Headaches - Exam 3 Flashcards
How are HA classified? What do each mean?
primary or secondary
primary: headache syndrome
-migraine
-tension
-cluster
secondary: symptoms of other illness (meningitis and intracranial mass)
primary headaches account for ____ of the total headaches. Only ___ are due to serious, life-threatening conditions
90% are primary
1% are life threatening
poor vision or eye strain causes what type of HA?
tension HA
** What is the most important question to ask about HA?
is this HA new or old? if old, is the HA typical?
any hx of previous HA?
aka what makes this one different?
What are two additional questions that are bolded?
Presence or absence of aura or prodrome
Response to previous treatment
What are other features associated with a HA that would make you think the cause is secondary?
Halos around lights
Visual field defects
Unilateral vision loss
Blurred vision with bending over
N/V
worsening with changes in body position
change in pattern
**What are the danger signs of a HA? What are 2 highlighted things worth mentioning?
“thunderclap”
if the HA woke you up from sleep
What 2 organ systems should be checked if a pt complains of a HA?
eyes and reflexes
What is the imaging of choice for HA complaint in PCP office?
normally no studies are indicated!
What clinical features about the HA would make you want to order imaging?
Age of onset >40
Focal neurologic signs or symptoms
Onset of headache with exertion, cough, or sexual activity
Change in pattern of normal headaches
Frequency or severity (think thunderclap!)
In a patient with cancer, Lyme disease, or HIV
Progressively worsening of headache despite adequate therapy
If imaging is needed, _____ is the most sensitive and preferred imaging study
MRI
Lumbar puncture need to measure ______ because need to think about a possible _______
open pressure
suspected subarachnoid hemorrhage
When would you need to hospitalize a pt for a HA?
-need repeat doses of parenteral pain meds
-expedited work-up to find source of HA
-Monitoring for progression of symptoms and neurologic consultation when the initial emergency department work-up is inconclusive
- severe pain that impaired ADLs or limit participation in f/u appointments
When would you need to refer out for a pt who presents with a HA?
Thunderclap onset
Increasing headache unresponsive to simple measures
History of trauma, HTN, fever, visual changes
Presence of neurologic signs or of scalp tenderness
What is the pathophys behind a migraine HA?
unclear
Neuronal dysfunction in the trigeminal system resulting in the release of vasoactive neuropeptides → neurogenic inflammation
or
genetic factors
or
serotonin release triggering pain signals
What is the MC pt type with migraine? **What is the MC migraine type?
women, 25-55 with a family hx
**migraine without aura
What are the 4 phases to the typical migraine presentation?
- Prodrome
- Aura
- Headache
- Postdrome
What are some characteristics of a prodrome? How common are they? When do they start?
things that happen for a migraine that signal a migraine is coming: Euphoria, depression, irritability, food cravings, constipation, neck stiffness, and increased yawning
60% report a prodome
start 24-48 hours prior to HA
How common are auras? What are they attributed to? What are the MC types? How long do they last?
25% of migraines have an aura
attributed to cortical spreading depression
MC: visual but can be sensory, verbal or motor
develop gradually and typically last no longer than 1 hour
**Describe a migraine HA? What are some associated symptoms? How long do they last? What makes them worse?
unilateral, throbbing or pulsatile is classic
but may be bilateral
N/V, photophobia, phonophobia,
hours to days (typically 4-72 hours)
routine physical activity
What is a postdrome? What type of HA is this associated with?
Patient often feels drained or exhausted
Some patients will have aches and pains - stiff neck
migraine
**What is the ICHD-3 criteria to dx migraine WITHOUT aura? WITH aura? What do you do next?
W/O: at least 5 attacks that fulfill criteria B-D
WITH: only 2 attacks
HA attacks last 4-72 hours
If they qualify for the dx then it is appropriate to start preventative therapy
What is the difference between preventative and abortive treatments for migraines?
preventatives are taken daily to PREVENT migraine attacks and abortives are taken onces s/s have started to appear
What are the abortive tx options for a mild to moderate attack?
