headaches Flashcards
List the two types of primary headaches (occur independently)
- vascular
- muscle contraction -> tension type
List the two types of vascular headaches
- migraine
- cluster
List the two types of secondary headaches (associated with another disorder)
- traction
- organic diseases of the head (ex: intracranial mass)
- inflammatory
- ex: meningitis
what is the most important factor in establishing a diagnosis for headache
headache history
- frequency
- duration
- intensity
- location
- quality
- time and setting of onset
- aggravating/alleviating factors
- age of onset
- associated sx
clinical presentation
- throbbing, pulsating, typicall unilateral
- duration: 4-72 hours
- +/- photophobia, phonophobia, N/V
- movement makes it worse
Migraine
List the two main types of Migraines
- migraine without aura (“common”)
- migraine with aura (“classic”)
what type of migraine is this
- visual aura, vertigo, dysarthria, ataxia, decreased level of consciousness, syncope, tinnitus, hypacusis (hearing impairment)
migraine with brainstem aura (“Basilar”)
what type of migraine is this
- visual loss or disturbance in one eye
- retinal migraine
what type of migraine is this
- unilateral HA with oculomotor palsy
- diplopia, ptosis, dilated pupil
- ophthalmoplegic neuropathy
what type of migraine is this
- hx of episodic vertigo with hx of migraines
vestibular migraine
what type of migraine is associated with menstrual cycle
menstrual migraine
what type of migraine is this
- temporary paralysis
- familial component
hemiplegic migraine
what type of migraine is this
- rare, severe disabling migraine lasting > 72 hours
- requires hospitalization
status migrainosus
how long does an aura last both before the HA comes on and total time
- visual and/or other neurological sx 10-60 min prior to HA
- aura last less than 60 min
What is the premonitory symptoms phase of migraine
- 24-48 hours prior to HA
- food craving, mood change, uncontrollable yawning, fluid retention, inc urination, neck stiffness
what are the positive symtoms of an aura
- visual
- auditory
- sensory
- motor
what are the negative symtoms of an aura
- loss of function, vision, hearing, sensation, or motor
what is characteristic about the onset of a migraine
builds gradually in intensity
postdrome phase of migraine may be associated with
- confusion
- exhaustion
describe the sensory aura associated with a migraine
- unilateral tingling (face, limb)
- abnormal sensations
define cutaneous allodynia
- abnormal pain response from things like combing hair, shaving, wearing glasses, contact lens, earrings, tight fitting clothing
how are migraines diagnosed
- history and physical exam
- no imaging necessary
what are clinical scenarios involving HA that warrant imaging
- “worst headache of my life”
- changes in HA presentation
- new or unexplained neurologic symptoms
- HA not responding to treatment
- new onset after 50 or in pts with CA or HIV
what imaging is recommended in evaluation of HA
CT
acute migraine tx
- decrease triggers
- rest in dark quiet environment
- cool cloths on forehead
- fluid
- caffeine in early stages
- meds
first line medications/abortive for mild/moderate migraine
- oral NSAIDs, acetaminophen or OTC combination (excedrin, midrin)
- N/V -> add antiemetic
first line medications/abortive for moderate/severe migraine
-
triptans and Ergots
- oral triptans or combination with NSAID (sumatriptan, naproxen)
side effects of Triptans
- “Tripton sensation”
- chest pressure, weakness, dizziness, paresthesia
- resolve in 30 min
contraindications to Triptans and Ergotamine
- these meds are vasoconstrictors
- uncontrolled HTN
- pregnancy
- Hx of MI, Cerebrovascular disease, peripheral vascular disease
List the three medications that are first-line for preventative migraine management
- propranolol (B-blocker)
- amitriptyline (TCA)
- Topiramate (anticonvulsant)
*consider co-morbidies when choosing
clinical presentation
- bilateral pressure, band-like
- mild-moderate intensity
- duration 30 min-7 days
- anorexia, head/neck pain with muscle tenderness, bruxism (grinding teeth)
- no N/V
