Headaches Flashcards
Red flags for headaches
First or worst
Abrupt onset
Fundamental pattern change
New headache pattern when
– ≤5 years old
– ≥50 years old
Cancer, HIV, pregnancy
Abnormal physical exam
Neuro symptoms ≥ one hour
Headache onset:
– with seizure or syncope
– with exertion, sex or valsalva
Comfort signs for headache
Normal physical exam
Stable pattern
Long-standing history
Family history of similar headaches
Consistently triggered by:
– Hormonal cycle
– Specific foods
– Specific sensory input: Light or Odors
– Weather changes
large meta-analysis reports that 0.18% of patients with migraine and normal Neurologic
exam will have significant intracranial pathology, this means
we have Secondary headaches that are a presentation of something else, make sure to do proper workup of headahe
Headache is idiopathic with no identifiable underlying pathology
No diagnostic test
Defined by clinical symptomatology
Diagnosis based on ruling out pathology
Primary Headache
- Headache is symptom reflecting underlying pathology
- Diagnostic tests available
- Diagnosis based on defining pathology
Secondary headache
Causes of Primary headache
- Migraine
- Cluster
- Tension-type
Causes of secondary headache
- Traumatic (e.g. TBI) • Vascular (e.g. SAH) • Infectious (e.g. sinusitis)
- Metabolic (e.g. CO poisoning)
- Oncologic – Primary – Secondary
- Inflammatory (e.g. Giant Cell Arteritis)
What do all the below structures have in common?
Meningeal arteries
Proximal portions of the cerebral arteries
Dura at the base of the brain
Venous sinuses
Cranial nerves 5, 7, 9, and 10, and cervical nerves 1, 2, and 3
Pain sensitive intracranial structures
Pt comes in with recurrent migraines, normally DO NOT get CT or MRI unless:
– Recent change in headache pattern
– New onset seizures
– Focal neurologic signs or symptoms
____of Headache Seen in Primary Care Practices (PCP) Medical Offices is Migraine and ____of Patients in PCP Waiting Rooms have Migraine with _____ of migraneurs undiagnosed
~75%
33%
50%
_____ Women has Migraines
____ Households has a Migraine Sufferer
1 in 5
1 in 4
These types of headaches are brief: may see 1 every other day up to 8 per day and are SEVERE, Unilateral orbital/supraorbital/temrporal and last 15-180 mins
Cluster headaches
Cluster headaches have characteristic UNIlateral orbital/supra/temporal headahce for 15-180 mins and one of which types of symptoms
Conjucntival injection, miosis, ptosis, lacrimation, eyelid edema, rhinorrhea, congestion, forehead/face swelling
so bacially weird eye/nose/face stuff
We may see pain around one eye, along with drooping lid and tearing or conjestion on same side as pain
Horner sydrome associated with Cluster headaches
To be Dx with headaches without aura, you must have at least 5 of them, they last 4-72 hrs and have two of the following:
unilateral location
pulsating quality
moderate or severe intensity
aggravated by walking up stairs/physical activity
You must have at least ONE associated symptom to have dx of migraine w/out auras. These are:
Nausea
vomitting
photophobia/phonophobia
What three features are most predictive of diagnosis with migraines
Nausea
disability
photophobia
What is a fortification specra with partial scotoma
fancy way to describe aura that sometimes preceeds migraines
last 15-20 mins, sometimes see brief seizures; all aura have + visual elements thus its a HYPERexcitable state
To be Dx with tension-type headaches, you must have a head that lasts
hours or may be continous
We need two descriptors of tension headaches to dx; what are they?
What associated findings are seen in tension headaches?
no more then ONE!!!
photo/phonophobia
mild nausea
**no moderate or severe nausea nor vomitting
Weird way to describe tension headache
Stress as associated event
Location: Tension Headache as Premonitory Symptom
If neck pain 82% get Tension Headache diagnosis
75% reported neck pain with their migraine
43% described neck pain as bilateral and 57% as unilateral
69% described the neck pain as “tightness” and 17% as “stiffness”
How does someone truly suffer from sinus headache?
need to have fully filled sinus and congestion
**migrains will cause nasal stuffiness and pressure before treatment
*people may think they have sinus headache when it is migrain and will experience some symptom relief from decongestants bc tx syptoms of migraine
What do we need to consider when dx sinus headache
location, autonomic symptoms, weather as trigger and OTC advertisement
Non modifiable risk facotrs for chronic daily headache
migrain
female sex (estrogen)
low education
low socioeconmic class
head injury
What are MODIFIABLE risk factors for chronic daily headaches
Attack frequency
Obesity
Medication overuse
Stressful life events
Snoring (sleep apnea, sleep disturbance)
42 year old male presents with complaint of sinus headache
Current headache problem has been recurrent every night waking patient from sleep
Pain is in left eye and feels “like a dagger”
Has intense nasal congestion leading to rhinorreha as well as a red eye that tears profusely.
Pain last 30 minutes. He thinks nasal sprays help
- He had similar headaches last December which went away after a month on antibiotics.
- His PMH/PSH/FH are unremarkable. He drinks socially but has stopped since these headaches began because of “hangover” as soon as he imbibes.
- PE: unrmarkable, no intranasal findings, no percsussion tenderness
correct dx??
CLUSTER headaches
- 31 year old female presents with complaint of headaches that “won’t go away”
- Had occasional headaches like these for years. Never “big deal” as came and went and rarely required medicine.
