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Clin Med III Unit 3 > Headaches > Flashcards

Headaches Flashcards

1
Q

90% of benign headaches fall into these three categories

A

Migraine
Cluster
Tension

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2
Q

What types of HA are vascular events?

A

Migraine

Cluster

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3
Q

What types of HA are the result of muscle contraction?

A

Tension

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4
Q

Traction HAs are the result of…

A

Organic diseases of the head such as an intracranial mass

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5
Q

Inflammatory HAs can be from…

A

Meningitis, giant cell arteritis, etc

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6
Q

HAs are considered primary if…

A

They occur independently of other conditions

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7
Q

HAs are considered secondary if…

A

Associated with another disorder

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8
Q

Most commonly diagnosed HA

A

Migraine

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9
Q

Most debilitating type of HA

A

Cluster

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10
Q

Most frequently occurring type of HA

A

Tension

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11
Q

Less common types of HA

A

Chronic daily HA
Primary stabbing
Primary exertional
Hypnic (“alarm clock”)

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12
Q

What is the most important factor in establishing a diagnosis for HA?

A

Thorough History 🙄

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13
Q

What types of things do you wanna ask when taking hx for a HA patient?

A

Frequency, duration, intensity, location

Quality (dull, achy, sharp, throbbing, tight, radiating)

Time and setting of onset

Aggravating/alleviating factors (meds, light/dark, mvmt, food, drink)

Age of onset

Associated Sx: N/V, photophobia, phonophobia, focal neuro sx

PMH: trauma, previous tx, changes in presentation

FHx

SHx: alcohol, caffeine, work, life changes, diet

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14
Q

What are some common dietary triggers for HAs?

A 
Alcohol
Chocolate
Caffeine
MSG
Nuts
Nitrates
Aspartame
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15
Q

What are some common hormonal triggers for HAs?

A

Menses
Ovulation
HRT (progesterone)

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16
Q

What are some common sensory triggers for HAs?

A

Strong light
Flickering light
Odor
Sound

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17
Q

What are some common stress triggers for HAs?

A

Intense activity
Let-down periods
Loss/change
Crisis

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18
Q

What are some common environmental triggers for HAs?

A

Weather
Elevation
Time zone change

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19
Q

What are some common habitual triggers for HAs?

A

Dietary changes
Sleep changes
Physical activity

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20
Q

Who gets migraines more, men or women?

A

W>M 3:1

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21
Q

Name that headache:

Throbbing, pulsating, typically unilateral

A

Migraine

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22
Q

Name that headache:

Duration = 4-72 hours

A

Migraine

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23
Q

Name that headache:

Photophobia, phonophobia, n/v

A

Migraine

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24
Q

What are the different theories of pathogenesis of migraines?

A

Vascular (not really considered anymore) - pain assoc with dilation/constriction of arteries

Cortical spreading depression - wave of neuronal and glial depolarization that spreads across cerebral cortex

Central - pain mediated by unstable serotonergic neurotransmission

Neurogenic inflammation - trigeminovascular system activation w/ release of vasoactive neuropeptides

Sensitization - spontaneous neuronal activity develops as neurons increase responsiveness to stimuli

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25
Q

What are the two main types of migraine?

A

“Common” - migraine w/o aura

“Classic” - migraine w/ aura

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26
Q

Other types of migraines that you don’t really need to know

A 
Migraine with brainstem aura
Retinal migraine
Ophthamoplegic neuropathy
Vestibular migraine
Menstrual migraine
Hemiplegic migraine
Status migrainosus
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27
Q

Which main type of migraine is more common?

A

Migraine w/o aura (“common”) - 75% of migraines

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28
Q

Name that migraine:

Occurs without warning

A

Common

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29
Q

Name that migraine:

Most frequent type

A

Common

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30
Q

Name that migraine:

Four phase migraine attack

A

Classic

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31
Q

Name that migraine:

Triggers often associated with HA onset

A

Classic

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32
Q

What are the four phases of migraine attack for classic migraines?

A

Prodrome 24-48 hours prior (food cravings, mood change, yawning, fluid retention, constipation, neck stiffness)

Aura prior to or concurrent with onset

Headache

Post drone (confused/exhausted)

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33
Q

What are some examples of positive aura sx for classic migraines?

A

Visual
Auditory
Sensory
Motor

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34
Q

What are some examples of negative aura sx for classic migraines?

A 
Loss of function
Loss of vision
Loss of hearing
Loss of sensation
Loss of motor function
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35
Q

Describe the classic migraine headache

A

Builds gradually in intensity following aura

Commonly unilateral, pulsatile, or throbbing

May also experience n/v, photophobia, phonophobia

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36
Q

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

A

Cutaneous allodynia

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37
Q

How are migraines diagnosed?

A

Based on Hx and PE

No imaging necessary

Follow International Classification of HA Disorders

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38
Q

Clinical scenarios that warrant imaging for a HA

A

“Worst HA of my life”

Changes in HA presentation

New or unexplained neuro sx

HA not responding to treatment

New onset after 50 or in pt with CA or HIV

(CT typically recommended vs MRI)

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39
Q

How do you treat an acute migraine?

