Headaches Flashcards
When a patient presents with a headache, what type of history questions do you need to ask?
Location, onset, frequency, duration, quality, severity, timing, aggravating/alleviating, associated sxs (worse with…)
If a patient can’t answer a lot of those history questions, what would it be important to ask them to do?
Keep a headache diary
What type of PE would you do for a patient with HA?
BP, examine the head, vision, visual fields, EOM’s, funduscopic, neuro exam, gait, motor & reflexes
Migraines most frequently occur in what population?
Women
Does everyone with a migraine have an aura?
No, only 15% have an aura
What is the typical onset of migraines?
Initiate in adolescents/early adulthood (peaks 30-45; and regresses after age 60)
What are typical migraine triggers?
Physical activity (including sex), emotional stress, lack of sleep, foods, odors, missed meals, and menstruation
What is the main physiologic theory behind migraine headaches?
Neurogenic Theory – involving inflammatory & vascular components
the brain activates or sensitizes the trigeminal nerve → initiating a HA via neurologic inflammation.
The vascular changes that occur are a results of vascular inflammation
Physiologically, how does serotonin contribute to migraines?
A neurotransmitter that activates pain fibers and then contributes to vasoconstriction and inflammation
What is an aura?
15-30 minute episodes of focal neurological dysfunction that appear before the HA
How does an aura present?
Expanding scotoma (blind spot) with scintillating margins (stars, sparks, zigzags of light); visual field deficits, unilateral paresthesias, numbness, weakness, dysphagia
Are vertigo, ataxia, tinnitus, and hearing loss associated with an aura?
NO
What if a patient has a prolonged aura with neurological defects for an hour or more?
Then we are concerned about a complex migraine
If a patient has a complex migraine what must we rule out?
a stroke
What does the headache phase of a migraine involve?
Throbbing or pulsatile pain that can be lateralized or generalized that can last 4-72 hours
What are the associated symptoms of migraines?
N/V, photophobia, phonophobia, and anorexia
What are the rules of therapy for migraines?
Treat early, treat aggressively until HA is gone (may need more than one dose of meds), consider pros vs cons of oral meds
What is the main type of med we use for migraines?
triptans
How do tiptans work?
They have a high affinity for serotonin receptors in the trigeminal nerve branches to cause vasoconstriction
Why should a serotonin agonist abort a migraine?
Because it functions at the presynaptic autoreceptors whose activation inhibits the release of serotonin
How would we treat a mild to moderate migraine?
Oral triptan
If it’s an acute severe migraine, how would we treat it?
Consider alternative route = injection or intra-nasal
If the migraine is severe and intractable, and the patient is now at the hospital, what do we do?
Inject Demerol + anti-emetic
Would morphine help a migraine patient?
NO! it will make it worse (since it’s a vasodilator)
When would we treat a patient prophylactically for their migraines?
If their HA’s limit work/ALD’s for 3+ days/month; is the sxs of HA are severe, previous migraines are associated with stroke (complex migraine)
What meds are best to treat prophylactically?
Beta Blockers (propranolol); Tricyclic antidepressants, Ca channel blockers, Anticonvulsants, Botox injections
If a patient gets mild attack migraines, how do we abort it?
Rest in dark room, ASA & NSAIDS (EARLY!), Ergotamine, or Cafergot-Ergotamine
Can ergotamines be used in anyone?
Not in patients with a history of HTN, CAD, or stroke
If you are seeing a patient for a headache that they describe as a “band” around their head, with steady tightness/pressure. They deny N/V, photophobia, or getting worse with activities. Diagnosis?
Tension headache
What is a tension headache often associated with?
stress/fatigue, depression, or minor trauma
How would you treat your patient with a tension headache?
Acetaminophen & NSAIDS
How can you prevent a tension headache?
Relaxation techniques
If you are seeing a patient regarding intense unilateral pain around the eye/temporal area with watery eyes and drooping of the eyelid with a runny nose on the opposite side, what diagnosis?
Cluster headache
For how long does a cluster headache continue?
15 minutes – 2 hours, can recur daily for weeks
What are the triggers for cluster headaches, which one should you be sure to always ask you patient about?
Alcohol (always ask!), stress, glare, and foods
What is likely occurring during a cluster headache?
Activation of the trigeminal-vascular system
If you are seeing a patient who has intermittent headaches, but then realizes that they are getting 15 or more headaches per month, what diagnosis would this be?
Chronic daily headache
What types of headaches are included in chronic daily headaches?
Tension, cluster, migraine, and other vascular HA
What is the most common risk factor to developing chronic daily HA?
Medication overuse
How do you treat chronic daily HA?
Withdrawal of meds often improves it, along with massage/acupuncture/PT/relaxation
If a patient presents with a dull frontal (or occipital) HA that starts in the morning and is worsened by exertion, and they also have N/V, what diagnosis?
Intracranial Mass lesions
What are two significant clues that a patient has an intracranial lesion?
New onset of HA’s and they’re 45+
Usually a disturbance in cerebral function
If a patient presents with acute onset of hearing loss in one ear, what must you think?
Schwannoma (benign acoustic neuroma)
How do you diagnose an intracranial mass?
CT or MRI
What if the intracranial mass was a glioma, what is the prognosis?
Not as good