NSAIDS!!
Excedrin migraine: ASA, caffeine, acetaminophen
+/- antiemetic
What are the abortive tx options for a moderate to severe attack?
triptains or combo of sumatriptan/naproxen
+/- antiemetic agents
What is an medication overuse HA? What is the limit to PRN meds in 1 month?
Due to an overuse of medications; occurs most frequently with opioids and ASA/caffeine/acetaminophen combos
aka using PRN meds QD
Limit use to 10 – 15 days per month -> more than that, need to be on preventative therapy
With regards to NSAID, what should you tell your pt if one does not work?
If one does not work, may try another or a combo
_____ MOA has an agonistic effects on serotonin 5-HT1b (meningeal arteries) and 5-HT1d (trigeminal nerve) receptors in cranial blood vessels. They also inhibit _______ release. What routes are options?
Triptans - Serotonin (5-HT1b/1d) Agonists
proinflammatory neuropeptide
SubQ-> fastest route
nasal
oral
**What are first line therapy for mild/mod migraine HA? mod/severe?
mild/mod: NSAIDs are first line
mod/severe: triptan or triptan plus naproxen
Which -triptans provide the highest likelihood of consistent success?
Rizatriptan (Maxalt)
Eletriptan (Relpax)
Almotriptan (Axert)
What are the CI for -triptans?
CAD or PAD
Have not been studied in patients >65 years of age - so avoidance best option
What are the cautions associated with -triptans?
Patients who are taking meds to lower heart rate (CCB, BB, MAOI’s)
Patients taking SSRI’s or SNRI’s = Serotonin Syndrome
pregnant pts
What is the pregnancy category associated with triptans?
Was listed as Preg Cat C – best to avoid breastfeeding for 12 hrs after tx
**What are two important pt education points for triptans?
Wait 2 hrs after taking a sumatriptan tab before taking another one. Do not exceed 200 mg in 24 hrs. Wait 2 hrs with second dose of nasal spray as well. Do not exceed 40 mg of the nasal spray in 24 hrs
**NOT a prophylaxis tx, only works once s/s have started
_____ MOA acts as an agonist, binding to several different receptors, producing peripheral vasoconstriction and decreased blood flow. It is structurally related to biogenic amines like norepinephrine, epinephrine, dopamine, and serotonin. It also acts upon serotonin receptors to cause vasoconstriction as well
What happens if ingested in very large amounts?
Ergotamine (Ergots)
vasodilation!
What are the pt instructions for ergots?
2 mg SL followed by 1-2 mg q 30 min until attack abated; not to exceed 6 mg/day and no more than 10 mg/week (injection is 1 mg, repeat in 1 hr with no more than 6 mg/d)
What are the SE of ergots? CI and caution?
think many many heart problems due to vasoconstriction
CI and caution: people with PAD, CAD, HTN due to vasoconstriction and the elderly
think vasoconstriction and the elderly
**What is the BBW for ergots?
Serious and/or life-threatening peripheral ischemia has been associated with the coadministration of Cafergot (ergotamine/caffeine) with potent CYP3A4 inhibitors including protease inhibitors and macrolide antibiotics.
aka cannot use with CYP3A4 inhibitors
What are the top 3 antiemetics listed in lecture?
Ondansetron (Zofran)
Promethazine (Phenergan)
Metoclopramide (Reglan)
What is the new emerging ABORTIVE therapy? What drug class? What makes this drug class special?
ditans
5-HT1F receptor agonist
does not have the same vasoconstrictor activity of other triptan meds so it CAN be given to pts with CAD/PAD etc etc
**What migraine medication is safe for pts with CAD/PAD? What is the drawback?
ditan
but expensive!!
**_______ is the only medication that can be used for prophaxylaxis and abortive therapy
CGRP ends in -gepants
_____ MOA blocks the CGRP protein that carry pain signals along nerve endings that cause the pain associated with migraines
Calcitonin Gene-related Peptide Antagonists - CGRP
-gepants
Rimegepant (Nurtec) is the commonly used one
_______ do NOT cause medication overuse HA
-gepants
**if your pt has CAD and migraine HA, what is the tx?
start with tylenol then move to -ditan
What are 4 factors that would indicate the need for prophylaxis tx? **What is the major one?
