Headaches and Treatment Flashcards
1
Q
Definition of Headache
A
Pain anywhere in the region of the head or neck
2
Q
Causes of Headaches
A
Sleep deprivation
Stress
Effects of medication/drugs
Infections
3
Q
Primary Headaches
A
Migraines
Tension-type
Cluster
4
Q
Secondary Headaches
A
Trauma (subdural, epidural) Subarachnoid hemorrhage Meningitis Brain tumor Temporal arteritis
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
6
Q
Population affected
A
Women > men
Ages 30-39
7
Q
Precipitating and exacerbating factors
A
Emotional stress Hormones in women Not eating Weather Sleep disturbances
8
Q
4 Phases of a Migraine
A
Migraine prodrome
Migraine with aura
Migraine headache
Migraine postdrome
9
Q
Symptoms of Migraine Prodrome
A
Euphoria
Depression
Irritability
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
11
Q
Migraine Headache
A
Throbbing or pulsatile quality pain
N/V
Photophobia
Phonophobia
12
Q
Migraine Postdrome
A
Drained/exhausted
Mild elation
Euphoria
13
Q
Migraine Subtypes
A
Migraine with brainstem aura Hemiplegic migraine Retinal migraine Vestibular migraine Menstrual migraine
14
Q
Migraine with Brainstem Aura
A
Uncommon Female > Male Ages 7-20 Symptoms: vertigo, dysarthria, tinnitus, diplopia, ataxia, decreased LOC Need 2+ symptoms
15
Q
Hemiplegic Migraine
A
Unilateral motor weakness
Manifestations: severe HA, scintillating scotoma, visual field defect, numbness, parathesia, aphasia, fever, lethargy, coma, seizures
16
Q
Retinal Migraine
A
Repeated attacks of monocular scotomata or blindness lasting
17
Q
Vestibular Migraine
A
Episodic vertigo with hx of migraines
Exclude brainstem disease
18
Q
Menstrual Migraine
A
Occur before and throughout menstruation
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
20
Q
Red Flag Sign/Symptoms for Migraines
A
Stiff neck Fever Papilledema Cognitive impairment Personality change
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
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
23
Q
Treatment of Migraines
A
1st- NSAIDs or aspirin
2nd- Triptans
3rd- Triptans + NSAID
Opiods/Barbituates
24
Q
Define Tension-Type Headaches
A
Bilateral non-throbbing headache without other associated features
25
Pathophysiology of Tension-Type Headaches
Peripheral activation or sensitization of myofacial nociceptors that migrate through pain pathways in the CNS
26
Clinical Features of Tension-Type Headache
Mild-moderate intensity
Dull, band-like, tight cap, pressure
Pericranial muscle tenderness
Poor concentration
27
Precipitating Factors of Tension-Type Headache
Stress/mental tension
Fatigue
Noise
28
Treatment of Tension-Type Headache
```
Techniques for relaxation
1st- ASA, Tylenol, Ibuprofen, Naproxen
2nd- 1st line with caffeine
3rd- Butalbital
Parenteral- Toradol
```
29
Cluster Headache
Characterized by recurrent severe HA on one side of the head
30
Eye Symptoms of Cluster HA
```
Watering of the eye
Nasal congestion
Swelling of the eye
Rhinorrhea
Lacrimation
```
31
Pathophysiology of Cluster Headaches
Hypothalamic activation with secondary activation of trigeminal-autonomic vascular system via the trigeminal-hypothalamic pathways
32
Epidemiology of Cluster Headache
Male >> Female
33
Clinical Features of Cluster Headache
Unilateral
8+ episodes/day from 7 days to 12 months
Patients can't get comfortable
34
Signs/Symptoms of Cluster Headache
Ipsilateral nasal congestion
Rhinorrhea
Lacrimation
Horner's syndrome (ptosis of the eyelid, meiosis of the pupil, anhidrosis)
35
Cluster Headache Triggers
ETOH
Stress
Glare
Ingestion of specific foods
36
Neuroimaging for Cluster Headaches
MRI with/without contrast
| Non-contrast CT of head
37
Treatment of Cluster Headache
1st- SubQ Sumatriptan & 100% oxygen
| Other- intra-nasal lidocaine, ergotomine
38
Prevention of Cluster Headache
Verapamil
39
Subarachnoid Hemorrhage
Bleed in the subarachnoid space
Occur spontaneously, ruptured aneurysm, stroke, or trauma
Age 40-65
40
Pathophysiology of Subarachnoid Hemorrhage
Blood in subarachnoid space cause chemical meningitis that increases ICP
41
Clinical Features of Subarachnoid Hemorrhage
"Thunderclap" HA
N/V
Confusion
Abnormal heart & RR
42
Diagnosis of Subarachnoid Hemorrhage
Non-contrast CT
| Lumbar Puncture
43
Treatment of Subarachnoid Hemorrhage
ABC's
Surgical clipping of aneurysms
Nimodipine for vasospasm
Nicardipine if MAP is >130
44
Goals of Treatment of Subarachnoid Hemorrhage
BP control
Prevention of seizures
Treatment of nausea
Management of ICP
45
Temporal Arteritis
Chronic vasculitis of large and medium size vessels
46
Most common individuals
Scandinavian descent with a mean age of 70
| Women > Men
47
Most Feared Complication of Temporal Arteritis
Vision Loss
48
Pathophysiology of Temporal Arteritis
