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Systemic Final > Headaches > Flashcards

Headaches Flashcards

1
Q

What types of headaches make up 90% of headaches?

A

Migraine: Most commonly diagnosed
Tension: Most frequent
Cluster: Common and very painful
Chronic daily

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2
Q

What questions would you ask a patient with headaches?

A

Where? When? How often, how long, how bad?

FHx? Relieving factors/meds? Changes in health or life?

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3
Q

What vision workup would you do on a patient with headaches?

A

Dilated fundus exam: Usually don’t see anything unless actively having headache. May see transient vasculature changes
Visual field to rule out tumor and aneurysm
Check blood pressure
Eval other cranial nerves

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4
Q

What are danger signs of headaches?

A 
SNOOP
Systemic sympts (Includes pregnancy)
Neuro sympts (Includes bilater disk edema)
Onset new? (Concern if pt > 40)
Other signs (Drugs? Trauma?)
Past headaches with progression?
First or worst headache
Not responding to treatment
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5
Q

What do you do if you notice danger signs of headaches?

A

Patient needs to get imaging and lumbar puncture

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6
Q

What type of imaging would you do with a patient with danger signs of headaches?

A

MRI preferred - better images lesions and hemes

CT good if acute or hemorrhagic - also more common

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7
Q

What might you see in a lumbar puncture of a patient suffering from danger signs of headaches?

A

WBCs if meningitis

RBCs if subarachnoid hem

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8
Q

What are the risk factors for Migraines?

A

Lady in her 30s

Genetics (50%)

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9
Q

True or false? Migraines are typically unilateral

A

True

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10
Q

How often to Migraines occur per month?

A

1-4 times per month

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11
Q

What’s more common: migraines with aura or migraines without aura?

A

Migraines without aura more common (75%)

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12
Q

What’re diagnostic criteria to be considered a migraine without aura?

A

1.At least 5 attacks lasting 4-72 hours without treatment or with unsuccessful treatment
2. HA must have one of the 2 following qualities (PUMA)
Pulsatile
Unilateral
Moderate to severe pain
Aggravated by routine exercise
3. During HA, must have one of the following
Nausea and/or vomitting
Phono or photophobia
4. Other headache causes are ruled out

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13
Q

Diagnostic criteria to be considered migraine with aura?

A
  1. At least 2 attacks
  2. 1+ totally reversible auras
  3. 2 of the following aura characteristics
    1 aura that grows over 5 minutes or multiple that happen in succession
    Lasts 5 - 60 minutes
    Unilateral
    Followed by or comes with headache
  4. Rule out other headaches as well as TIA
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14
Q

What did we used to think caused migraines?

A

Vascular problems in brain

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15
Q

What do we now know causes migraines?

A

Neurological dysfunctions, namely Cerebral spreading depression (CSD)

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16
Q

What happens in cerebral spreading depression (CSD) that causes migraines?

A

Causes release of glutamate which overfires and overexcites neurons in a part of the brain. Area affected will determine the type of aura.
CSD also causes trigeminovascular activation
Causes vasodilation and sterile inflammation
Pain NTs released (CGRP, Substance P, Neurokinin A)

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17
Q

What are the causes of migraine?

A 
Cerebral spreading depression
Permeability of blood brain barrier
Sensitization of nociceptors
Decreased serotonin and estrogen
Increase in dopamine
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18
Q

What markers cause permeability of the blood brain barrier?

A

COX2
TNF alpha
MMPs

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19
Q

What are the vasoactive peptides released with activation of trigeminovascular system?

A

CGRPs
Substance P
Neurokinin A

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20
Q

What are the phases of a migraine?

A

Prodrome
Aura
Headache
Postdrome

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21
Q

What are some migraine triggers?

A 
In order of how common
Stress
Hormones
Hunger
Neckpain
Certain foods (Nitrates, sulfates, aspartame)
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22
Q

Describe a migraine prodrome

A

Occurs 24-48 hours before migraine
Depressed, irritable, fatigued/yawning
Can’t concentrate, Cravings, neck stiffness
Aversion to light, sounds and smells

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23
Q

How long does a migraine aura last? Is it reversible?

A

Duh it’s reversible

Gradually increases and lasts about an hour

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24
Q

Describe visual aura

A

Usually C shaped
Gradually grows over about 5 minutes. Scintillating figure that leaves behind central scotoma
As resolves, scotoma resolves first followed by edges
Unilateral

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25
Q

Describe somatosensory aura

A

Burning, pain, paresthesia

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26
Q

Describe auditory aura

A

Tinnitus, hearing things

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27
Q

Describe motor aura

A

Heavy limbs, difficulty speaking

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28
Q

Describe a migraine headache

A

Begins dull and gradually escalates to throbbing
May be accompanied by nausea and vomitting
Resolves with sleep

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29
Q

What’s cutaneous allodynia?

A

Usually peaks with migraine headache and doesn’t last any longer than headache itself
Skin sensitized to pain. Feel pain with inocuous stimuli

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30
Q

Describe migraine postdrome

A

Migraine hangover

Exhausted, pain with sudden head movements

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31
Q

What is a migraine without headache called?