**Recurring migraines (>4 migraine headache days a month) that significantly interfere with daily routine in the patient’s opinion despite acute treatment
Contraindication to or failure or overuse of acute therapies
Adverse events with acute therapies
Patient preference
What is the prescribing train of thought when it comes to prescribing preventative therapies for migraine HA?
might have to try a few drugs in the class to see what works for them
Once a drug has been found to help, it should be continued for several months (at least 8 weeks)
consider botox injection and acupuncture
What are the preventive therapy medication options?
Topiramate (Topamax)
Valproic acid (Depakote)
Beta-blockers
Amitriptyline (Elavil) 10 – 150 mg QHS
Venlafaxine
botox injections
Riboflavin
Calcitonin Gene-related Peptide Monoclonal Antibodies- emerging!
What are the first line preventive therapy options for migraines?
antiepileptic:
topiramate and valproic acid
How do you choose the best preventive medication for migraine HA?
Think similar to psych meds!
Prior experiences
Response to relative
Pattern of headache
Comorbid conditions
______ is the MC type of HA. Describe the classic presentation. What is the MC trigger?
tension HA
generalized, typically bilateral, non-pulsatile, and may be most intense about the neck and/or back of head
Constant, daily headache with band-like/vise-like or tight in quality pain
stress
**What is the tx for a tension HA? What do you need to pay special treatment to?
Analgesics such as NSAIDS or acetaminophen are mainstay of tx
Triptan and Ergot drugs are not typically indicated, but may be used as a last resort
Treatment of comorbid anxiety or depression is important
+/- relaxation, massage, hot baths and behavioral therapy
What is the pathophys behind a cluster HA?
idiopathic
but the theory includes the
activation of cells in the ipsilateral hypothalamus (area in charge of circadian rhythm) with secondary triggering of the trigeminal autonomic vascular system
What are 3 classic signs that the HA is a cluster HA?
ptosis
tearing
running nose
ONLY ON 1 SIDE!!!
**What are the risk factors for a cluster HA? what are the 2 highlighted ones?
middle-aged men (30-50)
**alcohol use especially heavy alcohol use
**tobacco use- greater than 80% are heavy smokers
family hx
hx of head trauma/sx
unilateral temporal headaches in grouped attacks over a period of weeks to months
What am I?
How long do attacks usually last?
When do attacks usually take place?
What is a common trigger?
cluster HA
15-180 minutes
occur at night and will wake the pt up
alcohol is a common trigger
What is the preferred imaging for a cluster HA? Why?
MRI w/ and w/o contrast for the initial evaluation
concerned about a tumor, stroke or aneurysm
**What is the management for a cluster HA?
100% Oxygen at 7 – 12 L/min over 15 min with a non-rebreather mask
then
Sumatriptan (Imitrex) 6 mg SubQ or 20 mg intranasal (contralateral administration to side of headache)
then
DHE (Ergot derivative) 1 mg IM or IV
What is benign intracranial hypertension? What is another name for it?
Defined as a syndrome of increased intracranial pressure without a space occupying lesion
Pseudotumor Cerebri
Who is the MC pt type for BIH? What is a major risk factor?
women, 20-44 that are greater than 20% over ideal body weight
women are 9x more likely to be affected than men
Obesity, postpubertal white, non-Hispanic, female
obesity is a huge risk factor!!!
What are 3 factors that potentially contribute to BIH? What will the ventricles look like on imaging?
Excessive cerebrospinal fluid (CSF) and extracellular edema
Increased venous sinus pressure
Defective CSF absorption
ventricles will appear NORMAL on imaging
When are children more likely to develop increased cranial pressure?
after thrombosis of 1 or more dural sinuses, usually after otitis media or mastoiditis causing increase in venous sinus pressure
What are some medications associated with BIP?
