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Neuro Module > Headaches > Flashcards

Headaches Flashcards

1
Q

What structures are sensing the pain of a headache?

A

NOT brain

meninges, blood vessels, muscles

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2
Q

Characteristics of HA to question in history

A

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

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3
Q

Primary headaches

A

migraine, tension, cluster

unchanging HA x 6 months

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4
Q

What is most common primary headache? Least common?

A

Tension

Cluster

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5
Q

Neuro exam and imaging of primary headaches

A

Usually normal

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6
Q

Migraine location

A

classically unilateral (60%); can be global or bifrontal (30%)

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7
Q

Cluster HA location

A

strictly unilateral (orbit or temple)

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8
Q

Time course of tension HA

A

episodic, waxes and wanes

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9
Q

Characteristics of tension HA?

A

bilateral, “band-like tightness/pressure”, pain at back of head/upper neck

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10
Q

Etiology of tension headache?

A

sustained pericardial muscle contraction

abnormal endothelial function, CNS pathway disruption??

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11
Q

Tension headache treatment

A

OTC NSAID/Tylenol
Lifestyle changes: stress, sleep, exercise
Treat co-morbidities (depression, migraine)

If chronic (+2/week, lasting +4 hrs) then Nortriptyline, Amitripyline, biofeedback

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12
Q

Time course of migraine headaches?

A

episodic, disabling

Builds over 10-45 min, peaks at 2 hrs, resolves in 4-72 hrs

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13
Q

prodrome

A

sxs of migraine that occur 24-48 hrs before headache

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14
Q

auras

A

sxs of migraine that occur min to hrs before

Visual (65%)
Sensory
Motor
Speech/language
Photophobia
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15
Q

Etiology of migraines

A

NEUROGENIC (cortical spreading of depolarization)

Histamine, serotonin, substance P, trigeminal nerve, etc.

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16
Q

Common epidemiology of migraines

A

F > M
80% first migraine < 30 yo
+FHX

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17
Q

When would you consider getting MRI/CT for migraines?

A

consider if HA changes, new onset at > 40 yo

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18
Q

Abortive tx of migraines

A

(taken at prodrome/aura)
APAP, ASA, NSAID
Benadryl
Various Triptans

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19
Q

Acute tx of severe migraines

A

TRIPTANS

anti-emetics (metoclopramide)

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20
Q

Migraine prophylaxis

A

BB, CCB, TCA, SSRI, anti-seizure, diet changes

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21
Q

Associated sx of migraine

A

N/V, photophobia, phonophobia, visual aura

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22
Q

Associated sx of cluster headache

A

ipsilateral tearing, eye redness, stuffy nose, sweating

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23
Q

Associated sx of tension headache

A

None

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24
Q

Timing of cluster headaches

A

episodic clusters with long inactive phases
sudden onset
peaks in minutes
lasts 30-180 min (avg 1 hour)

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25
Q

What increases risk of cluster headaches?

A

smoking

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26
Q

Characteristic of cluster headache pain

A

deep, excruciating, explosive in quality

patient restless and prefers to be active with HA

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27
Q

Abortive tx of cluster HA

A

inhalation of oxygen (x 15 min)

Triptans

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28
Q

Prophylactic tx of cluster HA

A

Varapamil, Prednisone, Lithium, Indomethacin

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29
Q

What if cluster HA is chronic and unresponsive to meds?

A

complete/partial section of CN V (trigeminal)

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30
Q

Rebound headaches

A

rhythmic cycle of pain and narcotic use
daily HA that varies in location & intensity
tx: taper off pain meds

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31
Q

Common causes of secondary headaches and what associated symptoms?

A

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

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32
Q

recent change in chronic HA, new onset of HA in adult

A

secondary headache

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33
Q

HA caused by intracranial tumor

A
  • worsening over days to weeks
  • dull ache or pressure-like more similar to tension HA
  • intermittent, mod/severe intensity, worse with valsalva and bending
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34
Q

typical patient with pseudotumor cerebri

A

F, 20-40 yo, obese

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35
Q

What type of HA in pseudotumor cerebri?

A

worse in AM, N/V, worse with activities that increase ICP (valsalva, coughing, sneezing, head down), pulsatile, tinnitus

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36
Q

If untreated pseudotumor cerebri can lead to what?

A

sx of high ICP = papilledema, atrophy of optic nerves, blindness

37
Q

General definition of pseudotumor cerebri

A

increased ICP with absence of tumor or other disease state (make too much CSF??)

38
Q

PE of pseudotumor cerebri?

A

bilateral papilledema, extraocular motor impairment

39
Q

pseudotumor cerebri treatment

A

Goal: reduce ICP to prevent blindness

  • Lumbar puncture to drain CSF
  • Acetazolamide (decrease CSF production)
40
Q

Symptoms of Giant Cell/Temporal Arteritis

A

New HA over temporal skull
Abrupt onset of visual disturbances
Polymyalgia rheumatic sxs (pain, stiffness of shoulders/hips)

41
Q

Giant Cell/Temporal Arteritis PE

A

tenderness over temporal artery

42
Q

Giant Cell/Temporal Arteritis treatment

A

Steroids immediately!!!

Urgent ophthalmologic consultation

43
Q

What confirms Giant Cell/Temporal Arteritis dx?

