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X Clin Med III Exam 3 > Headaches > Flashcards

Headaches Flashcards

1
Q

Most common benign headaches

A

Migraine, cluster, tension

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2
Q

Types of headache

A

Vascular (migraine, cluster)
Muscle contraction (tension)
Traction (organic diseases of head like intracranial mass)
Inflammatory (meningitis, giant cell arteritis etc)

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3
Q

Types of primary HAs

A

Migraine, cluster, tension type

Chronic daily HA, primary stabbing, primary exertional, hypnic (“alarm-clock”)

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4
Q

Most common diagnosis given

A

Migraine

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5
Q

Most debilitating HA

A

Cluster

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6
Q

Most frequent HA

A

Tension type

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7
Q

Most important factor in establishing diagnosis of HA

A

History

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8
Q

Important history questions for HAs

A 
Frequency, duration, intensity, location
Quality
Time and setting of onset
Aggravating/ alleviating factors
Age of onset
Associated sxs (nausea, photophobia, phonophobia, focal neuro presentation)
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9
Q

Triggers of HAs

A 
Diet (caffeine, alcohol, chocolate)
Hormones (menses, HRT)
Sensory stimuli (light, odor, sound)
Stress 
Environment
Change in habits
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10
Q

Pneumonic for migraines

A 
Pulsatile
hOurs 4-72 hrs
Unilateral
Nausea
Debilitating
ing
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11
Q

Associated sxs of migraines

A

Photophobia
Phonophobia
N/v
Movement worsens sxs

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12
Q

Types of migraines

A

Migraine without aura (common)- more frequent type

Migraine with aura (classic/complex)

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13
Q

Characteristics of migraine without aura

A

HA occurs without warning
Unilateral pain 4-72 hrs (throbbing, pulsatile)
Nausea, confusion, blurred vision, mood changes, sensitivity to light/sound

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14
Q

4 phases of migraine with aura

A

Prodrome
Aura
Headache
Postdrome

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15
Q

When does the aura occur?

A

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)

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16
Q

Prodrome of migraine

A

24-48 hrs prior to HA

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

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17
Q

Aura associated with a migraine

A

May occur prior to or concurrent with HA
Positive sx: visual, auditory, sensory, motor
Negative sx: loss of function, vision, hearing, sensation, motor

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18
Q

HA in migraine with aura

A

Builds gradually in intensity
Commonly unilateral pulsatile or throbbing pain
Same associated sxs

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19
Q

Postdrome of migraine with aura

A

Confused or exhausted

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20
Q

Types of migraine auras

A

Visual (area of visual loss, bright spot, lights, shapes, heat waves)
Sensory (tingling, weakness)
Language

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21
Q

What is cutaneous allodynia?

A

Associated with migraine
Abnormal pain response from things like combing hair, shaving, wearing glasses, contact lens, earrings, tight fitting clothes

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22
Q

Imaging for migraine

A

No imaging needed if have classic hx and no change in sxs

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23
Q

Scenarios that might warrant imaging with a migraine

A 
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
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24
Q

How to differentiate between aura and TIA

A

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

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25
Q

Tx of acute migraine

A

Decrease triggers, dark quiet environment, cool cloth
Fluids, caffeine early on
Meds depending on severity

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26
Q

First line meds for abortive therapy of mild to moderate migraine

A

Oral NSAIDs, acetaminophen or OTC combo

n/v add antiemetic

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27
Q

First line meds for abortive therapy of moderate to severe migraine

A

Triptans and Ergots (oral or combo with NSAID–subq if n/v etc)

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28
Q

Side effects of triptans

A

Tripton sensation: injection site rxn, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, malaise, feeling of warmth, paresthesia
Resolves in 30 min tho

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29
Q

Contraindications of triptans and ergotamine

A

It is a vasoconstrictor so uncontrolled HTN, pregnancy or hx of MI, cerebrovascular disease, peripheral vascular disease

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30
Q

Lifestyle changes to prevent migraines

A

Appropriate amt of sleep
Routine meal schedule
Regular exercise
Avoidance of triggers

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31
Q

Meds for preventative migraine tx

A 
BB: propranolol
Amitriptyline
Anticonvulsants: valproate and topiramate
Others (CRGP antagonists etc)
*start low and go slow
32
Q

Characteristics of tension type HAs

A

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)

33
Q

What will not be seen with a tension HA?

A

Phonophobia, photophobia, aura or n/v

34
Q

Triggers for tension HAs

A

Stress, jaw clenching, missed meals, depression, too little sleep, head/neck strain

35
Q

Episodic tension headaches

A

Infrequent: <12 days/ yr and lasting <1 day/mo
Frequent: 1-14 days/mo lasting 30 min to several days
Not disabling

36
Q

Chronic tension headaches

A

> 15 days/mo, lasts hours to days, may be unremitting

37
Q

Imaging for tension headache?