A

Acephalgic migraine

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32
Q

Do you get postdromes with acephalgic migraines?

A

Yeah man, that’s the one you get all the time

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33
Q

How would you treat acute migraines?

A

Mild to moderate: NSAIDs and acetaminophen
Moderate to severe: Triptans or combo
Extremely severe: SubQ sumatriptan
IV or IM antiemetic + benadryll OR dihydroergotamine
IV or IM Ketorolac or dexamethason

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34
Q

What should you never give people with migraines?

A

Opiods or narcotics

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35
Q

What OTC meds can you use for migraines?

A 
Excedrine migraine or extrastrength
Aspirin
Acetaminophen
Naproxen
Ibuprofen
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36
Q

Is it better to take multiple small doses or one large dose for migraines?

A

One large dose

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37
Q

What is the mechanism of action for triptans?

A

Serotonin agonist
Inhibition of vasoactive peptides and pain receptors
Promote vasoconstriction

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38
Q

What are possible adverse effects of triptans?

A

Serotonin syndrome - too much serotonin
HTN, dilation and agitation
TIA if previous heart disorder (due to promoted vasoconstriction)
Tachyphylaxis

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39
Q

What’s the suffix for triptans? Which one is best to use if patient is nauseous?

A

“-triptan”

Sumatriptan is best, can be taken orally, nasally or IM

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40
Q

What symptom are triptans especially indicated for?

A

Cutaneous allodynia

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41
Q

What’s treximet?

A

Expensive drug made of sumatriptan and naproxen

42
Q

What is dihydroergotamine good for? How does it work? What should you take it with and why?

A

Good for migraines
Acts as serotonin agonist and weak vasoconstrictor
May cause decrease in dopamine leading to Parkinson-like symptoms. Take with diphenhydramine (Benadryll)

43
Q

What should not be taken with dihydrogergotamine? why?

A

Other triptans

Too much serotonin and vasoconstriction

44
Q

Why would you use anti-emetics for migraine? What are the drugs?

A

Acts as dopamine antagonist! It usually has too much
Metoclopramide
“-azine”

45
Q

What’re some preventative therapies for migraines?

A 
Beta blockers: Increase serotonin, blocks pain
     "-olol"
SSRIs: Increase serotonin
     Amitriptyline and venlafaxine
AntiConvulsants: Verapamil, topiramate, lamotrigine
     Increase GABA
Ca channel blockers: not as effective
     Verapamil
Maybe Botox
46
Q

What’re nonpharm treatments of migraines

A

Avoid triggers and keep HA diary
Regular eat, sleep and exercse
Acupuncture
TENS

47
Q

What’s the most common type of headache?

A

Tension headaches

48
Q

What demographic is most affected by tension headaches?

A

Women

49
Q

What’s the diagnostic criteria of tension headaches based on the ICHD3?

A
  1. At least 10 episodes
  2. HA lasts 30 mins to 7 days
  3. HAs have 2 of following qualities
    Bilateral
    Pressing quality
    Mild to moderate
    Not aggravated by physical activity
  4. Cannot have N/V and can’t have both photo and phonophobia but can have one of them
50
Q

What are the types of tension headaches? which is most common?

A

Most common: Infrequent

15 days per month

51
Q

What kind of pain do you feel with post herpetic neuralgia?

A

Unilateral sharp pain in the V1 (Ophthalmic region) of the trigeminal nerve
Also get cutaneous allodynia

52
Q

What are risk factors for postherpetic neuralgia?

A

Older age
Immuncompromised
Severity of the initial herpzoster rash

53
Q

How long can postherpetic neuralgia last?

A

Greater than 4 months after initial outbreak

54
Q

How would you treat postherpetic neuralgia?

A

Amitriptyline: TCA
Gabapentin: Anticonvulsant. Increases GABA to inhibit pain
Capsaicin: Decreases Substance P
Possibly Botox

55
Q

What is the quality of headaches for Trigeminal autonomic cephalgias? What causes it?

A

Unilateral trigeminal pain with autonomic problems

Abnormal trigeminal nerve or hypothalamus

56
Q

Which trigeminal autonomic cephalgia is also known as “suicide headaches?”

A

Cluster headaches

57
Q

What are the headaches like in cluster headaches?

A

Excrutiating nonpulsatile unilateral orbital or temporal pain accompanied with autonomic symptoms

58
Q

What autonomic symptoms might you find in cluster headaches?

A

Sympathetic is decreased so parasympathetic prevails
Ptosis, Miosis, Lid edema
Lacrimation and nasal congestion
Conj injection

59
Q

What other symptoms might you note in cluster headaches?

A

Restless and agitated

60
Q

What is the frequency of cluster headaches and how long do they typically last?

A

Happen up to 8x a day for 15 minutes to 3 hours
Occurs daily for few weeks before remission
They occur more often at night during sleep

61
Q

What are triggers of cluster headaches? Why do we think these triggers cause cluster headaches?