A

temporal artery biopsy

44
Q

Who is most likely to have Giant Cell/Temporal Arteritis?

A

> 50 yo

45
Q

HA with explosive onset (“thunderclap”)

A

subarachnoid hemorrhage

46
Q

HA + seeing “holes” around light + over 50 yo

A

glaucoma

47
Q

HA with fever and/or constitutional symptoms

A

CNS infection??

48
Q

HA with neck pain and facial pain

A

carotid artery dissection

49
Q

PE findings of increased ICP

A

mental changes, no venous pulsations, papilledema, poor balance/coordination, CN VI deficit, Cushing’s Triad

50
Q

Hx findings of increased ICP

A

blurry vision with bending forward, HA, double vision, vomiting w/o nausea, seizures, delirium

51
Q

Cushing’s response

A

HTN, bradycardia, irregular respirations

52
Q

Tx for increased ICP

A

IV Mannitol; water from edema to blood

53
Q

CT scan of patient with high ICP

A

ventricular dilation = hydrocephalus

54
Q

What must you not do with increased ICP?

A

lumbar puncture because may cause herniation

55
Q

Most common secondary headache cause?

A

systemic infection (fighting virus)

56
Q

Proposed pathophysiological causes of migraine?

A

Cortical spreading depression- depolarizing wave
Trigeminovascular system- stimuli to pain sensitive structures in brain
Sensitization- increased neuron response
Serotonin- deficit in pain inhibitory system

57
Q

Pathophysiology of tension HA

A

CNS stimuli misinterpreted as pain

58
Q

Pathophysiology of cluster HA

A

Activation of Trigeminal-autonomic pathway

59
Q

What does papilledema indicate?

A

increased ICP

60
Q

What does neck stiffness with HA indicate?

A

meningitis

61
Q

What does focal neuro findings with HA indicate?

A

stroke, ataxic gait

62
Q

Secondary systemic illness HA will have what associated symptoms?

A

fever, HTN, sinusitis

63
Q

Causes of local life-threatening secondary HAs?

A

tumor, hemorrhage, trauma, local infection

64
Q

Body systems evaluated with c/o headache

A

Neuro, HEENT, neck

65
Q

Common triggers of primary headaches?

A

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

66
Q

Common sx of migraine

A

Nausea, photophobia, lightheadedness, scalp tenderness, vomiting, vision changes

67
Q

How is migraine dx’d?

A

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

68
Q

How to determine need for prophylaxis of migraine?

A
  • 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)
69
Q

Abortive therapy for migraines?

A

NSAIDs (aspirin, Naproxen > ibuprofen)
Anti-HTN (propranolol)
Anti-depressants (TCA-amytriptyline)
Anti-epileptic (Valproate)

70
Q

How long for migraine meds to work? How long should be tried?

A

several weeks and should be tried for at least 3 months

71
Q

Can migraine meds be d/c’d?

A

may try taper after 6 months of effective tx

72
Q

How to treat a migraine that is currently occurring?

A

provide pain relief and anti-emesis rather than try to stop completely

73
Q

1st and 2nd line tx for mild migraine

A
  1. Naproxen

2. Tylenol (peds & pregnant)

74
Q

1st and 2nd line tx for moderate migraine

A
  1. Excedrin

2. Triptans (sumitriptan, rizatriptan)

75
Q

1st and 2nd line tx for severe migraine

A
  1. IV Ketorolac (Toradol)

2. SQ Triptans (sumitriptan) or Dopamine agonists (metoclopramide, prochlorperazine)

76
Q

Last resort tx for migraines

A

If other meds aren’t working refer out

Ergotamines is next line tx

77
Q

Common ADR of triptans

A

chest tightness

78
Q

What meds should you try to avoid in treating migraine? Why?

*may still have to use

A

Opioids, Codeine Combos (Tylenol #3), Barbituates

all cause rebound headaches and dependency

79
Q

What is a good adjunct tx for all severities of migraine?

A

Diphenhydramine (Benedryl) to help with nausea and sleep

80
Q

How are tension headaches classified by frequency?

A 
infrequent episodic (< 1 day/mon)
frequent episodic (1-14 days/mon)
chronic (>14 days/month)
81
Q

Indications for tension HAs prophylaxis therapy?

A
  • frequent or chronic type
  • significant impact on ADLs
  • failure of acute tx
82
Q

Medications for prevention of tension headaches?

A

Tricyclic antidepressants (Amitryptiline only proven tx)

83
Q

Abortive tx for tension headaches - first line, rescue, adjunct

A

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

84
Q

How is tension differentiated from migraines?

A

No N/V

No photophobia or phonophobia (maybe only 1)

85
Q

Diagnosis of cluster headaches

A
  • 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
86
Q

Preventative tx for cluster headaches

A

Verapamil (drug of choice)
Lithium
Topiramate

87
Q

Abortive tx for cluster headaches

A

High flow oxygen (10-12L/min for 15 min)

Sumitriptan (SQ best)

88
Q

Adjunct tx for cluster headaches

A

Glucocorticoids (prednisone, dexamethasone)

Used in preventative and abortive tx

89
Q

Surgery for cluster headaches

A

Trigeminal denervation - resection, cauterization, or injection

Deep brain stimulation

Neuro Module (13 decks)

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