A

Not needed unless unexplained abnormal neuro findings or atypical presentation

38
Q

Management of tension headaches

A

Underlying cause
Acute: NSAIDs, acetaminophen, aspirin, combo (high initial dose)
Hot shower or heat to back of neck

39
Q

Management for chronic tension HA

A

Most often have stress, anxiety, depression

Antidepressants, biofeedback, relaxation training, meds etc

40
Q

What should be avoided with chronic tension HA?

A

Opioids or barbiturates b/c high potential for med overuse HA

41
Q

Characteristics of cluster HAs

A

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)

42
Q

Chronic cluster HA

A

Clusters lasting >1 yr or remission <1 mo

43
Q

Presentation of cluster HA

A

Restless and pacing
Severe orbital, supraorbital or temporal pain
Autonomic sxs
May have an soociated sx like migraine aura

44
Q

What autonomic sxs are seen in cluster HAs?

A

Conjunctival infection, lacrimation, eyelid edema, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis
Ipsilateral to the pain!!!
Parasympathetic hyperactivity and sympathetic impairment

45
Q

Triggers of cluster HA

A

Alcohol and smoking (can not have!), smells stress

46
Q

How to diagnose cluster HA

A

MRI with and without contrast or plain CT with initial dx (looking for a secondary cause)

47
Q

1 tx for cluster HA

A

O2 in nonrebreathing facemask 100% 02 at >12L/min
Sitting upright
Continue for 15 min even if attack ends before that

48
Q

When to not use O2 with cluster HA

A

Severe COPD (risk of hypercapnia and CO2 narcosis)

49
Q

Other tx for cluster HA

A

Triptian, intranasal lidocaine, ergots

50
Q

DOC to prevent cluster HA

A

Verapamil (at onset of cluster episode)

51
Q

Chronic daily HA characteristics

A

> 15 days/mo during 3+ mos

Moderate pain on sides or top of head

52
Q

Types of chronic daily HA

A

Chronic migraine
Chronic tension type
Hemicrania continua
New daily persistent HA

53
Q

What is hemicrania continua?

A

Continuous, fluctuating pain on same side of face/head lasting minutes to days
Associated sxs: tearing, irritated eyes, rhinorrhea, swollen eyelids

54
Q

Tx for hemicrania continua

A

Indomethacin

55
Q

Presentation of new daily persistent HA

A

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

56
Q

Characteristics of primary stabbing HA

A

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

57
Q

Characteristics of primary exertional HA

A

Trigger: coughing, sneezing, intense activity
Last minutes to days
Associated sx: n/v

58
Q

Imaging for primary exertional HA

A

MRI/MRA to r/o vascular abnormalities (risk increases >40 YO and focal neuro sx)

59
Q

Tx for primary exertional HA

A

Warm up exercises, NSAIDs, indomethacin

60
Q

Characteristics of hypnic HA

A 
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
61
Q

Imaging for hypnic HA

A

For new presentation (MRI preferred to CT)

62
Q

Tx for hypnic HA

A

Caffeine at night, indomethacin, lithium

63
Q

Alerts that indicate referral with secondary HA!!!!

A 
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
64
Q

Pneumonic for when to evaluate for secondary HA

A 
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)
65
Q

Sxs of secondary HA related to structural abnormalities

A

Chiari malformation, syringomyelia
Septum deviation causing obstruction
TMJ dysfunction

66
Q

Sxs of secondary HA related to cranial neuralgias

A 
Trigeminal neuralgia (stabbing, shock like pain)
Occipital neuralgia
67
Q

Sxs of secondary HA related to CSF pressure

A

Idiopathic intracranial HTN (pseudotumor cerebri-sx increase with cough, exertion, straining, position)
Post lumbar puncture HA (leak)

68
Q

Sxs of secondary HA related to brain tumors

A

Steady worsening HA and neuro sxs

Night time awakenings

69
Q

Sxs of secondary HA related to SAH (vascular)

A

Abrupt severe HA
(LOC, nuchal rigidity, first and worst HA)
See hemorrhage on CT

70
Q

Sxs of secondary HA related to CVA (vascular)

A

Unilateral HA on affected side (hemorrhagic or ischemic)

71
Q

Sxs of secondary HA related to temporal arteritis (vascular)

A

Age >50
Throbbing temporal pain, tenderness with palpation
Elevated ESR and biopsy

72
Q

Sxs of secondary HA related to head trauma

A

Post concussion syndrome: delayed onset of dizziness, tinnitus, visual changes
Subdural hematoma

73
Q

What precedes medication overuse HA?

A

Usually episodic HA disorder

74
Q

Medications with risk of MOH

A

High: opioids, barbs, aspirin
Medium: triptans
Low: NSAIDs

75
Q

When to refer?

A 
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

X Clin Med III Exam 3 (7 decks)

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