A

Alcohol and smoking

Hypoxic events can lead to dilation causing cluster headaches

62
Q

Treatments for acute cluster headaches?

A

100% O2

SubQ or intranasal sumatriptan

63
Q

Treatments for chronic cluster headaches?

A

Verapamil
Prednisolone
Vasoconstrictors

64
Q

Chronic cluster headaches can also be caused by neural stimulation to the hypothalamus, autonomic and occipital nerves

A

Free Card

65
Q

What are the headaches like in SUNCT?

A

Short lasting unilateral with conj injection and tearing

66
Q

How long do SUNCT headaches last? How often do they occur?

A

Last 1 - 240 seconds
Occur up to 200 x a day
Average is about 60x per day

67
Q

Who is more likely to get SUNCT?

A

50 year old males

68
Q

What autonomic finding is noted in SUNCT

A

Conj injection and tearing

69
Q

What kind of relapse/remilssion pattern do you note with SUNCT?

A

Sawtooth pattern

70
Q

Will those with SUNCT have cutaneous allodynia?

A

Yes

71
Q

What are triggers of SUNCT?

A

Touching, Talking, chewing

72
Q

What’s the treatment for acute SUNCT?

A

IV lidocaine

73
Q

What’s the treatment for chronic SUNCT?

A

Lamotrigine

Optic nerve stimulation

74
Q

So what are all the Trigeminal autonomic cephalgias?

A

Cluster headaches
Paroxysmal hemicrania
SUNCT

75
Q

What is the headache quality with paroxysmal hemicrania?

A

Throbbing unilateral pain (always on the same side) with at least 1 other autonomic symptom

76
Q

How long do paroxysmal hemicrania headaches usually last?

A

2-3 minutes for 11-14 times per day

77
Q

Who does paroxysmal hemicrania typically affect?

A

Women 34-40 years old

78
Q

How can you diagnose paroxysmal hemicrania?

A

Will resolve in 1-2 days with indomethacin

79
Q

What is the headache quality of thunderclap headaches?

A

Severe sudden headache onset that is unilateral or bilateral

80
Q

How long do thunderclap headaches last? How often do they last?

A

Lasts at least 5 minutes but up to a week

Don’t usually reoccur

81
Q

What do you need to rule out with thunderclap headaches? How would you do that?

A

Subarachnoid hemorrhages or ruptured aneurysm
Typically done with CT but can also be checked with MRA and CTA as well as lumbar puncture (will see bilirubin or RBCs in CSF)

82
Q

How would you be able to tell if there was an underlying cause for the thunderclap headache?

A

If N/V present, there is an underlying cause, if not, then it could just be that headache

83
Q

What is the treatment for thunderclap headaches?

A

No prophylactic

Just treat underlying disease if there is one

84
Q

What are symptoms of sinus headaches?

A

Headaches with congestion and mucopurulent discharge

85
Q

What can symptoms be confused for?

A

Migraine headaches

86
Q

Who is more affected by sinusitis?

A

Females over 50

87
Q

What is the typical cause of sinusitis?

A

Viral infection which leads to inflammation of sinuses and paranasal sinuses

88
Q

What would differentiate migraine headaches verses sinus headaches?

A

Migraines will not respond to decongestants, may not last as long and are not accompanied by a fever

89
Q

Along with headaches, what other features may you notice in sinusitis?

A

Nasal congestion, the pressure worsens as you bend over, fever, cough, face/tooth pain

90
Q

How would you treat a viral sinusitis?

A

Observation, NSAIDs, decongestants, saline irrigation

91
Q

How would you treat a bacterial sinusitis?

A

Antibacterial (augmentin)

92
Q

How would you treat chronic sinusitis?

A

Oral/topical NSAID with antibiotic

93
Q

What are some secondary causes of headache?

A

TBI, Pregnancy (Pre eclampsia), fever, sinusitis, IIH, Intracranial mass, giant cell arteritis

94
Q

What are headaches from intracranial masses like?

A

Initial complaint of deep and dull HA that worsens with waking. New headache in older patients

95
Q

What other symptoms might you notice with headaches from intracranial masses?

A

Nausea and vomitting
Seizures, vision loss, focal weakness
Personality change

96
Q

What are the most common causes of primary intracranial tumors?

A

Meningioma: Benign
Pituitary adenoma: Hormonal changes, Bitemporal vision loss
Glioma: Worst prognosis. Fast growing and may lead to vision loss of near eyes

97
Q

What are common causes of intracranial tumors from metastases?

A

Breast or lung cancer

98
Q

How would you treat intracranial tumors?

A

How you’d treat every other tumor. Chemo, radiation and surgery

99
Q

What age of onset would you notice giant cell arteritis?

A

~70

Uncommon in patients under 50 years old

100
Q

In what demographic would you notice giant cell arteritis?

A

White females over 50

101
Q

What are the symptoms of giant cell arteritis?

A

New onset headache with scalp tenderness and jaw claudication

Systemic Final (8 decks)

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