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Neurology > Headaches and Treatment > Flashcards

Headaches and Treatment Flashcards

1
Q

Definition of Headache

A

Pain anywhere in the region of the head or neck

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2
Q

Causes of Headaches

A

Sleep deprivation
Stress
Effects of medication/drugs
Infections

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3
Q

Primary Headaches

A

Migraines
Tension-type
Cluster

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4
Q

Secondary Headaches

A 
Trauma (subdural, epidural)
Subarachnoid hemorrhage
Meningitis
Brain tumor
Temporal arteritis
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5
Q

Pathophysiology Migraine

A

Headache results from dilation of blood vessels innervated by the trigeminal nerve caused by release of neuropeptides from parasympathetic nerve fibers

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6
Q

Population affected

A

Women > men

Ages 30-39

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7
Q

Precipitating and exacerbating factors

A 
Emotional stress
Hormones in women
Not eating
Weather
Sleep disturbances
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8
Q

4 Phases of a Migraine

A

Migraine prodrome
Migraine with aura
Migraine headache
Migraine postdrome

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9
Q

Symptoms of Migraine Prodrome

A

Euphoria
Depression
Irritability

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10
Q

Symptoms of Migraine with Aura

A

Positive- flashing lights, ringing in ears, music, burning pain, jerking/repetitive movement of muscles
Negative- loss of vision, hearing or feeling; inability to move a part of the body

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11
Q

Migraine Headache

A

Throbbing or pulsatile quality pain
N/V
Photophobia
Phonophobia

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12
Q

Migraine Postdrome

A

Drained/exhausted
Mild elation
Euphoria

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13
Q

Migraine Subtypes

A 
Migraine with brainstem aura
Hemiplegic migraine
Retinal migraine
Vestibular migraine
Menstrual migraine
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14
Q

Migraine with Brainstem Aura

A 
Uncommon
Female > Male
Ages 7-20
Symptoms: vertigo, dysarthria, tinnitus, diplopia, ataxia, decreased LOC
Need 2+ symptoms
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15
Q

Hemiplegic Migraine

A

Unilateral motor weakness
Manifestations: severe HA, scintillating scotoma, visual field defect, numbness, parathesia, aphasia, fever, lethargy, coma, seizures

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16
Q

Retinal Migraine

A

Repeated attacks of monocular scotomata or blindness lasting

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17
Q

Vestibular Migraine

A

Episodic vertigo with hx of migraines

Exclude brainstem disease

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18
Q

Menstrual Migraine

A

Occur before and throughout menstruation

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19
Q

Red Flags for Migraines

A 
"Worst or first" headache
Significant change in severity, frequency, or pattern
New or unexplained neurologic symptoms
HA always same side
New onset HA after age 50
HA not responding to treatment
New onset HA with HIV/cancer
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20
Q

Red Flag Sign/Symptoms for Migraines

A 
Stiff neck
Fever
Papilledema
Cognitive impairment
Personality change
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21
Q

Diagnostic Criteria for Migraine without Aura

A

At least 5 attacks
HA attacks 4-72 hours
HA with 2 of the following- unilateral location, pulsating quality, moderate/severe pain intensity, avoidance of routine physical activity
N/V, photophobia, phonophobia occur during HA

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22
Q

Diagnostic Criteria for Migraine with Aura

A

At least 2 attacks
1+ reversible aura symptoms: visual, sensory, speech, motor
2+ characteristics: one aura symptom >5 minutes and/or 2+ symptoms in succession, aura symptom 5-60 minutes, one aura symptom unilateral, aura accompanied by HA within 60 minutes

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23
Q

Treatment of Migraines

A

1st- NSAIDs or aspirin
2nd- Triptans
3rd- Triptans + NSAID
Opiods/Barbituates

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24
Q

Define Tension-Type Headaches

A

Bilateral non-throbbing headache without other associated features

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25
Q

Pathophysiology of Tension-Type Headaches

A

Peripheral activation or sensitization of myofacial nociceptors that migrate through pain pathways in the CNS

