Headaches Flashcards
1
Q
H/a types
A
- Vascular - migraine, cluster
- Muscle contraction - tension
- Traction - organic disease of the head like intracranial mass
- Inflammatory: meningitis, giant cell arteritis
2
Q
Secondary h/a
A
associated w/ another disorder
3
Q
Primary h/a
A
migraine
cluster
tension
Less common: chronic daily, primary stabbing, primary exertional, hypnic (“alarm-clock”
4
Q
Most frequent h/a
A
tension
5
Q
Most commonly diagnosed h/a
A
migraine
6
Q
Most debilitating h/a
A
cluster
7
Q
Diet triggers for h/a
A
alcohol chocolate caffeine MSG Nuts Nitrates Aspartame
8
Q
Hormonal triggers of h/a
A
menses, ovulation, HRT
9
Q
Migraine epidemiology
A
W>M
Genetic/familial component
10
Q
What is migraine?
A
neurovascular HA (throbbing, pulsating, unilateraly) lasts 4-72 hours
11
Q
Associated sx w/ migraine
A
photophobia, phonophobia, n/v; movement worsens sx
12
Q
Two main types of migraines
A
Migraine w/o aura (common)
migraine w/ aura (classic)
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
14
Q
Migraine w/ aura sx
A
Prodrome
Aura - occurs 10-60 min prior to HA
H/a
Postdrome
usually have trigger
15
Q
Prodrome of migraine
A
(77%) 24-48 hours prior to HA
food cravings, mood change, uncontrollable yawning, fluid retention, constipation, neck stiffness
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
17
Q
HA migraine
A
builds gradually in intensity
Commonly unilateral/pulsatile or throbbing
May cause n/v, photophobia, phonophobia
18
Q
Postdrome of migraine
A
confused or exhausted
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!
20
Q
Dx of migraine
A
hx and PE - no imaging; international classification of HA disorders
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)
22
Q
Max time for aura
A
60 minutes (if longer…think TIA)
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)
24
Q
Meds for mild/mod migraines
A
oral NSAIDs, acetaminophen or OTC combo (Excedrin, Medrin)
+/- antiemetic
25
Meds for mod/severe migraines
TRIPTANS! & Ergots (abortive)
Triptan +/- combo w/ NSAID (sumatriptan & naproxen)
N/V:
- SC or nasal sumatriptin (imitrex)
- Nasal zolmitriptan (Zomig)
- antiemetic
- parenteral dihydroergotamine (ergotamine)
26
Triptan SE
```
"triptan sensation"
- Injection site rxn
- chest pressure/heaviness
- flushing, weakness, drowsiness, dizziness
- malaise, feeling of warmth
- paresthesia
RESOLVES IN 30 MINUTES
```
27
Contraindications to triptans and ergots
(they are vasoconstrictors)
Uncontrolled HTN
Pregnancy
Hx of MI, cerebrovascular disease, PVD
28
Lifestyle preventative migraine tx
good sleep
routine meals
regular exercise
avoid triggers
29
Meds for prevention of mes
BB: propranolol
TCA (amitryptyline) or SSRI (venlafaxine)
Anticonvulsant: valproate & Topiramate*
NSAIDS
Others: coenzyme Q10, riboflavin, calcitonin, botox, feverfew, CCB, CGRP antagonist
30
Auras can mimic
TIA (more rapid onset, last up to 24 hours, multiple deficits simulatneously)
31
Most common type of HA
Tension-Type HA (TTH)
32
Character of TTH
```
bilateral pressure
band-like
non-throbbing HA
mild/mod in intensity
30 min- 7 days
```
33
Associated sx w/ TTH
anorexia
head/neck pain w/ muscle tenderness
bruxism
34
Bruxism
clenching teeth
35
Frequency of TTH
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
36
Dx of TTH
hx and PE
| no imaging unless unexplained neuro findings or atypical presentation
37
Acute management of TTH
NSAIDs* (high initial dose)
acetaminophin, aspirin, combo
Hot shower or heat to back of neck
38
When are analgesics not sufficient for TTH
Comorbidites: stress, anxiety and depression
39
Additional Tx for TTH
antidepressants
| Alternate therapy: biofeedback, relaxation training, meditation, CBT, massage
40
First monthly injectable for migraine prevention
CGRP antagonists
41
More common in females
migraines
| TTH
42
More common in males
Cluster HA (older >40)
43
Character of cluster HA
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
How long due cluster HA last
15-180 minutes
45
Timing for clusters
6-12 weeks
46
Remission timing for cluster HA
12+ months
47
Chronic cluster HA
clusters lasting >1 year or remission < 1 month
48
Often at night
cluster HA
49
Presentation of cluster HA
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
associated sx w/ cluster HA
aura
| sensitive to light, sound, smell
51
Triggers for cluster HA
alcohol
smoking
smells
stress
52
Dx of cluster HA
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
Tx for acute cluster HA
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
Preventative tx for cluster HA
CCB: veramapil***
Others: glucocorticoids, lithium, topiramate
Extreme: electrical stim, steroid injection, deep brain stimulation of hypothalamus, surgery
55
Chronic daily HA sx
>15 days/month during 3+ months
| moderate pain of side/top of head
56
Types of chronic daily HA
1. Chronic Migraine
2. Chronic TTH
3. Hemicrania continua
4. New Daily persistent HA (NDPH)
57
Hemicrania continua
continuous, fluctuating pain on same side of face/head lasting minutes to days
associated w/: tearing, irritated eyes, rhinorrhea, swollen eyelids
58
Tx of hemicrania continua
Indomethacin
59
New daily persistent HA (NDPH) sx
abrupt onset/does not remit
previously "chronic benign HA"
mild/severe: throbbing/tightening bilaterally!
