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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
Describe somatosensory aura
Burning, pain, paresthesia
26
Describe auditory aura
Tinnitus, hearing things
27
Describe motor aura
Heavy limbs, difficulty speaking
28
Describe a migraine headache
Begins dull and gradually escalates to throbbing May be accompanied by nausea and vomitting Resolves with sleep
29
What's cutaneous allodynia?
Usually peaks with migraine headache and doesn't last any longer than headache itself Skin sensitized to pain. Feel pain with inocuous stimuli
30
Describe migraine postdrome
Migraine hangover | Exhausted, pain with sudden head movements
31
What is a migraine without headache called?
Acephalgic migraine
32
Do you get postdromes with acephalgic migraines?
Yeah man, that's the one you get all the time
33
How would you treat acute migraines?
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
34
What should you never give people with migraines?
Opiods or narcotics
35
What OTC meds can you use for migraines?
``` Excedrine migraine or extrastrength Aspirin Acetaminophen Naproxen Ibuprofen ```
36
Is it better to take multiple small doses or one large dose for migraines?
One large dose
37
What is the mechanism of action for triptans?
Serotonin agonist Inhibition of vasoactive peptides and pain receptors Promote vasoconstriction
38
What are possible adverse effects of triptans?
Serotonin syndrome - too much serotonin HTN, dilation and agitation TIA if previous heart disorder (due to promoted vasoconstriction) Tachyphylaxis
39
What's the suffix for triptans? Which one is best to use if patient is nauseous?
"-triptan" | Sumatriptan is best, can be taken orally, nasally or IM
40
What symptom are triptans especially indicated for?
Cutaneous allodynia
41
What's treximet?
Expensive drug made of sumatriptan and naproxen
42
What is dihydroergotamine good for? How does it work? What should you take it with and why?
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
What should not be taken with dihydrogergotamine? why?
Other triptans | Too much serotonin and vasoconstriction
44
Why would you use anti-emetics for migraine? What are the drugs?
Acts as dopamine antagonist! It usually has too much Metoclopramide "-azine"
45
What're some preventative therapies for migraines?
``` 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
What're nonpharm treatments of migraines
Avoid triggers and keep HA diary Regular eat, sleep and exercse Acupuncture TENS
47
What's the most common type of headache?
Tension headaches
48
What demographic is most affected by tension headaches?
Women
49
What's the diagnostic criteria of tension headaches based on the ICHD3?
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
What are the types of tension headaches? which is most common?
Most common: Infrequent | 15 days per month
51
What kind of pain do you feel with post herpetic neuralgia?
Unilateral sharp pain in the V1 (Ophthalmic region) of the trigeminal nerve Also get cutaneous allodynia
52
What are risk factors for postherpetic neuralgia?
Older age Immuncompromised Severity of the initial herpzoster rash
53
How long can postherpetic neuralgia last?
Greater than 4 months after initial outbreak
54
How would you treat postherpetic neuralgia?
Amitriptyline: TCA Gabapentin: Anticonvulsant. Increases GABA to inhibit pain Capsaicin: Decreases Substance P Possibly Botox
55
What is the quality of headaches for Trigeminal autonomic cephalgias? What causes it?
Unilateral trigeminal pain with autonomic problems | Abnormal trigeminal nerve or hypothalamus
56
Which trigeminal autonomic cephalgia is also known as "suicide headaches?"
Cluster headaches
57
What are the headaches like in cluster headaches?
Excrutiating nonpulsatile unilateral orbital or temporal pain accompanied with autonomic symptoms
58
What autonomic symptoms might you find in cluster headaches?
Sympathetic is decreased so parasympathetic prevails Ptosis, Miosis, Lid edema Lacrimation and nasal congestion Conj injection
59
What other symptoms might you note in cluster headaches?
Restless and agitated
60
What is the frequency of cluster headaches and how long do they typically last?
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
What are triggers of cluster headaches? Why do we think these triggers cause cluster headaches?
Alcohol and smoking | Hypoxic events can lead to dilation causing cluster headaches
62
Treatments for acute cluster headaches?