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26
Q

Clinical Features of Tension-Type Headache

A

Mild-moderate intensity
Dull, band-like, tight cap, pressure
Pericranial muscle tenderness
Poor concentration

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27
Q

Precipitating Factors of Tension-Type Headache

A

Stress/mental tension
Fatigue
Noise

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28
Q

Treatment of Tension-Type Headache

A 
Techniques for relaxation
1st- ASA, Tylenol, Ibuprofen, Naproxen
2nd- 1st line with caffeine
3rd- Butalbital
Parenteral- Toradol
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29
Q

Cluster Headache

A

Characterized by recurrent severe HA on one side of the head

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30
Q

Eye Symptoms of Cluster HA

A 
Watering of the eye
Nasal congestion
Swelling of the eye
Rhinorrhea
Lacrimation
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31
Q

Pathophysiology of Cluster Headaches

A

Hypothalamic activation with secondary activation of trigeminal-autonomic vascular system via the trigeminal-hypothalamic pathways

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32
Q

Epidemiology of Cluster Headache

A

Male&raquo_space; Female

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33
Q

Clinical Features of Cluster Headache

A

Unilateral
8+ episodes/day from 7 days to 12 months
Patients can’t get comfortable

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34
Q

Signs/Symptoms of Cluster Headache

A

Ipsilateral nasal congestion
Rhinorrhea
Lacrimation
Horner’s syndrome (ptosis of the eyelid, meiosis of the pupil, anhidrosis)

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35
Q

Cluster Headache Triggers

A

ETOH
Stress
Glare
Ingestion of specific foods

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36
Q

Neuroimaging for Cluster Headaches

A

MRI with/without contrast

Non-contrast CT of head

37
Q

Treatment of Cluster Headache

A

1st- SubQ Sumatriptan & 100% oxygen

Other- intra-nasal lidocaine, ergotomine

38
Q

Prevention of Cluster Headache

A

Verapamil

39
Q

Subarachnoid Hemorrhage

A

Bleed in the subarachnoid space
Occur spontaneously, ruptured aneurysm, stroke, or trauma
Age 40-65

40
Q

Pathophysiology of Subarachnoid Hemorrhage

A

Blood in subarachnoid space cause chemical meningitis that increases ICP

41
Q

Clinical Features of Subarachnoid Hemorrhage

A

“Thunderclap” HA
N/V
Confusion
Abnormal heart & RR

42
Q

Diagnosis of Subarachnoid Hemorrhage

A

Non-contrast CT

Lumbar Puncture

43
Q

Treatment of Subarachnoid Hemorrhage

A

ABC’s
Surgical clipping of aneurysms
Nimodipine for vasospasm
Nicardipine if MAP is >130

44
Q

Goals of Treatment of Subarachnoid Hemorrhage

A

BP control
Prevention of seizures
Treatment of nausea
Management of ICP

45
Q

Temporal Arteritis

A

Chronic vasculitis of large and medium size vessels

46
Q

Most common individuals

A

Scandinavian descent with a mean age of 70

Women > Men

47
Q

Most Feared Complication of Temporal Arteritis

A

Vision Loss

48
Q

Pathophysiology of Temporal Arteritis

A

Affects arteries containing elastic tissue

Mononuclear cell infiltrates the adventitia form granulomas containing activated T cells and macrophages

49
Q

Clinical Features of Temporal Arteritis

A 
Fever
HA
Jaw claudication
Visual manifestations
Polymyalgia rheumatica
Aortic dissections or aneurysms
50
Q

Diagnostics of Temporal Arteritis

A 
Temporal artery biopsy
CBC
CMP
ESR
 CRP
51
Q

Treatment of Temporal Arteritis

A

Corticosteroid therapy

Low-dose aspirin

52
Q

Cause of Intracranial Pressure

A 
Subdural/Epidural hemorrhage
Ruptured aneurysm
CNS infection
Ischemic stroke
Neoplasm
Hydrocephalus
53
Q