Associated sx: light/sound sensitivity
60
Triggers for NDPH
infection
meds
trauma
61
Tx of NDPH
Muscle relaxants
antidepressant
anticonvulsants
62
DO NOT SMOKE/DRINK
Cluster HA
63
Always requires MRI
Cluster HA
64
Primary stabbing HA ("ice pack" or "jabs and jolts")
1-10 seconds
near eye but anywhere along trigeminal nerve
daily to yearly
often w/ other headaches
65
Tx of primary stabbing HA
indomethacin
Abortive meds if many episodes
Avoid triggers
66
Indomethacin used to treat
Hemicrania continua
Primary Stabbing Headache
Primary exertional (prior to exercise or daily)
67
DOC for cluster preventative
Verapamil
68
Primary exertional HA
trigger: cough, sneeze, intense activity
Last minutes- days
N/V
69
Imaging for exertional HA
MRI/MRA to r/o vascular abnormalities
| - risk increases >40 YO and focal neuro sx
70
Tx for exertional HA
warm-up exercise
NSAIDs
Indomethacin
71
Hypnic HA aka
Alarm-clock HA
72
Hypnic HA sx
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
Imaging for hypnic HA
MRI
74
Tx of hypnic HA
caffeine @ night > indomethacin > lithium
75
Get an MRI for these primary HA
Cluster
Primary exertional (r/o vascular cause)
Hypnic HA
76
Alerts for secondary HA
* 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
Structural abnormalities causing secondary HA
* Chiari malformation, syringomyelia
* Septum deviation causing obstruction
* TMJ dysfunction
78
Cranial neuralgia cause of 2ndary HA
```
Trigeminal Neuralgia (stabbling, shock-like pain)
Occipital Neuralgia
```
79
SNOOP criteria for secondary HA
```
Systemic sx/illness
Neuro (focal sx, decreased LOC)
Onset sudden
Older (>50)
Previous HA Hx (1st or changed)
```
80
Idiopathic intracranial hypetension (pseudotumor cerebri) sx
increased pain w/ cough, exertion, straining, position
Papilledema, vision loss, pulsatile tinnitus
Increased ICP w/o associated disease
81
CSF pressure causes of HA
Pseudotumor cerebri
| Post-LP HA (spinal fluid leak)
82
Sx of brain tumor HA
steady, worsening HA +/- neuro signs
| night time awakenings
83
Vascular defects causing HA
```
Subarachnoid hemorrhage: thunderclap
CVA: unilateral HA to affected side
Temporal arteritis (>50 YO) - throbbing temporal pain, tenderness w/ palpation
Aneurysm
Arteriovenous malformation (AVM)
```
84
Sx of subarachnoid hemorrhage
Thunderclap HA
decreased LOC
nuchal rigidity
first and worst HA
85
Dx for SA hemorrhage
CT- hemorrhage
| LP - bloody CSF
86
Dx of temporal arteritis
Elevated ESR and biopsy
87
Infectious causes of HA
meningitis
| Encephalitis
88
Head trauma HA
post concussion syndrome: delayed onset of dizziness, tiniitus, n/v, visual changes
Subdural hematoma
89
Medication overuse HA (MOH)
worsens w/ med overuse
90
Highest risk of MOH
opiods, barbs, aspirin, acetaminophen combo
91
Medium risk of MOH
triptans
92
Low risk of MOH
NSAIDs (not ASA)
93
When to refer a HA
* 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
cause eye sx
Cluster HA
| Hemicrania continua
