Headaches Flashcards
Most common benign headaches
Migraine, cluster, tension
Types of headache
Vascular (migraine, cluster)
Muscle contraction (tension)
Traction (organic diseases of head like intracranial mass)
Inflammatory (meningitis, giant cell arteritis etc)
Types of primary HAs
Migraine, cluster, tension type
Chronic daily HA, primary stabbing, primary exertional, hypnic (“alarm-clock”)
Most common diagnosis given
Migraine
Most debilitating HA
Cluster
Most frequent HA
Tension type
Most important factor in establishing diagnosis of HA
History
Important history questions for HAs
Frequency, duration, intensity, location Quality Time and setting of onset Aggravating/ alleviating factors Age of onset Associated sxs (nausea, photophobia, phonophobia, focal neuro presentation)
Triggers of HAs
Diet (caffeine, alcohol, chocolate) Hormones (menses, HRT) Sensory stimuli (light, odor, sound) Stress Environment Change in habits
Pneumonic for migraines
Pulsatile hOurs 4-72 hrs Unilateral Nausea Debilitating ing
Associated sxs of migraines
Photophobia
Phonophobia
N/v
Movement worsens sxs
Types of migraines
Migraine without aura (common)- more frequent type
Migraine with aura (classic/complex)
Characteristics of migraine without aura
HA occurs without warning
Unilateral pain 4-72 hrs (throbbing, pulsatile)
Nausea, confusion, blurred vision, mood changes, sensitivity to light/sound
4 phases of migraine with aura
Prodrome
Aura
Headache
Postdrome
When does the aura occur?
Classically 10-60 min prior to HA (may be during HA or no HA occurs)
Last less than 60 min!! (if longer than that then be worried about something else)
Prodrome of migraine
24-48 hrs prior to HA
Food cravings, mood change, uncontrollable yawning, fluid retention, constipation, neck stiffness
Aura associated with a migraine
May occur prior to or concurrent with HA
Positive sx: visual, auditory, sensory, motor
Negative sx: loss of function, vision, hearing, sensation, motor
HA in migraine with aura
Builds gradually in intensity
Commonly unilateral pulsatile or throbbing pain
Same associated sxs
Postdrome of migraine with aura
Confused or exhausted
Types of migraine auras
Visual (area of visual loss, bright spot, lights, shapes, heat waves)
Sensory (tingling, weakness)
Language
What is cutaneous allodynia?
Associated with migraine
Abnormal pain response from things like combing hair, shaving, wearing glasses, contact lens, earrings, tight fitting clothes
Imaging for migraine
No imaging needed if have classic hx and no change in sxs
Scenarios that might warrant imaging with a migraine
Worst HA of my life Changes in HA presentation New or unexplained neurologic sxs HA not responding to tx New onset after 50 or in pts with CA or HIV *CT recommended over MRI
How to differentiate between aura and TIA
Aura: gradual onset, duration no longer than an hour, types may overlap and ebb and flow
TIA: rapid onset, maximal intensity within few minutes lasting up to 24 hrs, multiple deficits occur simultaneously
Tx of acute migraine
Decrease triggers, dark quiet environment, cool cloth
Fluids, caffeine early on
Meds depending on severity
First line meds for abortive therapy of mild to moderate migraine
Oral NSAIDs, acetaminophen or OTC combo
n/v add antiemetic
First line meds for abortive therapy of moderate to severe migraine
Triptans and Ergots (oral or combo with NSAID–subq if n/v etc)
Side effects of triptans
Tripton sensation: injection site rxn, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, malaise, feeling of warmth, paresthesia
Resolves in 30 min tho
Contraindications of triptans and ergotamine
It is a vasoconstrictor so uncontrolled HTN, pregnancy or hx of MI, cerebrovascular disease, peripheral vascular disease
Lifestyle changes to prevent migraines
Appropriate amt of sleep
Routine meal schedule
Regular exercise
Avoidance of triggers
Meds for preventative migraine tx
BB: propranolol Amitriptyline Anticonvulsants: valproate and topiramate Others (CRGP antagonists etc) *start low and go slow
Characteristics of tension type HAs
Bilateral pressure, band-like
Non-throbbing, mild to moderate in intensity
Lasts 30 min to 7 days
Associated sx: anorexia, head/neck pain with muscle tenderness, bruxism (grinding teeth)
What will not be seen with a tension HA?
Phonophobia, photophobia, aura or n/v
Triggers for tension HAs
Stress, jaw clenching, missed meals, depression, too little sleep, head/neck strain
Episodic tension headaches
Infrequent: <12 days/ yr and lasting <1 day/mo
Frequent: 1-14 days/mo lasting 30 min to several days
Not disabling
Chronic tension headaches
> 15 days/mo, lasts hours to days, may be unremitting
Imaging for tension headache?
Not needed unless unexplained abnormal neuro findings or atypical presentation
Management of tension headaches
Underlying cause
Acute: NSAIDs, acetaminophen, aspirin, combo (high initial dose)
Hot shower or heat to back of neck
Management for chronic tension HA
Most often have stress, anxiety, depression
Antidepressants, biofeedback, relaxation training, meds etc
What should be avoided with chronic tension HA?
