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Clin Med III Exam 3 > Headaches > Flashcards

Headaches Flashcards

1
Q

H/a types

A
  1. Vascular - migraine, cluster
  2. Muscle contraction - tension
  3. Traction - organic disease of the head like intracranial mass
  4. Inflammatory: meningitis, giant cell arteritis
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2
Q

Secondary h/a

A

associated w/ another disorder

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3
Q

Primary h/a

A

migraine
cluster
tension

Less common: chronic daily, primary stabbing, primary exertional, hypnic (“alarm-clock”

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4
Q

Most frequent h/a

A

tension

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5
Q

Most commonly diagnosed h/a

A

migraine

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6
Q

Most debilitating h/a

A

cluster

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7
Q

Diet triggers for h/a

A 
alcohol
chocolate
caffeine
MSG
Nuts
Nitrates
Aspartame
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8
Q

Hormonal triggers of h/a

A

menses, ovulation, HRT

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9
Q

Migraine epidemiology

A

W>M

Genetic/familial component

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10
Q

What is migraine?

A 
neurovascular HA (throbbing, pulsating, unilateraly)
lasts 4-72 hours
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11
Q

Associated sx w/ migraine

A

photophobia, phonophobia, n/v; movement worsens sx

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12
Q

Two main types of migraines

A

Migraine w/o aura (common)

migraine w/ aura (classic)

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13
Q

Migraine w/o aura sx

A 
h/a w/o warning
chronic/recurring
pain lasting 4-72 hours 
Throbbing, pulsatile
n/v, confusion, blurred vision, mood change, sensitivity to light/sound
FHx
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14
Q

Migraine w/ aura sx

A

Prodrome
Aura - occurs 10-60 min prior to HA
H/a
Postdrome

usually have trigger

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15
Q

Prodrome of migraine

A

(77%) 24-48 hours prior to HA

food cravings, mood change, uncontrollable yawning, fluid retention, constipation, neck stiffness

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16
Q

Aura

A

(25%) may occur prior to or concurrent w/ HA

Positive sx: visual/auditory/sensory/motor
Negative sx: loss of function/vision/hearing/sensation/motor

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17
Q

HA migraine

A

builds gradually in intensity
Commonly unilateral/pulsatile or throbbing
May cause n/v, photophobia, phonophobia

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18
Q

Postdrome of migraine

A

confused or exhausted

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19
Q

Cutaneous Allodynia

A

abnormal pain response from things like combing hair, shaving, wearing glasses, contact lens, earrings, tight fitting clothes

associated w/ migraines!

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20
Q

Dx of migraine

A

hx and PE - no imaging; international classification of HA disorders

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21
Q

When to image

A
  • “worst HA of my life”
  • change in HA presentation
  • new or unexplained neuro sx
  • HA not responding to tx
  • New onset after 50 or in pts w/ CA or HIV

(CT > MRI)

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22
Q

Max time for aura

A

60 minutes (if longer…think TIA)

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23
Q

Tx for acute migraines

A 
Decrease triggers
rest in dark room
cool cloths on forehead
fluids
caffeine in early stage
Meds (depending on severity; acute & preventative)
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24
Q

Meds for mild/mod migraines

A

oral NSAIDs, acetaminophen or OTC combo (Excedrin, Medrin)

+/- antiemetic

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25
Q

Meds for mod/severe migraines

A

TRIPTANS! & Ergots (abortive)
Triptan +/- combo w/ NSAID (sumatriptan & naproxen)

N/V:

  • SC or nasal sumatriptin (imitrex)
  • Nasal zolmitriptan (Zomig)
  • antiemetic
  • parenteral dihydroergotamine (ergotamine)
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26
Q

Triptan SE

A 
"triptan sensation"
- Injection site rxn
- chest pressure/heaviness
- flushing, weakness, drowsiness, dizziness
- malaise, feeling of warmth
- paresthesia
RESOLVES IN 30 MINUTES
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27
Q

Contraindications to triptans and ergots

A

(they are vasoconstrictors)
Uncontrolled HTN
Pregnancy
Hx of MI, cerebrovascular disease, PVD

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28
Q

Lifestyle preventative migraine tx

A

good sleep
routine meals
regular exercise
avoid triggers

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29
Q

Meds for prevention of mes

A

BB: propranolol
TCA (amitryptyline) or SSRI (venlafaxine)
Anticonvulsant: valproate & Topiramate*
NSAIDS