100% O2 | SubQ or intranasal sumatriptan
63
Treatments for chronic cluster headaches?
Verapamil Prednisolone Vasoconstrictors
64
Chronic cluster headaches can also be caused by neural stimulation to the hypothalamus, autonomic and occipital nerves
Free Card
65
What are the headaches like in SUNCT?
Short lasting unilateral with conj injection and tearing
66
How long do SUNCT headaches last? How often do they occur?
Last 1 - 240 seconds Occur up to 200 x a day Average is about 60x per day
67
Who is more likely to get SUNCT?
50 year old males
68
What autonomic finding is noted in SUNCT
Conj injection and tearing
69
What kind of relapse/remilssion pattern do you note with SUNCT?
Sawtooth pattern
70
Will those with SUNCT have cutaneous allodynia?
Yes
71
What are triggers of SUNCT?
Touching, Talking, chewing
72
What's the treatment for acute SUNCT?
IV lidocaine
73
What's the treatment for chronic SUNCT?
Lamotrigine | Optic nerve stimulation
74
So what are all the Trigeminal autonomic cephalgias?
Cluster headaches Paroxysmal hemicrania SUNCT
75
What is the headache quality with paroxysmal hemicrania?
Throbbing unilateral pain (always on the same side) with at least 1 other autonomic symptom
76
How long do paroxysmal hemicrania headaches usually last?
2-3 minutes for 11-14 times per day
77
Who does paroxysmal hemicrania typically affect?
Women 34-40 years old
78
How can you diagnose paroxysmal hemicrania?
Will resolve in 1-2 days with indomethacin
79
What is the headache quality of thunderclap headaches?
Severe sudden headache onset that is unilateral or bilateral
80
How long do thunderclap headaches last? How often do they last?
Lasts at least 5 minutes but up to a week | Don't usually reoccur
81
What do you need to rule out with thunderclap headaches? How would you do that?
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
How would you be able to tell if there was an underlying cause for the thunderclap headache?
If N/V present, there is an underlying cause, if not, then it could just be that headache
83
What is the treatment for thunderclap headaches?
No prophylactic | Just treat underlying disease if there is one
84
What are symptoms of sinus headaches?
Headaches with congestion and mucopurulent discharge
85
What can symptoms be confused for?
Migraine headaches
86
Who is more affected by sinusitis?
Females over 50
87
What is the typical cause of sinusitis?
Viral infection which leads to inflammation of sinuses and paranasal sinuses
88
What would differentiate migraine headaches verses sinus headaches?
Migraines will not respond to decongestants, may not last as long and are not accompanied by a fever
89
Along with headaches, what other features may you notice in sinusitis?
Nasal congestion, the pressure worsens as you bend over, fever, cough, face/tooth pain
90
How would you treat a viral sinusitis?
Observation, NSAIDs, decongestants, saline irrigation
91
How would you treat a bacterial sinusitis?
Antibacterial (augmentin)
92
How would you treat chronic sinusitis?
Oral/topical NSAID with antibiotic
93
What are some secondary causes of headache?
TBI, Pregnancy (Pre eclampsia), fever, sinusitis, IIH, Intracranial mass, giant cell arteritis
94
What are headaches from intracranial masses like?
Initial complaint of deep and dull HA that worsens with waking. New headache in older patients
95
What other symptoms might you notice with headaches from intracranial masses?
Nausea and vomitting Seizures, vision loss, focal weakness Personality change
96
What are the most common causes of primary intracranial tumors?
Meningioma: Benign Pituitary adenoma: Hormonal changes, Bitemporal vision loss Glioma: Worst prognosis. Fast growing and may lead to vision loss of near eyes
97
What are common causes of intracranial tumors from metastases?
Breast or lung cancer
98
How would you treat intracranial tumors?
How you'd treat every other tumor. Chemo, radiation and surgery
99
What age of onset would you notice giant cell arteritis?
~70 | Uncommon in patients under 50 years old
100
In what demographic would you notice giant cell arteritis?
White females over 50
101
What are the symptoms of giant cell arteritis?
New onset headache with scalp tenderness and jaw claudication

Systemic Final (8 decks)

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