Headaches Flashcards
“red flag” symptoms of headache
- 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
sudden onset headache maximum severity “worst headache”, new/different headache
ddx: subarachnoid hemorrhage, pituitary apoplexy, hemorrhage into a mss leson/AVM, mass lesion
eval with imaging, LP if imaging negative
headaches increasing in seveirty and frequency, brought on my valsalva/exertion
mass lesion, subdural hematoma, med overuse
eval with imaging/drug screen
headache beginning after age 50, esp with jaw pain/claudication
temporal arteritis; mass lesion
eval with imaging, ESR
new-onset headache in patient with risk factors for HIV/cancer
meningitis, brain abscess (including toxo), metastases
eval with imaging first, then LP if imaging negative
headahe with systemic symptoms (fever, rash, stiff neck)
meningitis, encephalitis, lyme dx, systemtic infection, collagen vascular disease
eval with imaging, LP, serology
focal neurologic signs
mass lesion, avm, stroke, collagen vascular disease
eval with imaging, collagen vascular evaluation, including antiphospholipid antibodies)
papilledema
mass lesion, pseudotumor cerebri, meningitis
neuroimaging and LP
headache after trauma
intracranial hemorrhage, subdural hematoma, epidural hematoma, post traumatic headache
image brain, skull, and cervical spine
Diagnostic criteria for migraine
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
What to ask when evaluating headache
- 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
status headache
headache lasted more than 72 hours
When to do neuroimaging for headache
when there is an unexplained neurologic deficit or if headache is different from a primary headache disorder
Nonpharm treatment of migraines
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
Components of migraine treatment
patient education, simple analgesics/NSAIDS (acetaminophen, naproxen, ibuprofen), migraine specific agents (triptans, dihydroergotamine, etc), oral vs nasal route, rescue medications, migraine prophylaxis
Who should get migraine specific agents like triptans ?
Severe migraines refractory to NSAIDS or analgesics
Who should get nasal route of migraine treatment?
Migraines assocaited with nausea or vomiting
Who should get migraine prophylaxis
patients who require acute treatment two or more times per week; guard against med overuse or rebound headaches
What classes of drugs can be used for migraine prophylaxis?
beta blockers (propanolol, metoprolol), antidepressants (amitriptyline, venlafaxine) anticonvulsants (topiramte, valproate) serotonergic drugs, calcium channel blockers
most prevalent form of primary headache disorder
tension headaches
typical presentation of tension headache
pericranial muscle tenderness; description of bilateral band-like distribution of pain. can last 30 min - 7days
How are tension headaches different from migraines?
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)
Episodic vs chronic tension headaches
180 days/year (chronic)
Initial medical therapy for tension headaches and second line
aspirin, ,acetaminophen, NSAIDS
second line - combo analgesics containing caffeine