Affects arteries containing elastic tissue
| Mononuclear cell infiltrates the adventitia form granulomas containing activated T cells and macrophages
49
Clinical Features of Temporal Arteritis
```
Fever
HA
Jaw claudication
Visual manifestations
Polymyalgia rheumatica
Aortic dissections or aneurysms
```
50
Diagnostics of Temporal Arteritis
```
Temporal artery biopsy
CBC
CMP
ESR
CRP
```
51
Treatment of Temporal Arteritis
Corticosteroid therapy
| Low-dose aspirin
52
Cause of Intracranial Pressure
```
Subdural/Epidural hemorrhage
Ruptured aneurysm
CNS infection
Ischemic stroke
Neoplasm
Hydrocephalus
```
53
Pathophysiology of Intracranial Pressure
Increased ICP >20
Homeostatic mechanism stabilizes ICP
Increase in spinal fluid or intracranial mass will increase the volume inside
54
Clinical Features of Intracranial Pressure
```
HA
N/V
Ocular palsies
Altered LOC
Back pain
Papilledema
```
55
Diagnostics of Intracranial Pressure
Head CT
Brain MRI
Lumbar puncture
56
Treatment of Intracranial Pressure
ICP monitoring either by intraventricular, intraparenchymal, subarachnoid, epidural
57
Cause of Infectious Headaches
Meningitis
Encephalitis
Brain Abscess
58
Preventative Medications for Headaches
```
Beta blockers
Anticonvulsants
Antidepressants
Calcium channel blockers
Serotonin antagonists
```
59
Tylenol
325-650 mg every 4-6 hours
Watch liver toxicity
1st choice during pregnancy and breastfeeding
60
Aspirin
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
NSAIDs
MOA: inhibits the enzyme COX-2
SE: abdominal cramps, nausea, indigestion
Ex: ibuprofen, naproxen
62
Barbiturates
Fiorinal
| Fioricet
63
Fiorinal
Butalbital/Caffeine/ASA: 1-2 tabs q4h (6/day)
MOA: inhibit prostaglandin, sedation, cerebral vasoconstriction
SE: drowsiness, N/V, abdominal pain
Pregnancy C
64
Fioricet
Butalbital/Caffeine/Acetaminophen: 1-2 tabs q4h (6/day)
MOA: inhibit prostaglandin, sedation, cerebral vasoconstriction
SE: drowsiness, N/V, abdominal pain
Pregnancy C
65
Midrin
Isometheptene/dichloralphenazone/acetaminophen: 1-2 caps q4h (8/day)
MOA: Cerebral vasoconstriction, sedation, analgesia
SE: drowsiness, N/V, abdominal pain
Pregnancy C
66
Phenothiazine
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
Metoclopromide (Reglan)
```
5-10 mg q6-8 hours
MOA: antagonizes central and peripheral dopamine receptors
SE: drowsiness, restless, fatigue
Black box: tardive dyskinesia
Pregnancy B
```
68
Triptans
```
Sumatriptan (Imitrex)
Naratriptan (Amerge)
Rizatriptan (Maxalt)
Zolmitriptan (Zomig)
Almotriptan (Axert)
Eletriptan (Relpax)
Frovatriptan (Frova)
```
69
Triptan
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
Sumatriptan (Imitrex)
PO: 25-100 mg at headache onset
SQ- 6 mg
Nasal- 5-20 mg
71
Naratriptan (Amerge)
1-2.5 mg every 4 hours (5 mg/day)
Higher bioavailability
Lower rate of recurrence
72
Rizatriptan (Maxalt)
5-10 mg q2 hours (30 mg/day
| Early onset of action
73
Zolmitriptan (Zomig)
2.5 mg PO/Nasal/Disintegrating tablet
| Onset of migraine
74
Almotriptan (Axert)
6.25-12.5 q2 hours (25 mg/day)
75
Eletriptan (Relpax)
20-40 q2 hours (80 mg/day)
| Rapid onset
76
Frovatriptan (Frova)
2.5 mg q2 hours (7.5 mg/day)
Long half life
Good for menstrual related migraines
77
Ergot Alkaloids
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
Ergotamine tartrate (Ergostat, Ergomar)
SE: rebound HA, vascular occlusion, dependence
79
Dihydroergotamine (Migranal)
IM/SQ or IV- 1 mg first sign of HA (6 mg/week)
| Nasal- 1 spray each nostril (8 sprays/week)
80
DHE Adverse Effects
```
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
Combination Therapy
Triptan + Aleve
NSAID with antiemetic
Moderate narcotic with antiemetic
82
Goals of Preventative Therapy
Decrease attack frequency and duration
Improve responsiveness to treatment
Improve function
Decrease disability
83
Preventative Therapy Options
Beta-blockers: Propranolol (Inderal)
Anticonvulsants: Valproic acid (Depakote), Topromax (Topiramide)
Antidepressants: TCA's, SSRI's
Calcium Channel Blockers: Calan (Verapamil)
84
Beta-blockers
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
Calcium Channel Blockers
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
Valproic Acid (Depakote)
Decrease HA frequency
Dose: 250 mg BID (1000 mg/day)
SE: Weight GAIN, tremor, nausea, hair loss
Pregnancy D
87
Topiramate (Topamax)
Dose: 25-100 mg qhs
SE: concentration & memory impairment, fatigue, weight LOSS, nausea
Contraindications: liver & renal impairment
Pregnancy C
88
Antidepressants
TCA: Elavil (Amitryptiline)
SSRI: venlafaxine (Effexor)
SE: sedation, dry mouth, constipation, weight GAIN
89
Goals for Prevention
Improve patients' QOL
Intiate meds with highest level of effectiveness and lowest SE
May take 2-6 months
