Headaches Flashcards
What types of headaches make up 90% of headaches?
Migraine: Most commonly diagnosed
Tension: Most frequent
Cluster: Common and very painful
Chronic daily
What questions would you ask a patient with headaches?
Where? When? How often, how long, how bad?
FHx? Relieving factors/meds? Changes in health or life?
What vision workup would you do on a patient with headaches?
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
What are danger signs of headaches?
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
What do you do if you notice danger signs of headaches?
Patient needs to get imaging and lumbar puncture
What type of imaging would you do with a patient with danger signs of headaches?
MRI preferred - better images lesions and hemes
CT good if acute or hemorrhagic - also more common
What might you see in a lumbar puncture of a patient suffering from danger signs of headaches?
WBCs if meningitis
RBCs if subarachnoid hem
What are the risk factors for Migraines?
Lady in her 30s
Genetics (50%)
True or false? Migraines are typically unilateral
True
How often to Migraines occur per month?
1-4 times per month
What’s more common: migraines with aura or migraines without aura?
Migraines without aura more common (75%)
What’re diagnostic criteria to be considered a migraine without aura?
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
Diagnostic criteria to be considered migraine with aura?
- At least 2 attacks
- 1+ totally reversible auras
- 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 - Rule out other headaches as well as TIA
What did we used to think caused migraines?
Vascular problems in brain
What do we now know causes migraines?
Neurological dysfunctions, namely Cerebral spreading depression (CSD)
What happens in cerebral spreading depression (CSD) that causes migraines?
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)
What are the causes of migraine?
Cerebral spreading depression Permeability of blood brain barrier Sensitization of nociceptors Decreased serotonin and estrogen Increase in dopamine
What markers cause permeability of the blood brain barrier?
COX2
TNF alpha
MMPs
What are the vasoactive peptides released with activation of trigeminovascular system?
CGRPs
Substance P
Neurokinin A
What are the phases of a migraine?
Prodrome
Aura
Headache
Postdrome
What are some migraine triggers?
In order of how common Stress Hormones Hunger Neckpain Certain foods (Nitrates, sulfates, aspartame)
Describe a migraine prodrome
Occurs 24-48 hours before migraine
Depressed, irritable, fatigued/yawning
Can’t concentrate, Cravings, neck stiffness
Aversion to light, sounds and smells
How long does a migraine aura last? Is it reversible?
Duh it’s reversible
Gradually increases and lasts about an hour
Describe visual aura
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
Describe somatosensory aura
Burning, pain, paresthesia
Describe auditory aura
Tinnitus, hearing things
Describe motor aura
Heavy limbs, difficulty speaking
Describe a migraine headache
Begins dull and gradually escalates to throbbing
May be accompanied by nausea and vomitting
Resolves with sleep
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
Describe migraine postdrome
Migraine hangover
Exhausted, pain with sudden head movements
What is a migraine without headache called?
Acephalgic migraine
Do you get postdromes with acephalgic migraines?
Yeah man, that’s the one you get all the time
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
What should you never give people with migraines?
Opiods or narcotics
What OTC meds can you use for migraines?
Excedrine migraine or extrastrength Aspirin Acetaminophen Naproxen Ibuprofen
Is it better to take multiple small doses or one large dose for migraines?
One large dose
What is the mechanism of action for triptans?
Serotonin agonist
Inhibition of vasoactive peptides and pain receptors
Promote vasoconstriction
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
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
What symptom are triptans especially indicated for?
Cutaneous allodynia
What’s treximet?
Expensive drug made of sumatriptan and naproxen
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)
What should not be taken with dihydrogergotamine? why?
Other triptans
Too much serotonin and vasoconstriction
Why would you use anti-emetics for migraine? What are the drugs?
Acts as dopamine antagonist! It usually has too much
Metoclopramide
“-azine”
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 BotoxWhat’re nonpharm treatments of migraines
Avoid triggers and keep HA diary
Regular eat, sleep and exercse
Acupuncture
TENS
What’s the most common type of headache?
Tension headaches
What demographic is most affected by tension headaches?
Women
What’s the diagnostic criteria of tension headaches based on the ICHD3?