Pathophysiology of Intracranial Pressure

A

Increased ICP >20
Homeostatic mechanism stabilizes ICP
Increase in spinal fluid or intracranial mass will increase the volume inside

54
Q

Clinical Features of Intracranial Pressure

A 
HA
N/V
Ocular palsies
Altered LOC
Back pain
Papilledema
55
Q

Diagnostics of Intracranial Pressure

A

Head CT
Brain MRI
Lumbar puncture

56
Q

Treatment of Intracranial Pressure

A

ICP monitoring either by intraventricular, intraparenchymal, subarachnoid, epidural

57
Q

Cause of Infectious Headaches

A

Meningitis
Encephalitis
Brain Abscess

58
Q

Preventative Medications for Headaches

A 
Beta blockers
Anticonvulsants
Antidepressants
Calcium channel blockers
Serotonin antagonists
59
Q

Tylenol

A

325-650 mg every 4-6 hours
Watch liver toxicity
1st choice during pregnancy and breastfeeding

60
Q

Aspirin

A

MOA: inhibits prostaglandin synthesis, reducing inflammatory response and platelet aggregation
Contraindications: hx of bleeding disorders, asthma, hypersensitivity
325-650 mg every 4-6 hours

61
Q

NSAIDs

A

MOA: inhibits the enzyme COX-2
SE: abdominal cramps, nausea, indigestion
Ex: ibuprofen, naproxen

62
Q

Barbiturates

A

Fiorinal

Fioricet

63
Q

Fiorinal

A

Butalbital/Caffeine/ASA: 1-2 tabs q4h (6/day)
MOA: inhibit prostaglandin, sedation, cerebral vasoconstriction
SE: drowsiness, N/V, abdominal pain
Pregnancy C

64
Q

Fioricet

A

Butalbital/Caffeine/Acetaminophen: 1-2 tabs q4h (6/day)
MOA: inhibit prostaglandin, sedation, cerebral vasoconstriction
SE: drowsiness, N/V, abdominal pain
Pregnancy C

65
Q

Midrin

A

Isometheptene/dichloralphenazone/acetaminophen: 1-2 caps q4h (8/day)
MOA: Cerebral vasoconstriction, sedation, analgesia
SE: drowsiness, N/V, abdominal pain
Pregnancy C

66
Q

Phenothiazine

A

Promethazine (Phenergan)
Prochlorperazine (Compazine)
MOA: non-selectively antagonizes central & peripheral histamine H1 receptors
SE: drowsiness, sedation
Black box: respiratory depression, Dementia-related psychosis (compazine)

67
Q

Metoclopromide (Reglan)

A 
5-10 mg q6-8 hours
MOA: antagonizes central and peripheral dopamine receptors
SE: drowsiness, restless, fatigue
Black box: tardive dyskinesia
Pregnancy B
68
Q

Triptans

A 
Sumatriptan (Imitrex)
Naratriptan (Amerge)
Rizatriptan (Maxalt)
Zolmitriptan (Zomig)
Almotriptan (Axert)
Eletriptan (Relpax)
Frovatriptan (Frova)
69
Q

Triptan

A

MOA: agonist effects on serotonin 5-HT1 receptors in cranial blood vessels and subsequent inhibition of pro-inflammatory neuropeptide release
Contraindications: CAD, PVD, stroke, hemiplegic and basilar migraine
SE: nausea; jaw, neck, or chest pressure/tightness; fatigue; burning sensation of skin
Pregnancy C

70
Q

Sumatriptan (Imitrex)

A

PO: 25-100 mg at headache onset
SQ- 6 mg
Nasal- 5-20 mg

71
Q

Naratriptan (Amerge)

