Headaches Flashcards
What quality descriptors may clue you into a migraine?
“Pulsating”
“Throbbing”
Lateral
What quality descriptors may clue you into a tension headache?
Tightness/pressure
Band-like
What quality descriptors may clue you into a neuritis headache?
Sharp
Lancinating
What quality descriptors may clue you into an intracranial lesion?
Dull or steady
What quality descriptors may clue you into a headache due to ophthalmologic disorder?
Pre-ocular pain
What quality descriptors may clue you into a migraine caused by neuralgia?
Localized division of trigeminal nerve
What 5 things do you need to ask a pt with a headache?
- Quality
- Intensity
- Location
- Onset/timing
- Relation to biologic events
What do you mean when you ask a pt about the intensity of a headache?
Degree to which the pain incapacitates the patient and disrupts their quality of life
If a headache awakens the pt from sleep, what are 3 possibilities?
- Meningitis
- Subarachnoid hemorrhage
- Cluster headache
Location of migraine headache
Unilateral
Migraine is associated with what sx’s?
- N/V
- Sensitivity to light, sound, smells
Intracranial lesions in posterior fossa would lead to headache in what region?
Occipitonuchal region, lateral if one-sided lesion
Supratentorial lesions would lead to headache in what region?
Frontotemporal or approximate site of lesion
Onset of subarachnoid hemorrhage
Abrupt onset, with maximum severity in sec. or min.
What “thunderclap headaches” may mimic SAH?
- Cerebral venous thrombosis
- Vasospasm syndromes
What headaches may last minutes to hours?
- Migraines
- Cluster headache
- Intracranial tumor
What headache usually occurs at the same time each day/night?
Cluster headache
What headaches tend to be worse with awakening?
Intracranial mass
Sleep apnea
Which headaches tend to have more gradual onset, over several hours or days?
- Meningitis
- Tension headache
What headaches tend to be worse at the end of the day?
Tension headache
Pharyngeal cooling is more common in what type of headache pts?
Migrainers
What might you suspect in a pt with intense headache after inactivity (e.g. sleep), where the neck is initially stiff/painful?
C-spine disease
Describe sinusitis headache
- Face ache
- Midfrontal/maxillary tenderness
- Clock-like regularity
- Worsens by stopping/changes in atmospheric pressure
Describe bursting headache
Initiated by alcohol, intense exercise, stooping, straining
What headache occurs hours to days after intense activity/stress? i.e. “weekend”/”letdown”
Migraine
Allodynia is common in what headache?
Migraine (but could be GCA)
Most common type of primary headache
Tension headache
Presentation of tension headaches
- NO photophobia, phonophobia, N/V but can worsen with stress/noise/glare
- Band-like tightness/pressure
- Worse at end of day
What should also be on your differential if you are considering tension h/a in an elderly pt?
GCA
What findings would make you more suspicious of GCA than tension h/a in elderly pt?
- Elevated ESR (>65)
- Transient visual loss/changes
- Jaw claudication
Dx tension headache
- At least 10 episodes but <180/yr or <15/mo
- Lasts 30min to 7 days
- At least 2:
•Pressing/tightening but not pulsating quality
•Mild to moderate intensity (nonprohibitive)
•Bilateral
•No aggravation from normal ADLs - NO N/V
- NO photo/phonophobia or just one
Dx chronic tension-type headache
≤ 15 days/month for at least 6 months
Tx tension headache
- Treat comorbid anxiety or depression
- Behavioral therapy
- Relaxation training
- Massage
Most common presenting headache
Migraine
Presentation of migraine
- Triggered by environmental or physical stimuli
- Many pts experience aura
2 types of migraines
- Migraine with aura
- Migraine without aura
Dx migraine with aura
- 5+ attacks that last 4-72 hrs
- At least 2:
•Unilateral
•Pulsating
•Moderate-severe (interferes with ADLs)
•Aggravated by stairs - During headache, at least 1:
•Nausea and/or vomiting
•Photo and phonophobia
Dx migraine with aura
2+ attacks with at least 3 w/ no underlying disorder
- Fully reversible aura sx’s
- Aura developing gradually >4 min. or 2+ in succession
- Aura doesn’t last >60 min
- H/A <60 min. after aura
Tx migraine
- During acute attacks, rest in dark/quiet room + simple analgesic
- Triptans (may be better with naproxen)
- Cafergot
- Prochlorperazine
- Metoclopramide (Reglan)
- Butalbital-containing analgesics
What dosage forms do triptans come in?
