Headaches Flashcards
SSNOOPP
Systemic system - fever, weight loss
Secondary risk factors - HIV, cancer
Neurological symptoms
Onset - sudden/abrupt –> suspect SAH, venous sinus
thrombosis, etc.
Older individuals
Previous hx
Postural - worse lying down = high pressure headache;
worse standing up = low pressure headache
When is imaging warranted for recurrent migraines?
What type is preferred?
Warranted when:
1) Recent big change in headache pattern
2) Hx of SEIZURES
3) Focal neurological signs/symptoms
MRI more sensitive
CT if looking for acute blood
What are the ONLY indications for LP?
1) Suspect SAH (“thunderclap” headache) –> would see RBCs/xanthochromia
2) Suspect meningoencephalitis
3) Suspect high/low CSF pressure–even in absence of papilledema
Cluster headaches (primary headaches)
Attack frequency/cluster periods
Clinical features
Treatment
1 every other day, up to 8 daily
Clusters 2 weeks - 3 months with circadian/annual periodicity
Stabbing unilateral orbital, suborbital, or temporal pain
Autonomic features: lacrimation and congestion most common, sweating, miosis, ptosis, etc.
High flow O2 with sumatriptan injection
“A cluster of sumatra coffee is like oxygen to me.”
Cranial neuralgias (categorized separately from primary/ secondary headache)
Clinical features
Diagnostic Criteria
Treatment
Brief UNILATERAL “stabs” of pain on face at multiple divisions of CNV triggered by minor stimulation (talking, eating, etc).
Asymptomatic between paroxysms of pain.
1) Paroxysmal attacks of pain lasting from fraction of second to 2 minutes affecting at least one CNV division
2) Pain has at least one of following features: intense/ sharp/superficial/stabbing; precipitated by triggers
3) Attacks stereotyped in individual patient
MRI to look for CNV nerve compression.
Prevent with carbamazepine, gabapentin
“Common” migraine (w/o aura)
IHS criteria?
Common headache:
1) Recurrent HA (at LEAST 5) lasting 4-72 hours
2) At least TWO of following: unilateral, pulsating pain (TTH is NOT pulsating), moderate/severe intensity, aggravated by routine activity
3) At least ONE of following: N/V, photophobia/ phonophobia
“Classic” migraine (w/ aura)
Gradual onset over minutes
Persists 20-60 minutes
Risk and protective factors against migraines.
Risk factors: hormones, chronobiologic changes, vasodilators, diet, drugs, sensory input, stress, trauma
Protective factors: REGULAR sleep/meals/exercise, healthy lifestyle
Pathophysiology of migraine
Chemicals in brain (CGRP, substance P, NKA/neurokinin) released to cause vasodilation and inflammation of surrounding tissue and/or trigeminal.
Acute migraine treatments?
Ergotamine/DHE (old)
Triptans (mainstay treatment)
CGRP inhibitors
MoA for triptan
Triptan (i.e. Sumitriptan) used for acute treatment for migranes.
SELECTIVE 5HT (1B/1D) receptor agonists at interface between trigeminal endings and vessel walls
Preventative medications for migraines
B-blockers/CCBs to prevent vasodilation (propanolol)
NSAIDs for inflammation
5-HT antagonists
Anticonvulsants (Topiramate, Divalproex/type of valproic acid)
Antidepressants
What medication to treat following comorbid conditions?
1) Migraine + epilepsy
2) Migraine + depression
3) Migraine + HTN/angina
4) Classical migraine + HTN/angina/asthma
1) Topiramate, Divalproex
2) TCAs
3) B-blocker
4) CCB (verapamil)