- At least 10 episodes
- HA lasts 30 mins to 7 days
- HAs have 2 of following qualities
Bilateral
Pressing quality
Mild to moderate
Not aggravated by physical activity - Cannot have N/V and can’t have both photo and phonophobia but can have one of them
What are the types of tension headaches? which is most common?
Most common: Infrequent
15 days per month
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
What are risk factors for postherpetic neuralgia?
Older age
Immuncompromised
Severity of the initial herpzoster rash
How long can postherpetic neuralgia last?
Greater than 4 months after initial outbreak
How would you treat postherpetic neuralgia?
Amitriptyline: TCA
Gabapentin: Anticonvulsant. Increases GABA to inhibit pain
Capsaicin: Decreases Substance P
Possibly Botox
What is the quality of headaches for Trigeminal autonomic cephalgias? What causes it?
Unilateral trigeminal pain with autonomic problems
Abnormal trigeminal nerve or hypothalamus
Which trigeminal autonomic cephalgia is also known as “suicide headaches?”
Cluster headaches
What are the headaches like in cluster headaches?
Excrutiating nonpulsatile unilateral orbital or temporal pain accompanied with autonomic symptoms
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
What other symptoms might you note in cluster headaches?
Restless and agitated
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
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
Treatments for acute cluster headaches?
100% O2
SubQ or intranasal sumatriptan
Treatments for chronic cluster headaches?
Verapamil
Prednisolone
Vasoconstrictors
Chronic cluster headaches can also be caused by neural stimulation to the hypothalamus, autonomic and occipital nerves
Free Card
What are the headaches like in SUNCT?
Short lasting unilateral with conj injection and tearing
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
Who is more likely to get SUNCT?
50 year old males
What autonomic finding is noted in SUNCT
Conj injection and tearing
What kind of relapse/remilssion pattern do you note with SUNCT?
Sawtooth pattern
Will those with SUNCT have cutaneous allodynia?
Yes
What are triggers of SUNCT?
Touching, Talking, chewing
What’s the treatment for acute SUNCT?
IV lidocaine
What’s the treatment for chronic SUNCT?
Lamotrigine
Optic nerve stimulation
So what are all the Trigeminal autonomic cephalgias?
Cluster headaches
Paroxysmal hemicrania
SUNCT
What is the headache quality with paroxysmal hemicrania?
Throbbing unilateral pain (always on the same side) with at least 1 other autonomic symptom
How long do paroxysmal hemicrania headaches usually last?
2-3 minutes for 11-14 times per day
Who does paroxysmal hemicrania typically affect?
Women 34-40 years old
How can you diagnose paroxysmal hemicrania?
Will resolve in 1-2 days with indomethacin
What is the headache quality of thunderclap headaches?
Severe sudden headache onset that is unilateral or bilateral
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
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)
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
What is the treatment for thunderclap headaches?
No prophylactic
Just treat underlying disease if there is one
What are symptoms of sinus headaches?
Headaches with congestion and mucopurulent discharge
What can symptoms be confused for?
Migraine headaches
Who is more affected by sinusitis?
Females over 50
What is the typical cause of sinusitis?
Viral infection which leads to inflammation of sinuses and paranasal sinuses
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
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
How would you treat a viral sinusitis?
Observation, NSAIDs, decongestants, saline irrigation
How would you treat a bacterial sinusitis?
Antibacterial (augmentin)
How would you treat chronic sinusitis?
Oral/topical NSAID with antibiotic
What are some secondary causes of headache?
TBI, Pregnancy (Pre eclampsia), fever, sinusitis, IIH, Intracranial mass, giant cell arteritis
What are headaches from intracranial masses like?
Initial complaint of deep and dull HA that worsens with waking. New headache in older patients
What other symptoms might you notice with headaches from intracranial masses?
Nausea and vomitting
Seizures, vision loss, focal weakness
Personality change
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
What are common causes of intracranial tumors from metastases?
Breast or lung cancer
How would you treat intracranial tumors?
How you’d treat every other tumor. Chemo, radiation and surgery
What age of onset would you notice giant cell arteritis?
~70
Uncommon in patients under 50 years old
In what demographic would you notice giant cell arteritis?
White females over 50
What are the symptoms of giant cell arteritis?
New onset headache with scalp tenderness and jaw claudication