tension type headache
list common triggers for tension type headache
- stress
- jaw clenching
- missed meals
- depression
- too little sleep
- head/neck strain
criteria for infrequent episodic tension type headache
- < 12 days/ year
- lasting < 1 day/month
criteria for frequent episodic tension type headache
- 10-14 days/month
- lasting 30 min to several days
criteria for chronic tension type headache
- > 15 d/month
- lasts hours to days
- may be unremitting
how are tension type HA diagnosed
- history and clinical presentation
treatment for tension type HA
- NSAIDs
- high initial dose
cluster headaches are commonly seen more in what patient population
Men
cluster headaches are associated with what
- Trigeminal autonomic cephalgias (TACs): sharp, boring, unilateral, periorbital HA with autonomic sx
duration of cluster headaches
- brief, 15-180 minutes
how often can cluster headaches come on
- attacks: every other day - 8x/day
- clusters: typicallly 6-12 weeks
remission period for cluster HA
up to 12+ months
chronic cluster headache
- clusters lasting > 1 year or remission < 1 month
are cluster headaches associated with a certain time of day
- come on similar time of day/night
autonomic sx of cluster headache
-
parasympathetic hyperactivity and sympathetic impairment
- lacrimation
- eyelid edema
- nasal congestion
- rhinorrhea
- facial sweating
- miosis
- ptosis
- ***ipsilateral to pain
triggers commonly associated with cluster headache
- alcohol
- smoking
- stress
how is cluster headache diagnosed
- history and clinical presentation
-
MRI with and without contrast
- to evaluate brain and pituitary gland
treatment of acute cluster headache
-
Oxygen: nonrebreathing facemask 100% O2 at 12 L/min
- sitting upright
- continue x 15 min
- triptan: subcutaneous sumatriptan
preventative medication for cluster headache
- start at onset of cluster episode
- CCB: Verapamil
criteria for chronic daily headache
- > or = 15 days/month during 3+ months
list four types of chronic daily headaches
- chronic migraine
- chronic tension type
- hemicrania continua
- newly daily persistent headache
clinical presentation
- continuous, fluctuating pain on same side of face/head lasting minutes-days
- associated sx: tearing, irritated eyes, rhinorrhea, swollen eyelids
hemicrania continua
tx of hemicrania continua
indomethacin and/or corticosteroids
clinical presentation
- pain ranges mild-severe: throbbing/tightening on both sides of head
- associated sx: light/sound sensitivity
- may occur following infection, medication use, trauma, or other condition with no previous hx or headache
newly daily persistent headache
clinical presentation
- “ice pick” or “jabs and jolt” headache
- pain is intense and strikes without warning
- lasts 1-10 seconds
- may occur anywhere along trigeminal nerve
- occur daily-yearly
- primary stabbing headache
triggers associated with primary exertional headache
- coughing, sneezing, intense activity
imaging recommended for primary exertional headache
- MRI/MRA to r/o vascular abnormalities
clinical presentation
- “alarm clock headache”
- occurs later in life (> 50 yo)
- develops during sleep and awakens people at night
- > 10 episodes/month lasting 15 min-3 hours
hypnic headache
treatment for hypnic headache
- caffeine at night > indomethacin > lithium
What is the SNOOP checklist for secondary headaches
- Systemic sx or illness (fever, weight loss)
- Neurologic (focal sx, decreased LOC)
- Onset sudden
- Older (new onset > 50 yo)
- Previous HA hx (1st HA or change in HAs)
clinical presentation
- sx increase with cough, exertion, straining, position
- papilledema, vision loss, pulsatile tinnitus
- CSF pressure
- idiopathic intracranial hypertension
clinical presentation
- abrupt severe headache
- “thunderclap headahce”
- decreased LOC, nuchal rigidity
- first and worst HA
subarachnoid hemorrhage
clinical presentation
- primary HA develops or worsens with medication overuse
- typicall preceeded by an episodic HA disorder
- high risk: opioids, barbituates, aspirin, acetominophen
- HA often occurs when analgesic is withheld
medication overdose headaches