Retinoic acid
Antibiotics - tetracycline, nitrofurantoin, fluoroquinolones
Hormones - steroid use, OC, thyroxine
Vit A
Lithium
Immunizations - DTaP
What is the presentation of BIH? What are the 2 highlighted one?
Throbbing headache - worse on straining
Visual disturbances - unilateral or bilateral; diplopia, Abducen’s Nerve Palsy
Tinnitus
Nausea and/or vomiting
Papilledema on fundoscopic exam
What is abducen’s nerve palsy? What disorder is it associated with?
inability to pull eye laterally
BIH
What imaging should be ordered initially in BIH? why? what will the test show?
MRI or CT scan usually initial test
need to r/o mass or sinus obstruction
will show normal ventricles
**What is the gold standard dx test for BIH? What will the test show? Is it required for dx?
lumbar puncture to check CSF pressure
lumbar puncture opening pressure >250 mmHg is a positive result
required for true dx
What is the pharm tx for BIH? What is the MOA? What adjunct medication is used when?
Acetazolamide (Diamox) - diuretic
Reduces formation of CSF
+/- corticosteroids used only with visual changes to improve symptoms
**What is the other treatments for BIH? What is the highlighted one?
Repeated LP to lower ICP
Weight loss and low sodium diet
Surgery - optic nerve sheath decompression, LP shunt
every single person with BIH needs to lose weight and low sodium diet
What is the MC cause of Subarachnoid Hemorrhage?
trauma but may be spontaneous
What is the cause of a spontaneous Subarachnoid Hemorrhage? What is another name for it?
Spontaneously caused by rupture of arterial saccular (‘berry”) aneurysm or A-V malformation
*berry aneurysm
what are the mc pt demographics for a subarachnoid hemorrhage?
Older, female, non-Caucasian, HTN, tobacco use, excessive alcohol use
**THUNDERCLAP HEADACHE - “WORST HEADACHE” OF THEIR LIFE. what should you instantly think?
Subarachnoid Hemorrhage
What is the Ottawa Subarachnoid Hemorrhage Rule?
In neurologically intact patients presenting with acute nontraumatic headache that reached maximal intensity within one hour, a clinical decision rule its a subarachnoid hemorrhage until proven otherwise if any of the features mentioned below is true:
*Age ≥40 years
*Neck pain or stiffness
*Limited neck flexion on examination
*Witnessed loss of consciousness
*Onset during exertion
*Thunderclap headache (instantly peaking pain)
How do you dx a Subarachnoid Hemorrhage?
CT scan (with angiography if available)
if CT scan negative, immediate LP to Looking for presence of blood or xanthochromia in the spinal fluid
What is the basic tx for Subarachnoid Hemorrhage?
Hospitalize with bedrest and no exertion for at least 2 weeks
Neurology consult - urgent
How will a mass occupying lesion present? What is the imaging? tx of choice?
New onset headache over the age of 40 or 50. Headaches that are typically worse upon awakening or lying down
MRI is most important
Sx!
What is temporal arteritis? What is the trend?
Chronic vasculitis of large and medium sized vessels
Incidence steadily rises with age
______ is found in nearly 75% of the temporal arteries of affected patients. What are the s/s? What is the highlighted one?
Varicella-zoster antigen
Headache, jaw claudication, scalp tenderness, visual abnormalities
Temporal artery may be normal to nodular, tender, or pulseless
jaw claudication: jaw pain increases the more you use it!
What labs do you want to order in temporal arteritis? How do you CONFIRM dx? What will it show?
Lab values showing elevated ESR (over 50 typical) and anemia; may have elevated CRP and liver enzymes
Temporal artery biopsy = confirmatory
Will show giant cells (inflammation)
What is the tx for giant cell arteritis?
High dose corticosteroids
**What are the classic triad for a CNS infection? How do you dx it? What is the tx?
fever
HA
nuchal rigidity
dx: lumbar puncture
also want to order: WBC, plts, blood culture
tx: admit with IV abx +/- steroids
