Headaches Flashcards
What structures are sensing the pain of a headache?
NOT brain
meninges, blood vessels, muscles
Characteristics of HA to question in history
quality, site, radiation of pain, frequency, intensity, duration of attack, precipitating or relieving factors, time of onset, vision changes aura/prodrome, age of onset, days/month, recent trauma, menstrual cycle, food/etoh
Primary headaches
migraine, tension, cluster
unchanging HA x 6 months
What is most common primary headache? Least common?
Tension
Cluster
Neuro exam and imaging of primary headaches
Usually normal
Migraine location
classically unilateral (60%); can be global or bifrontal (30%)
Cluster HA location
strictly unilateral (orbit or temple)
Time course of tension HA
episodic, waxes and wanes
Characteristics of tension HA?
bilateral, “band-like tightness/pressure”, pain at back of head/upper neck
Etiology of tension headache?
sustained pericardial muscle contraction
abnormal endothelial function, CNS pathway disruption??
Tension headache treatment
OTC NSAID/Tylenol
Lifestyle changes: stress, sleep, exercise
Treat co-morbidities (depression, migraine)
If chronic (+2/week, lasting +4 hrs) then Nortriptyline, Amitripyline, biofeedback
Time course of migraine headaches?
episodic, disabling
Builds over 10-45 min, peaks at 2 hrs, resolves in 4-72 hrs
prodrome
sxs of migraine that occur 24-48 hrs before headache
auras
sxs of migraine that occur min to hrs before
Visual (65%) Sensory Motor Speech/language Photophobia
Etiology of migraines
NEUROGENIC (cortical spreading of depolarization)
Histamine, serotonin, substance P, trigeminal nerve, etc.
Common epidemiology of migraines
F > M
80% first migraine < 30 yo
+FHX
When would you consider getting MRI/CT for migraines?
consider if HA changes, new onset at > 40 yo
Abortive tx of migraines
(taken at prodrome/aura)
APAP, ASA, NSAID
Benadryl
Various Triptans
Acute tx of severe migraines
TRIPTANS
anti-emetics (metoclopramide)
Migraine prophylaxis
BB, CCB, TCA, SSRI, anti-seizure, diet changes
Associated sx of migraine
N/V, photophobia, phonophobia, visual aura
Associated sx of cluster headache
ipsilateral tearing, eye redness, stuffy nose, sweating
Associated sx of tension headache
None
Timing of cluster headaches
episodic clusters with long inactive phases
sudden onset
peaks in minutes
lasts 30-180 min (avg 1 hour)
What increases risk of cluster headaches?
smoking
Characteristic of cluster headache pain
deep, excruciating, explosive in quality
patient restless and prefers to be active with HA
Abortive tx of cluster HA
inhalation of oxygen (x 15 min)
Triptans
Prophylactic tx of cluster HA
Varapamil, Prednisone, Lithium, Indomethacin
What if cluster HA is chronic and unresponsive to meds?
complete/partial section of CN V (trigeminal)
Rebound headaches
rhythmic cycle of pain and narcotic use
daily HA that varies in location & intensity
tx: taper off pain meds
Common causes of secondary headaches and what associated symptoms?
Tumor - N/V, abnormal neuro exam
Pituitary adenoma - visual field defect
Optic neuritis - sudden unilateral vision loss, < 35 yo F
Temporal arteritis - night sweats, > 55 yo
recent change in chronic HA, new onset of HA in adult
secondary headache
HA caused by intracranial tumor
- worsening over days to weeks
- dull ache or pressure-like more similar to tension HA
- intermittent, mod/severe intensity, worse with valsalva and bending
typical patient with pseudotumor cerebri
F, 20-40 yo, obese
What type of HA in pseudotumor cerebri?
worse in AM, N/V, worse with activities that increase ICP (valsalva, coughing, sneezing, head down), pulsatile, tinnitus
If untreated pseudotumor cerebri can lead to what?
sx of high ICP = papilledema, atrophy of optic nerves, blindness
General definition of pseudotumor cerebri
increased ICP with absence of tumor or other disease state (make too much CSF??)
PE of pseudotumor cerebri?
bilateral papilledema, extraocular motor impairment
pseudotumor cerebri treatment
Goal: reduce ICP to prevent blindness
- Lumbar puncture to drain CSF
- Acetazolamide (decrease CSF production)
Symptoms of Giant Cell/Temporal Arteritis
New HA over temporal skull
Abrupt onset of visual disturbances
Polymyalgia rheumatic sxs (pain, stiffness of shoulders/hips)
Giant Cell/Temporal Arteritis PE
tenderness over temporal artery
Giant Cell/Temporal Arteritis treatment
Steroids immediately!!!
Urgent ophthalmologic consultation
What confirms Giant Cell/Temporal Arteritis dx?
temporal artery biopsy
Who is most likely to have Giant Cell/Temporal Arteritis?
> 50 yo
HA with explosive onset (“thunderclap”)
subarachnoid hemorrhage
HA + seeing “holes” around light + over 50 yo
glaucoma
HA with fever and/or constitutional symptoms
CNS infection??