- 6 months ago the headaches became increasingly frequent and longer lasting until they became constant.
- Denies any other symptoms with these headaches
- PMH/PSH/FH unremarkable. SH-began working for EPIC 7 months ago.
- ROS: has developed insomnia and “too tired” to go out with friends or exercise.
OTC meds afford no relief. Sometimes a glass of wine seems to help.
Exam: Negative except for subocciptial tenderness and increased muscle tension in Trapezius and Cervical Paraspinal muscles
DX
chronic tension type headache
Proposed mechanism for Migraine initiation
Genetic susceptibility
Cortical neuronal hyperexcitability/// abnormal brainstem fnx
What leads to cortical spinal depression which causes Actvation and peripheral sensitization of TGVS
Cortical neuralonal excitability cauases cortical spinal depression (which can lead to aura)
What plays a role in pain generation/perpetuation in headaches
Neurogenic inflammation and central sensitization as a result of TGVS activation and sensitizaiton (from corical spinal depresion)
Mechanism for Hyperexcitability
• Enhanced release of excitatory neurotransmitters
– For example, elevated plasma glutamate concentration in patients with migraine
– Identified genetic mutations in Familial Hemiplegic Migraine (FHM)
• Reduced intracortical inhibition
Low brain Mg2+
Altered brain energy metabolism
Initiating Mechanisms of Headache Pain: Cortical Spreading Depression
Wave of intense cortical neuron activity
– ↑rCBF
Followed by neuronal suppression
– ↓rCBF
– Often coincides with headache onset
What is responsible for Activation of the Trigeminovascular System and Pain Generation
Cortical spreading depression: releases AA, NO, H+ and K+ to meninges
get sensitized pain respons adn dilation of vessels
Initiating Mechanisms of Migraine: Brainstem Dysfunction
Dysfunction in areas involved in central control of nociception *** PAG
Induces migraine? ****Brainstem generator
Facilitates activation and sensitization of TNC neurons? **** Decreased descending inhibition during a migraine attack
Migraines can be a result of brainstem dysfnx
What facilitates activation and sensitization of TNC neurons?
**** Decreased descending inhibition during a migraine attack
Abortive Pharm for migraines
Triptans = Key for Abortive: includes Seratonin/ CGRP and Neurotransmission= major class
Hormonal manipulation: such as estrogen and NSAIDS
Mechanism of Triptans
Seratonin 1B/1D agonist, ≠release of vasoactive peptides such as CGRP, promte vasocnx, ≠brstm pain path, ≠trigeminal nucleus caudalis
Side effects of Triptans
Sides = periph vasocnx/ nauseua/vomit/angina/flush/dizzy
Contraindication:stroke and MI, uncontrolled HTN, ischemic heart disease
Prophy drugs for migraines
TCA, Beta Blockers, anti-seizure agents, BP type drugs, estrogens
TCAs used to treated migraines prophylactically
Amitryptyline, Nortirptyline
Facilitate sleep; sedating. Are anticholinergic and effective for many pain sources; Block reuptake of serotonin and Nepi
Amitryptyline, Nortirptyline
TCAs
Divalproex Sodium and Valpoic Acid, Topiramte
Anti-seizure meds to proph tx migraines
Vasoactivce compounds use to proph tx migraines
Beta blockers: Propranolol, Atenolol = A level and very effective
Ca+ channel blockers: verapamil, Dlitazem; possibly effective
Serotonin formation
Tryptophan –>(tryptophan hydroxylase as RLS)–>–> serotonin. Trypto.hydroxlase needs O2 and reduced pteridine cofactor; also limited by tryptophan entry into brain
Serotonin reactivation:
Active reuptake via SERT/ metabolized to 5-hyroxoindole acetic acid via MAO and converted to melatonin in pineal gland via hydorxindole-O-methyl transferase
Serotonin dispersment in the body
90% in GI system—some in neurons, 8% in plats and 2% in CNS; midbrain raphe nucleus projects all over brain; turnover w/in 4 hours
Descirbe Serotonin Receptors
Most GCPR except 5HT3 = ligand gated Cation channel
Inhibition of adenlyate cyclase; 5-HT1a also opens K+ channels
5HT-1a-e
Serotonin R that works via PI hydrolysis
5-HT2 (a-c)
Serotonin R that works via: Activation of adenylate cyclase or unknown
5-HT 4-7
Auto receptors that Decrease serotonin release
: 1A and 1D like
Serotonin effecs on CV system
Potent vasoCNX of large art/vns; cranial 5-HT1D blood vessels
vasoDIALATIOn in coronary, skeletal msl, cutaneous
Bezold-Jarish reflex = coronar chemoR; lead to hypotension, hypovent, brady
Plat aggregation: active uptake serotonin from circulation by plats
Serotonin and CNS system
NTs: cell body in midbrain raphe nuclei project rostrally and caudally
Sensory perception/slow wave sleep/temp regulation/neuroendo= ACTH,GH, prolact,TSH,FSH,LH release/ learning+memory + short term/ pain perception/ drug abuse
_____= emisis receptors
Has mental illness implications; anxiety =______
5-HT3 =
5-HT1A
5-HT1A partial agonist for antianxiety
buspirone
5-HT1B/D receptor on cerebral BV to tx migraines and stop exsisting
Sumatriptan