A

Treat early with abortive meds

Decrease triggers

Rest in dark/quiet environment

Cool cloth on forehead

Fluids

Caffeine in early stages

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40
Q

First line meds for mild-moderate acute migraine

A

Oral NSAIDs, acetaminophen, or OTC combo (ie Excedrin, Midrin)

N/V: add antiemetic

41
Q

First line meds for moderate-severe acute migraine

A

Oral Triptans or combo med with NSAID (Sumatriptan and naproxen)

N/V: SQ or nasal sumatriptan, nasal zolmitriptan, antiemetic, parenteral dihydroergotamine

42
Q

What are the main side effects of triptans?

A

“Tripton Sensation”

Injection site reaction, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, malaise, feeling of warmth, paresthesias (WARN YOUR PATIENT BEFORE GIVING)

Usually resolves in 30 min

43
Q

Contraindications for Triptans and Ergotamine

A

It’s a vasoconstrictor, so HTN, Hx of MI, Cerebrovascular disease, PVD

PREGNANCY (avoid triptans, absolutely NO ERGOTS)

44
Q

Lifestyle changes to prevent migraines

A

Appropriate amount of sleep

Routine meal schedule

Regular exercise

Avoidance of triggers

45
Q

Preventative migraine meds

A

Beta blockers: metoprolol, PROPRANOLOL***, timolol

Antidepressants: TCA (Amitriptyline***), SSRI (Venlafaxine)

Anticonvulsants: Valproate and Topiramate**

NSAIDs

Others: Coenzyme Q10, Riboflavin, Calcitonin, Botox, Feverfew, CCB, CGRP antagonists

46
Q

Name that headache:

Bilateral, band-like pressure

A

Tension

47
Q

Name that headache:

Non-throbbing, mild-moderate intensity

A

Tension

48
Q

Name that headache:

Duration = 30 min to 7 days

A

Tension

49
Q

Name that headache:

Associated Sx: anorexia, head/neck pain with muscle tenderness, bruxism

A

Tension

50
Q

Do you get phonophobia/photophobia with tension headaches?

A

Nope

No N/V either

51
Q

Triggers for tension headaches

A 
Stress
Jaw clenching
Missed meals
Depression
Too little sleep
Head/neck strain
52
Q

Tension headaches are considered infrequent if…

A

<12 days/year and lasting <1 day/month

53
Q

Tension headaches are considered frequent if…

A

1-14 days/month lasting 30 min to several days

54
Q

Tension headaches are considered chronic is…

A

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

55
Q

How are tension headaches diagnosed?

A

Based on Hx and presentation

Imaging not needed unless unexplained abnormal neuro findings or atypical presentation

56
Q

How are tension headaches managed?

A

Treat underlying cause (corrective devices for jaw/mouth, sleep study, less stress)

Acute: NSAIDs**, acetaminophen, aspirin, combo
Usually high dose, can be preemptive

Hot shower or heat to back of neck

57
Q

Additional treatments for patients with chronic tension headaches and comorbidities (stress, anxiety, depression)

A

Antidepressants

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

AVOID OPIOID/BARBITURATES - high potential for overuse headache

58
Q

Which type of headache is more common in men?

A

Cluster headaches (M>F 3:1)

59
Q

Cluster headaches are due to…

A

Trigeminal autonomic cephalgias (TACs)

60
Q

Sharp, boring, unilateral, periorbital HA with autonomic sx

A

Cluster headache

61
Q

Which type of headache is linked to suicide?

A

Cluster headaches

Excruciatingly painful

62
Q

Duration for cluster headaches

A

15-180 minutes

63
Q

Why are they called cluster headaches?

A

They occur every other day up to 8x/day for 6-12 weeks (a “Cluster”) then remission for up to 12+ months

64
Q

When are cluster headaches considered chronic?

A

Clusters lasting >1 year or remission <1 month

65
Q

Clinical presentation of cluster headache

A

Restless, paces, sits and rocks

Severe orbital, supraorbital, or temporal pain

Autonomic sx: conjunctival injection, lacrimation, eyelid edema, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis

Associated sx: similar to migraine aura

66
Q

In cluster headaches, the autonomic sx are _______ to the pain

A

Ipsilateral (on the same side)

67
Q

Triggers for cluster headaches

A

Alcohol, smoking, smells, stress

68
Q

How are cluster headaches diagnosed?

A

Hx and clinical presentation, +/- FHx

MRI W/ AND W/O CONTRAST or plain CT with initial dx
NEVER A CLINICAL DX*

Evaluate brain and pituitary gland to r/o potential secondary cause (ie brain lesion)

69
Q

DDx for cluster headaches

A

Secondary HA

Trigeminal neuralgia

Other trigeminal autonomic cephalgias:
SUNCT, SUNA, paroxysmal hemicrania (they differ in presentation, duration, tx though)

70
Q

Treatment for acute cluster headaches

A

O2 Nonrebreathing face mask 100% O2 at >12L/min
• Sitting upright
• Continue x 15 min even if attack ends in less time
• Do not use in pt with severe COPD

Triptan: SQ sumatriptan, intranasal sumatriptan or zolmitriptan, oral zolmitriptan

71
Q

Why don’t you want to treat a patient who has an acute cluster headache and COPD with 100% O2?