HA with neck pain and facial pain
carotid artery dissection
PE findings of increased ICP
mental changes, no venous pulsations, papilledema, poor balance/coordination, CN VI deficit, Cushing’s Triad
Hx findings of increased ICP
blurry vision with bending forward, HA, double vision, vomiting w/o nausea, seizures, delirium
Cushing’s response
HTN, bradycardia, irregular respirations
Tx for increased ICP
IV Mannitol; water from edema to blood
CT scan of patient with high ICP
ventricular dilation = hydrocephalus
What must you not do with increased ICP?
lumbar puncture because may cause herniation
Most common secondary headache cause?
systemic infection (fighting virus)
Proposed pathophysiological causes of migraine?
Cortical spreading depression- depolarizing wave
Trigeminovascular system- stimuli to pain sensitive structures in brain
Sensitization- increased neuron response
Serotonin- deficit in pain inhibitory system
Pathophysiology of tension HA
CNS stimuli misinterpreted as pain
Pathophysiology of cluster HA
Activation of Trigeminal-autonomic pathway
What does papilledema indicate?
increased ICP
What does neck stiffness with HA indicate?
meningitis
What does focal neuro findings with HA indicate?
stroke, ataxic gait
Secondary systemic illness HA will have what associated symptoms?
fever, HTN, sinusitis
Causes of local life-threatening secondary HAs?
tumor, hemorrhage, trauma, local infection
Body systems evaluated with c/o headache
Neuro, HEENT, neck
Common triggers of primary headaches?
Diet - alcohol, chocolate, aged cheese, caffeine, nuts, nitrates
Hormones - menses, ovulation, progesterone
Sensory stimuli - light, odor, sounds
Stress
Changes of environment - weather, seasons, altitude, sleeping pattern, skipping meals, irregular physical activity
Common sx of migraine
Nausea, photophobia, lightheadedness, scalp tenderness, vomiting, vision changes
How is migraine dx’d?
1) repeated HA attacks lasting 4-72 hrs in patients with normal PE
2) 2 of the following: unilateral pain, throbbing pain, aggravated by movement, mod or severe intensity
3) Plus 1 of following: N/V, photophobia and phonophobia
How to determine need for prophylaxis of migraine?
- recurring MHAs that interfere with ADL
- contraindication, failure, or overuse of acute tx
- patient preference
- 5 or more per month
- to prevent neuro damage (hemiplegic, migrainous infarct)
Abortive therapy for migraines?
NSAIDs (aspirin, Naproxen > ibuprofen)
Anti-HTN (propranolol)
Anti-depressants (TCA-amytriptyline)
Anti-epileptic (Valproate)
How long for migraine meds to work? How long should be tried?
several weeks and should be tried for at least 3 months
Can migraine meds be d/c’d?
may try taper after 6 months of effective tx
How to treat a migraine that is currently occurring?
provide pain relief and anti-emesis rather than try to stop completely
1st and 2nd line tx for mild migraine
- Naproxen
2. Tylenol (peds & pregnant)
1st and 2nd line tx for moderate migraine
- Excedrin
2. Triptans (sumitriptan, rizatriptan)
1st and 2nd line tx for severe migraine
- IV Ketorolac (Toradol)
2. SQ Triptans (sumitriptan) or Dopamine agonists (metoclopramide, prochlorperazine)
Last resort tx for migraines
If other meds aren’t working refer out
Ergotamines is next line tx
Common ADR of triptans
chest tightness
What meds should you try to avoid in treating migraine? Why?
*may still have to use
Opioids, Codeine Combos (Tylenol #3), Barbituates
all cause rebound headaches and dependency
What is a good adjunct tx for all severities of migraine?
Diphenhydramine (Benedryl) to help with nausea and sleep
How are tension headaches classified by frequency?
infrequent episodic (< 1 day/mon) frequent episodic (1-14 days/mon) chronic (>14 days/month)
Indications for tension HAs prophylaxis therapy?
- frequent or chronic type
- significant impact on ADLs
- failure of acute tx
Medications for prevention of tension headaches?
Tricyclic antidepressants (Amitryptiline only proven tx)
Abortive tx for tension headaches - first line, rescue, adjunct
1st line: Aspirin, Naproxen, Tylenol (less effective), caffeine combos (more effective)
Rescue (all IM or IV): Toradol or Reglan + Benadryl
Adjunct: occipital nerve block, trigger point injection
How is tension differentiated from migraines?
No N/V
No photophobia or phonophobia (maybe only 1)
Diagnosis of cluster headaches
- Unilateral orbital/temporal pain
- Lasts 30-180 min
- 1 of these ipsilateral to HA: conjunctival injection or lacrimation, nasal congestion or rhinorrhea, facial sweating/flushing
Preventative tx for cluster headaches
Verapamil (drug of choice)
Lithium
Topiramate
Abortive tx for cluster headaches
High flow oxygen (10-12L/min for 15 min)
Sumitriptan (SQ best)
Adjunct tx for cluster headaches
Glucocorticoids (prednisone, dexamethasone)
Used in preventative and abortive tx
Surgery for cluster headaches
Trigeminal denervation - resection, cauterization, or injection
Deep brain stimulation