SC
PO
Intranasal
Common side effects of triptans
Nausea, vomiting
AVOID triptans in these pts (5). Why?
Triptans cause vasoconstriction, esp. in cranial vessels
- Hemiplegic
- Basilar artery migraine
- Uncontrolled HTN
- Risk factors for stroke
- Coronary or peripheral vascular disease
Dosage forms of cafergot
IV or suppository
Avoid cafergot in these pts
- Pregnancy
- CVD
- CYP3A4 inhibitors (supratherapeutic)
Caution with butalbital-containing analgesics. Why?
Habit forming
Rebound h/a
When is preventative therapy indicated for migraines?
> 2-3/month
Preventative therapy for migraines
- Avoid ppt factors (homeostatic imbalances)
- Diary to identify triggers
- Rx ppx with triptans
- Botulism toxin
- Acupuncture
- Neurostimulation
Presentation of cluster headaches
- Unilateral
- Lasts 1-2 hrs
- Associated ipsilateral autonomic signs (tearing, miosis, ptosis, rhinorrhea)
- Deep, usually retro-orbital nonfluctuating pain
- NO focal neuro signs
- Daily at same time***
Dx cluster headaches
- 5+ attacks
- At least every other day
- Severe unilateral periorbital and/or temporal pain, last 15-180 min. untreated
- At least 1, ipsilateral to pain side:
•Lacrimation
•Nasal congestion
•Rhinorrhea
•Forehead/facial sweating
•Miosis
•Ptosis
•Eyelid edema
Tx cluster headache
- SC or intranasal sumatriptan (PO ineffective)
- 100% O2 via non-rebreather
- Zolmitriptan nasal spray
- Dihydroergotamine IM or IV
- Viscous lidocaine intranasal
Ppx for cluster headache
- Lithium carbonate
- Verapamil (monitor PR interval)
- Topiramate
Dx post-traumatic headache
- 1 day to 1 week after injury
- Can be accompanied by N/V, scintillating scotomas
Presentation of intracranial mass lesions
Headaches worsen when supine, awaken at night, peak in AM
When should you be concerned about a headache (i.e. needs further investigation)?
- New or worsening in mid-life (need CT)
- Signs of cerebral dysfunction or increased ICP
What neurologic conditions can cause headache?
- Cerebrovascular disease
- Internal carotid artery occlusion
- Carotid dissection
- S/p carotid endarectomy
- SAH
- Meningitis
- S/p LP
When to refer headache pt for urgent evaluation (5-ish)
- Thunderclap onset
- Refractory to simple measures
- Trauma, HTN, fever, visual changes
- Neuro signs
- Scalp tenderness
Presentation of psuedotumor cerebri
- Diffuse headache
- Papilledema
- CSF >250mm H2O
- Sx’s of increased ICP
- No localizing sx’s
- Nonspecific or normal imaging
Imaging for pseudotumor cerebri
CT to differentiate from space-occupying intracerebral mass - CT will be normal or nonspecific
Tx pseudotumor cerebri
- Repetitive LPs
- Acetazolamide
- Thiazide diuretics
- Corticosteroid for visual complaints
- Surgery: lumbar-peritoneal shunting, optic nerve sheath decompression
Population most at risk for psuedotumor cerebri
Obese women, esp. in 20s
Tx post-herpetic neuralgia
- Anticonvulsants (carbamazepine, oxcarbazepine)
- Gabapentin
- Antispasmodic agents alone or w/ anticonvulsant
- Botox injection
- Surgery (microvascular decompression)
- Brain stereotactic radiosurgery
- Glycerol injection
- Balloon compression
