ new onset in adulthood merits further imagining, not normal
Medication Overuse Headache (4)
- Responsible for half of daily chronic headaches
- Severe headache unresponsive to meds
- Hx of pain meds
- Start a migraine prevention regimen
Pseudotumor Cerebri (3)
- AKA benign intracranial HTN
- Headache is worse on straining
- visual disturbances are common d/t papilledema and Abducens nerve palsy (diplopia)
Pseudotumor Cerebri Causes (6)
- Thrombosis of the transverse sinus d/t sinusitis or mastoiditis – Thrombosis of the sagittal sinus – Chronic pulmonary disease – Endocrine disturbances - (Hypoparathyroidism) - (Addison’s disease) – Vitamin A toxicity – Tetracycline or OCs
Pseudotumor Cerebri Diagnosis (5)
- CT/MRI should be done to r/o mass lesions
- Small or normal ventricles may be seen
- MR venography:
– thrombosis of the intracranial venous sinuses
– LP confirms intracranial hypertension, CSF is normal
Pseudotumor Cerebri Tx (6)
– Untreated, PC will cause optic atrophy and blindness
– Acetazolamide – reduces CSF formation
– Prednisone may also be helpful
– Obese patients should be counseled to lose wt
– Repeat LP to lower ICP
– Medical treatment is mainstay – monitored by checking fundoscopic exam, visual fields and acuity and CSF pressure
What do you do if you cannot treat pseudo tumor cerebra?
If unresponsive to medical therapy, surgical lumboperitoneal shunt can be done or fenestration of the optic nerve sheath to preserve vision
Trigeminal Neuralgia (4)
- AKA Tic Doloureux
- Common in mid and later life
- F>M
- Facial Pain
Trigeminal Neuralgia Clinical Presentation (7)
- Stabbing pain on one side of the face
- Distribution of 2nd & 3rd branches of CN5
- Brief episodes of pain
- Exacerbated by touch, cold, moving, chewing
- Starts near mouth, radiates to ear, eye, nose
- Episodes become more frequent
- Dull ache may persist between episodes
Trigeminal Neuralgia PE
- Negative neurological exam
- CT/MRI normal
- If the patient is young, suspect MS
- Check CSF and evoked potentials
Trigeminal Neuralgia Pharmacological Tx
- Oxacarbazepine or carbamazepine
- Phenytoin
– Baclofen
– Lamotrigine
– Gabapentin
Trigeminal Neuralgia Ablative Tx
– Posterior fossa exploration to decompress the nerve (not in MS)
– Radiofrequency rhizotomy can be used in elderly patients
– Gamma knife on the root
Atypical Facial Pain
- Burning, constant pain, starts as localized but spreads
- May cross the midline, go to neck or posterior scalp
- Common in middle-aged women
- Associated with depression
Atypical Facial Pain Tx
- Treat with analgesics and TCA, carbamazepine, oxcarbazapine, phenytoin
- NO SURGERY
Glossopharyngeal Neuralgia (5)
- Similar to trigeminal neuralgia but affects the throat
- Peri-tonsillar or posterior tongue pain
- Pain may be precipitated by swallowing, chewing, yawning, talking
- Sometimes accompanied by syncope
- Rule out MS
Glossopharyngeal Neuralgia Tx
- Rule out MS
- Treat with carbamazepine, oxcarbazapine first
- Consider surgical exploration with decompression second
- Ablation is generally not used
Postherpetic Neuralgia
- Develops in 15% of ppl who had shingles Most likely in: - elderly - immunocompromised - severe rash - 1st division of CN5 is affected
Postherpetic Neuralgia Tx (4)
– Simple analgesics
– TCA
– Carbamazepine, phenytoin, gabapentin, pregabalin
– Topical capsaicin cream or lidocaine
What are other causes of facial pain? (7)
- TMJ dysfunction
- Giant cell arteritis (masticatory claudication)
- Dental pain
- Sinusitis
- Ear infections
- Glaucoma
- Pain in the jaw may be angina
When should you refer a facial pain pt?
- Acute onset of “the worst headache in my life”
- Increasing headache unresponsive to simple measures
- History of trauma, hypertension, visual changes, fever
- Presence of neurologic signs or scalp tenderness