A

1-2.5 mg every 4 hours (5 mg/day)
Higher bioavailability
Lower rate of recurrence

72
Q

Rizatriptan (Maxalt)

A

5-10 mg q2 hours (30 mg/day

Early onset of action

73
Q

Zolmitriptan (Zomig)

A

2.5 mg PO/Nasal/Disintegrating tablet

Onset of migraine

74
Q

Almotriptan (Axert)

A

6.25-12.5 q2 hours (25 mg/day)

75
Q

Eletriptan (Relpax)

A

20-40 q2 hours (80 mg/day)

Rapid onset

76
Q

Frovatriptan (Frova)

A

2.5 mg q2 hours (7.5 mg/day)
Long half life
Good for menstrual related migraines

77
Q

Ergot Alkaloids

A

Eihydroergotamine (DHE) & Ergotamine
First migraine-specific drug
Fallen out of favor (unpredictable patient response)
MOA: constriction of peripheral and cranial vessels
Black box warning: peripheral ischemia, effects are worse with administration with potent CYP3A4 inhibitors, protease inhibitors, and macrolide antibiotics
Pregnancy X

78
Q

Ergotamine tartrate (Ergostat, Ergomar)

A

SE: rebound HA, vascular occlusion, dependence

79
Q

Dihydroergotamine (Migranal)

A

IM/SQ or IV- 1 mg first sign of HA (6 mg/week)

Nasal- 1 spray each nostril (8 sprays/week)

80
Q

DHE Adverse Effects

A 
Burning/tingling sensation
Dry mouth
Dryness, soreness, or pain in the nose
Runny/stuffy nose
Change in sense of taste
Diarrhea
Dizziness
Fatigue
Headache
Increased sweating
N/V
Muscle stiffness
Anxiety
Blurred vision
Cold clammy skin
Confusion
Congestion in chest
Cough
Decreased appetite
Pounding heartbeat
Depression
Nervousness
81
Q

Combination Therapy

A

Triptan + Aleve
NSAID with antiemetic
Moderate narcotic with antiemetic

82
Q

Goals of Preventative Therapy

A

Decrease attack frequency and duration
Improve responsiveness to treatment
Improve function
Decrease disability

83
Q

Preventative Therapy Options

A

Beta-blockers: Propranolol (Inderal)
Anticonvulsants: Valproic acid (Depakote), Topromax (Topiramide)
Antidepressants: TCA’s, SSRI’s
Calcium Channel Blockers: Calan (Verapamil)

84
Q

Beta-blockers

A

Propranolol (40 mg BID)
Timolol (5 mg qd)
Considered 1st line agent for prophylactic treatment of migraines
SE: fatigue, depression, impotence, hypotension
Caution in patients with: baseline bradycardia, asthma, 2nd or 3rd degree AV block, CHF

85
Q

Calcium Channel Blockers

A

Verapamil (Calan): 40-80 mg TID; 2nd or 3rd line treatment
MOA: inhibition of serotonin release
SE: flushing, dizziness, constipation, peripheral edema
Contraindicated with: bradycardia, heart block, A-fib

86
Q

Valproic Acid (Depakote)

A

Decrease HA frequency
Dose: 250 mg BID (1000 mg/day)
SE: Weight GAIN, tremor, nausea, hair loss
Pregnancy D

87
Q

Topiramate (Topamax)

A

Dose: 25-100 mg qhs
SE: concentration & memory impairment, fatigue, weight LOSS, nausea
Contraindications: liver & renal impairment
Pregnancy C

88
Q

Antidepressants

A

TCA: Elavil (Amitryptiline)
SSRI: venlafaxine (Effexor)
SE: sedation, dry mouth, constipation, weight GAIN

89
Q

Goals for Prevention

A

Improve patients’ QOL
Intiate meds with highest level of effectiveness and lowest SE
May take 2-6 months

Neurology (10 decks)

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