Others: coenzyme Q10, riboflavin, calcitonin, botox, feverfew, CCB, CGRP antagonist

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30
Q

Auras can mimic

A

TIA (more rapid onset, last up to 24 hours, multiple deficits simulatneously)

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31
Q

Most common type of HA

A

Tension-Type HA (TTH)

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32
Q

Character of TTH

A 
bilateral pressure
band-like
non-throbbing HA
mild/mod in intensity
30 min- 7 days
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33
Q

Associated sx w/ TTH

A

anorexia
head/neck pain w/ muscle tenderness
bruxism

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34
Q

Bruxism

A

clenching teeth

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35
Q

Frequency of TTH

A

Episodic:

  • infrequent: < 12 days/year and last <1day/mo
  • Frequent: 1-14 days/month; last 30 min to several days

Chronic: >15 days/month, last hours to days, may be unremitting

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36
Q

Dx of TTH

A

hx and PE

no imaging unless unexplained neuro findings or atypical presentation

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37
Q

Acute management of TTH

A

NSAIDs* (high initial dose)
acetaminophin, aspirin, combo
Hot shower or heat to back of neck

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38
Q

When are analgesics not sufficient for TTH

A

Comorbidites: stress, anxiety and depression

39
Q

Additional Tx for TTH

A

antidepressants

Alternate therapy: biofeedback, relaxation training, meditation, CBT, massage

40
Q

First monthly injectable for migraine prevention

A

CGRP antagonists

41
Q

More common in females

A

migraines

TTH

42
Q

More common in males

A

Cluster HA (older >40)

43
Q

Character of cluster HA

A

trigeminal autonomic cephalgias (TACs): sharp, boring, unilateral, periorbital HA w/ autonomic sx
EXCRUCIATING - suicidal
lasts 15-180 minutes

similar time of day/night x several weeks w/ period of remission; attacks every other day - 8x/day

44
Q

How long due cluster HA last

A

15-180 minutes

45
Q

Timing for clusters

A

6-12 weeks

46
Q

Remission timing for cluster HA

A

12+ months

47
Q

Chronic cluster HA

A

clusters lasting >1 year or remission < 1 month

48
Q

Often at night

A

cluster HA

49
Q

Presentation of cluster HA

A

restless, pace, sits/rocks
pain: severe, orbital, supraorbital, temporal
Autonomic sx: conjunctival injection, LACRIMATION, eyelid edema, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis (ipsilateral to pain, PNS high, SNS low)

50
Q

associated sx w/ cluster HA

A

aura

sensitive to light, sound, smell

51
Q

Triggers for cluster HA

A

alcohol
smoking
smells
stress

52
Q

Dx of cluster HA

A

Hx and PE, +/- FHx

MRI w/ and w/o contrast or plain CT w/ initial dx
- evaluate brain and pituitary gland - potential secondary cause (lesion)

53
Q

Tx for acute cluster HA

A

O2 facemask >12L/min

  • sit up
  • continue 15 min
  • don’t use in COPD (hypercapnia, CO2 narcosis)

Triptan: SC sumatriptian, nasal suma or zomitriptan, oral zolmitriptan

Others: intranasal lidocaine, ergots

54
Q

Preventative tx for cluster HA

A

CCB: veramapil***

Others: glucocorticoids, lithium, topiramate

Extreme: electrical stim, steroid injection, deep brain stimulation of hypothalamus, surgery

55
Q

Chronic daily HA sx

A

> 15 days/month during 3+ months

moderate pain of side/top of head

56
Q

Types of chronic daily HA

A
  1. Chronic Migraine
  2. Chronic TTH
  3. Hemicrania continua
  4. New Daily persistent HA (NDPH)
57
Q

Hemicrania continua

A

continuous, fluctuating pain on same side of face/head lasting minutes to days

associated w/: tearing, irritated eyes, rhinorrhea, swollen eyelids

58
Q

Tx of hemicrania continua

A

Indomethacin

59
Q

New daily persistent HA (NDPH) sx

A

abrupt onset/does not remit
previously “chronic benign HA”
mild/severe: throbbing/tightening bilaterally!
Associated sx: light/sound sensitivity

60
Q

Triggers for NDPH

A

infection
meds
trauma

61
Q

Tx of NDPH

A

Muscle relaxants
antidepressant
anticonvulsants

62
Q

DO NOT SMOKE/DRINK

A

Cluster HA

63
Q

Always requires MRI

A

Cluster HA

64
Q

Primary stabbing HA (“ice pack” or “jabs and jolts”)