A

Risk of hypercapnia and CO2 narcosis

72
Q

What is the best preventative treatment for cluster headaches?

A

CCB (Verapamil**)
Start at onset of cluster episode
Goal is to suppress attacks and minimize need for abortive meds

Other options: glucocorticoids, lithium, topiramate

73
Q

How should you treat extreme chronic cases of cluster headaches

A

Electrical stimulation or glucocorticoid injections of occipital nerve

Deep brain stimulation of hypothalamus

Surgery targeting trigeminal nerve or autonomic pathways

74
Q

Chronic daily headaches are defined as…

A

HA ≥ 15 days/month during 3+ months

Can be chronic migraine, chronic tension, hemicrania continua, or new daily persistent headache (NDPH)

75
Q

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

A

Hemicrania continua

Associated sx: tearing, irritated eyes, rhinorrhea, swollen eyelids

76
Q

Dx and Tx of Hemicrania continua

A

Indomethacin

77
Q

Describe New Daily Persistent Headaches (NDPH)

A

Abrupt onset and does not remit

Pain ranges from mild to severe, throbbing/tightening on both sides of head

Associated sx: light/sound sensitivity

78
Q

NDPH may occur following:

A

Infection, medication use, trauma, or other condition with no previous hx of HA

79
Q

Treatment for NDPH

A

Muscle relaxants
Antidepressants
Anticonvulsants

80
Q

Primary stabbing headaches are also called…

A

“Ice pick” or “Jabs and Jolts” headaches

81
Q

Describe primary stabbing headache

A

Pain intense and strikes w/o warning, lasts 1-10 seconds

Usually around eye but may occur anywhere along trigeminal nerve

May occur anywhere from daily to yearly, often associated with other headaches

82
Q

Treatment for primary stabbing headaches

A

Indomethacin or abortive meds if multiple episodes occur

83
Q

Primary exertional headaches can be triggered by…

A

Coughing, sneezing, intense activity

Last minutes to days

Associated with N/V

84
Q

How do you diagnose primary exertional headaches?

A

MRI/MRA to r/o vascular abnormalities

Risk increases ≥40 yo and focal neuro sx

85
Q

Tx for primary exertional headaches

A

Warm-up exercises, NSAIDs, Indomethacin (prior to exercises or daily)

86
Q

What are hypnic headaches?

A

Occur later in life (≥50)

Develops during sleep and awakens people at night

≥10 episodes/month lasting 15 min to 3 hours

Mild-moderate throbbing pain on both sides of head

Associated sx: nausea, photo/phonophobia

87
Q

How do you diagnose Hypnic HA?

A

Imaging for new presentation MRI preferable to CT

88
Q

Tx for hypnic HA

A

Caffeine at night > Indomethacin > lithium

89
Q

Red flags for secondary headaches

A 
First HA in patient over 50
Sudden intense HA w/o previous Hx of HA
Nuchal rigidity (+) Kermit/Brudzinski signs
Diplopia
Papilledema/retinal hemorrhage
Persistent/new neuro signs
Fever
Excessive BP elevation
Hx of head trauma, malignancy, coagulopathy
Change in previous HA presentation
90
Q

What is the mnemonic for working up secondary HA?

A

SNOOP

Systemic sx/illness (HIV, CA, infection etc)

Neurologic (mass/lesion, vascular problem, SUD)

Onset sudden (SAH, mass, lesion)

Older (>50)

Previous Ha Hx (is it new?)

91
Q

Examples of structural abnormalities —> secondary HA

A

Chiari malformation, syringomyelia
Septum deviation causing obstruction
TMJ dysfunction

92
Q

Examples of cranial neuralgias —> secondary HA

A

Trigeminal neuralgia

Occipital neuralgia

93
Q

HA sx that increase with cough, exertion, straining, position

Papilledema, vision loss, pulsatile tinnitus

Increased ICP without associated disease

A

Idiopathic intracranial hypertension (pseudotumor cerebri)

94
Q

What are two examples of secondary headaches caused by CSF pressure

A

Idiopathic intracranial hypertension (pseudotumor cerebri)

Post-LP headache

95
Q

Vascular defects that can cause secondary HA

A

Subarachnoid HA (“thunderclap”)

CVA (unilateral on affected side)

Temporal arteritis (elevated ESR with throbbing temporal pain and TTP)

Aneurysm

Arteriovenous malformation

96
Q

Primary HA that develops or worsens with medication overuse, typically preceded by an episodic HA disorder

A

Medication Overuse Headache (MOH)

97
Q

Which drugs are riskiest for MOH?

A

Opioids
Barbiturates
Aspirin/acetaminophen combos
Triptans

NSAIDs are low risk

98
Q

When should you refer a HA patient?

A 
Upon request
Provider has low comfort level with Dx
Dx is questionable
Pt does not respond to tx
Condition worsens or changes
Unable to treat as outpatient

Clin Med III Unit 3 (5 decks)

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