Headaches

Question 1

“red flag” symptoms of headache

Answer 1

• sudden onset maximum severity (“worse headache of my life”),
• headaches increasing in severity/frequency brought on by valsalva/exertion
• headache beginning after age 50, usually with jaw pain
• headache with systemic symptoms
• headache in someone immunocompromised, HIV, or with cancer
• headahce with focal neurologic signs
• headache after trauma
• headache with papilledema

Question 2

sudden onset headache maximum severity “worst headache”, new/different headache

Answer 2

ddx: subarachnoid hemorrhage, pituitary apoplexy, hemorrhage into a mss leson/AVM, mass lesion

eval with imaging, LP if imaging negative

Question 3

headaches increasing in seveirty and frequency, brought on my valsalva/exertion

Answer 3

mass lesion, subdural hematoma, med overuse

eval with imaging/drug screen

Question 4

headache beginning after age 50, esp with jaw pain/claudication

Answer 4

temporal arteritis; mass lesion

eval with imaging, ESR

Question 5

new-onset headache in patient with risk factors for HIV/cancer

Answer 5

meningitis, brain abscess (including toxo), metastases

eval with imaging first, then LP if imaging negative

Question 6

headahe with systemic symptoms (fever, rash, stiff neck)

Answer 6

meningitis, encephalitis, lyme dx, systemtic infection, collagen vascular disease

eval with imaging, LP, serology

Question 7

focal neurologic signs

Answer 7

mass lesion, avm, stroke, collagen vascular disease

eval with imaging, collagen vascular evaluation, including antiphospholipid antibodies)

Question 8

papilledema

Answer 8

mass lesion, pseudotumor cerebri, meningitis

neuroimaging and LP

Question 9

headache after trauma

Answer 9

intracranial hemorrhage, subdural hematoma, epidural hematoma, post traumatic headache

image brain, skull, and cervical spine

Question 10

Diagnostic criteria for migraine

Answer 10

Repeated attacks of headache lasting 4-72 hours in patient with normal physical; no other reason for headache and…

at least 2:
unilateral pain, throbbing pain, aggravation by mvmt, moderate/sever intensity

at least 1
n/v, photophobia/phonophobia

Question 11

What to ask when evaluating headache

Answer 11

• OLDCARTS
• associated symptoms (esp neurologic)
• prior headaches/episodes
• age of onset
• frequency/duration
• amount of disability/distress
• what patient has done to treat headache/past headaches, medication details

Question 12

status headache

Answer 12

headache lasted more than 72 hours

Question 13

When to do neuroimaging for headache

Answer 13

when there is an unexplained neurologic deficit or if headache is different from a primary headache disorder

Question 14

Nonpharm treatment of migraines

Answer 14

patient education, bed rest in dark room, avoiding triggers, lifestyle modifications (diet, exercise, sleep, alcohol/caffeine, stress management), acupuncture, cold applications, constant temporal artery pressure

Question 15

Components of migraine treatment

Answer 15

patient education, simple analgesics/NSAIDS (acetaminophen, naproxen, ibuprofen), migraine specific agents (triptans, dihydroergotamine, etc), oral vs nasal route, rescue medications, migraine prophylaxis

Question 16

Who should get migraine specific agents like triptans ?

Answer 16

Severe migraines refractory to NSAIDS or analgesics

Question 17

Who should get nasal route of migraine treatment?

Answer 17

Migraines assocaited with nausea or vomiting

Question 18

Who should get migraine prophylaxis

Answer 18

patients who require acute treatment two or more times per week; guard against med overuse or rebound headaches

Question 19

What classes of drugs can be used for migraine prophylaxis?

Answer 19

beta blockers (propanolol, metoprolol), antidepressants (amitriptyline, venlafaxine)
anticonvulsants (topiramte, valproate)
serotonergic drugs, calcium channel blockers

Question 20

most prevalent form of primary headache disorder

Answer 20

tension headaches

Question 21

typical presentation of tension headache

Answer 21

pericranial muscle tenderness; description of bilateral band-like distribution of pain. can last 30 min - 7days

Question 22

How are tension headaches different from migraines?

Answer 22

unlike migraines, tension headaches aren’t aggravated by physical exertion, aren’t usually associated with n/v, and you won’t see photo and phonophobia together (maybe one or the other, if any at all)

Question 23

Episodic vs chronic tension headaches

Answer 23

180 days/year (chronic)

Question 24

Initial medical therapy for tension headaches and second line

Answer 24

aspirin, ,acetaminophen, NSAIDS

second line - combo analgesics containing caffeine

Question 25

presentation of cluster headache

Answer 25

STRICTLY UNILATERAL, usually seen in orbital, supraorbital, or temporal region

• described as deep, excruciating pain between 15 mins and 3 hours
• frequency can vary day by day (up to 8 attacks per day)
• associated with ipsilateral autonomic signs
• more prevalent in men

Question 26

How are cluster headaches different from migraines?

Answer 26

unlike migraines, patients with cluster headaches cannot find comfortable position (sitting in dark room doesn’t help)

Question 27

first line treatment for cluster

Answer 27

100% oxygen and triptans

Question 28

second line treatment for cluster

Answer 28

intranasal lidocaine, dihydroergotamine, prednisone, octreotide, somatostatin

Question 29

organic causes/conditions that can cause headaches

Answer 29

uncontrolled HTN, brain metastases, infection,

Question 30

What medications can cause headaches

Answer 30

analgesics or headache meds (ironically) via “rebound heaches” (if used frequently and then withdrawn), caffeine