A

1-10 seconds
near eye but anywhere along trigeminal nerve
daily to yearly
often w/ other headaches

65
Q

Tx of primary stabbing HA

A

indomethacin
Abortive meds if many episodes
Avoid triggers

66
Q

Indomethacin used to treat

A

Hemicrania continua
Primary Stabbing Headache
Primary exertional (prior to exercise or daily)

67
Q

DOC for cluster preventative

A

Verapamil

68
Q

Primary exertional HA

A

trigger: cough, sneeze, intense activity
Last minutes- days
N/V

69
Q

Imaging for exertional HA

A

MRI/MRA to r/o vascular abnormalities

- risk increases >40 YO and focal neuro sx

70
Q

Tx for exertional HA

A

warm-up exercise
NSAIDs
Indomethacin

71
Q

Hypnic HA aka

A

Alarm-clock HA

72
Q

Hypnic HA sx

A

later in life (>50 YO)
during sleep and awakens people @ night
>10x/month lasting 15 min-3 hrs
Pain: mild/mod throbbing, bilateral

Associated sx: nausea, senstivity to light/sound

73
Q

Imaging for hypnic HA

A

MRI

74
Q

Tx of hypnic HA

A

caffeine @ night > indomethacin > lithium

75
Q

Get an MRI for these primary HA

A

Cluster
Primary exertional (r/o vascular cause)
Hypnic HA

76
Q

Alerts for secondary HA

A
  • First HA in patient over 50
  • Sudden intense HA without previous hx of HAs
  • Nuchal rigidity, + Kernig or Brudzinski signs
  • Diplopia
  • Papilledema or retinal hemorrhage
  • Persistent or new neurological signs
  • Fever
  • Excessive BP elevation
  • Hx of head trauma, malignancy, coagulopathy
  • Change in previous HA presentation
77
Q

Structural abnormalities causing secondary HA

A
  • Chiari malformation, syringomyelia
  • Septum deviation causing obstruction
  • TMJ dysfunction
78
Q

Cranial neuralgia cause of 2ndary HA

A 
Trigeminal Neuralgia (stabbling, shock-like pain)
Occipital Neuralgia
79
Q

SNOOP criteria for secondary HA

A 
Systemic sx/illness
Neuro (focal sx, decreased LOC)
Onset sudden
Older (>50)
Previous HA Hx (1st or changed)
80
Q

Idiopathic intracranial hypetension (pseudotumor cerebri) sx

A

increased pain w/ cough, exertion, straining, position
Papilledema, vision loss, pulsatile tinnitus
Increased ICP w/o associated disease

81
Q

CSF pressure causes of HA

A

Pseudotumor cerebri

Post-LP HA (spinal fluid leak)

82
Q

Sx of brain tumor HA

A

steady, worsening HA +/- neuro signs

night time awakenings

83
Q

Vascular defects causing HA

A 
Subarachnoid hemorrhage: thunderclap
CVA: unilateral HA to affected side
Temporal arteritis (>50 YO) - throbbing temporal pain, tenderness w/ palpation
Aneurysm
Arteriovenous malformation (AVM)
84
Q

Sx of subarachnoid hemorrhage

A

Thunderclap HA
decreased LOC
nuchal rigidity
first and worst HA

85
Q

Dx for SA hemorrhage

A

CT- hemorrhage

LP - bloody CSF

86
Q

Dx of temporal arteritis

A

Elevated ESR and biopsy

87
Q

Infectious causes of HA

A

meningitis

Encephalitis

88
Q

Head trauma HA

A

post concussion syndrome: delayed onset of dizziness, tiniitus, n/v, visual changes

Subdural hematoma

89
Q

Medication overuse HA (MOH)

A

worsens w/ med overuse

90
Q

Highest risk of MOH

A

opiods, barbs, aspirin, acetaminophen combo

91
Q

Medium risk of MOH

A

triptans

92
Q

Low risk of MOH

A

NSAIDs (not ASA)

93
Q

When to refer a HA

A
  • Patient requests a referral
  • Provider has low comfort level with dx
  • Diagnosis is questionable
  • Patient dose not respond to treatment
  • Condition worsens or changes
  • Unable to treat as outpatient
94
Q

cause eye sx

A

Cluster HA

Hemicrania continua

Clin Med III Exam 3 (3 decks)

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