Opioids or barbiturates b/c high potential for med overuse HA
Characteristics of cluster HAs
Males!
Brief: 15-180 min
Sharp boring unilateral periorbital HA with autonomic sxs!! (trigeminal autonomic cephalgias)
Similar time of day/night x several wks with period of remission (clusters 6-12 wks and remission can be up to 12 mos)
Chronic cluster HA
Clusters lasting >1 yr or remission <1 mo
Presentation of cluster HA
Restless and pacing
Severe orbital, supraorbital or temporal pain
Autonomic sxs
May have an soociated sx like migraine aura
What autonomic sxs are seen in cluster HAs?
Conjunctival infection, lacrimation, eyelid edema, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis
Ipsilateral to the pain!!!
Parasympathetic hyperactivity and sympathetic impairment
Triggers of cluster HA
Alcohol and smoking (can not have!), smells stress
How to diagnose cluster HA
MRI with and without contrast or plain CT with initial dx (looking for a secondary cause)
1 tx for cluster HA
O2 in nonrebreathing facemask 100% 02 at >12L/min
Sitting upright
Continue for 15 min even if attack ends before that
When to not use O2 with cluster HA
Severe COPD (risk of hypercapnia and CO2 narcosis)
Other tx for cluster HA
Triptian, intranasal lidocaine, ergots
DOC to prevent cluster HA
Verapamil (at onset of cluster episode)
Chronic daily HA characteristics
> 15 days/mo during 3+ mos
Moderate pain on sides or top of head
Types of chronic daily HA
Chronic migraine
Chronic tension type
Hemicrania continua
New daily persistent HA
What is hemicrania continua?
Continuous, fluctuating pain on same side of face/head lasting minutes to days
Associated sxs: tearing, irritated eyes, rhinorrhea, swollen eyelids
Tx for hemicrania continua
Indomethacin
Presentation of new daily persistent HA
Abrupt onset and does not remit
Ranges from mild to severe (throbbing tightening on both sides of head)
Light/sound sensitivity
May be due to infection, meds, trauma etc
Tx: muscle relaxants, antidepressants, anticonvulsants
Characteristics of primary stabbing HA
Ice pick or jabs and jolts HA
Pain is intense and strikes without warning (1-10 sec)
Usually around eye but may be near trigeminal nerve
Often associated with other sxs
Tx: indomethacin or abortive meds if multiple episodes occur
Characteristics of primary exertional HA
Trigger: coughing, sneezing, intense activity
Last minutes to days
Associated sx: n/v
Imaging for primary exertional HA
MRI/MRA to r/o vascular abnormalities (risk increases >40 YO and focal neuro sx)
Tx for primary exertional HA
Warm up exercises, NSAIDs, indomethacin
Characteristics of hypnic HA
Later in life (>50 YO) Develops during sleep and awakens ppl at night >10 episodes/mo lasting 15 min-3 hrs Mild-mod throbbing at both sides of head N/v, sensitivity to light/sound
Imaging for hypnic HA
For new presentation (MRI preferred to CT)
Tx for hypnic HA
Caffeine at night, indomethacin, lithium
Alerts that indicate referral with secondary HA!!!!
First HA in pt over 50 Sudden intense HA without previous hx of HAs Nuchal rigidity, Kernig or Brudzinski Diplopia Papilledema or retinal hemorrhage Persistent or new neuro signs (>60 min) Fever Excessive BP elevation Hx of head trauma, malignancy, coagulopathy Change in previous HA presentation
Pneumonic for when to evaluate for secondary HA
Systemic sx or illness (HIV, CA, infection, meningitis) Neurologic (mass, lesion, stroke, SUD) Onset sudden Older (new onset>50 YO) Previous HA hx (1st HA or change in HAs)
Sxs of secondary HA related to structural abnormalities
Chiari malformation, syringomyelia
Septum deviation causing obstruction
TMJ dysfunction
Sxs of secondary HA related to cranial neuralgias
Trigeminal neuralgia (stabbing, shock like pain) Occipital neuralgia
Sxs of secondary HA related to CSF pressure
Idiopathic intracranial HTN (pseudotumor cerebri-sx increase with cough, exertion, straining, position)
Post lumbar puncture HA (leak)
Sxs of secondary HA related to brain tumors
Steady worsening HA and neuro sxs
Night time awakenings
Sxs of secondary HA related to SAH (vascular)
Abrupt severe HA
(LOC, nuchal rigidity, first and worst HA)
See hemorrhage on CT
Sxs of secondary HA related to CVA (vascular)
Unilateral HA on affected side (hemorrhagic or ischemic)
Sxs of secondary HA related to temporal arteritis (vascular)
Age >50
Throbbing temporal pain, tenderness with palpation
Elevated ESR and biopsy
Sxs of secondary HA related to head trauma
Post concussion syndrome: delayed onset of dizziness, tinnitus, visual changes
Subdural hematoma
What precedes medication overuse HA?
Usually episodic HA disorder
Medications with risk of MOH
High: opioids, barbs, aspirin
Medium: triptans
Low: NSAIDs
When to refer?
Pt asks for referral Provider has low comfort level with dx Diagnosis is questionable Pt not respond to tx Condition worsens or changes Unable to treat as outpatient
