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Neuro > Headaches - Exam 3 > Flashcards

Headaches - Exam 3 Flashcards

1
Q

How are HA classified? What do each mean?

A

primary or secondary

primary: headache syndrome
-migraine
-tension
-cluster

secondary: symptoms of other illness (meningitis and intracranial mass)

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2
Q

primary headaches account for ____ of the total headaches. Only ___ are due to serious, life-threatening conditions

A

90% are primary

1% are life threatening

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3
Q

poor vision or eye strain causes what type of HA?

A

tension HA

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4
Q

** What is the most important question to ask about HA?

A

is this HA new or old? if old, is the HA typical?

any hx of previous HA?

aka what makes this one different?

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5
Q

What are two additional questions that are bolded?

A

Presence or absence of aura or prodrome

Response to previous treatment

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6
Q

What are other features associated with a HA that would make you think the cause is secondary?

A

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

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7
Q

**What are the danger signs of a HA? What are 2 highlighted things worth mentioning?

A

“thunderclap”

if the HA woke you up from sleep

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8
Q

What 2 organ systems should be checked if a pt complains of a HA?

A

eyes and reflexes

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9
Q

What is the imaging of choice for HA complaint in PCP office?

A

normally no studies are indicated!

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10
Q

What clinical features about the HA would make you want to order imaging?

A

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

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11
Q

If imaging is needed, _____ is the most sensitive and preferred imaging study

A

MRI

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12
Q

Lumbar puncture need to measure ______ because need to think about a possible _______

A

open pressure

suspected subarachnoid hemorrhage

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13
Q

When would you need to hospitalize a pt for a HA?

A

-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
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14
Q

When would you need to refer out for a pt who presents with a HA?

A

Thunderclap onset

Increasing headache unresponsive to simple measures

History of trauma, HTN, fever, visual changes

Presence of neurologic signs or of scalp tenderness

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15
Q

What is the pathophys behind a migraine HA?

A

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

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16
Q

What is the MC pt type with migraine? **What is the MC migraine type?

A

women, 25-55 with a family hx

**migraine without aura

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17
Q

What are the 4 phases to the typical migraine presentation?

A
  1. Prodrome
  2. Aura
  3. Headache
  4. Postdrome
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18
Q

What are some characteristics of a prodrome? How common are they? When do they start?

A

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

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19
Q

How common are auras? What are they attributed to? What are the MC types? How long do they last?

A

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

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20
Q

**Describe a migraine HA? What are some associated symptoms? How long do they last? What makes them worse?

A

unilateral, throbbing or pulsatile is classic

but may be bilateral

N/V, photophobia, phonophobia,

hours to days (typically 4-72 hours)

routine physical activity

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21
Q

What is a postdrome? What type of HA is this associated with?

A

Patient often feels drained or exhausted

Some patients will have aches and pains - stiff neck

migraine

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22
Q

**What is the ICHD-3 criteria to dx migraine WITHOUT aura? WITH aura? What do you do next?

A

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

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23
Q

What is the difference between preventative and abortive treatments for migraines?

A

preventatives are taken daily to PREVENT migraine attacks and abortives are taken onces s/s have started to appear

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24
Q

What are the abortive tx options for a mild to moderate attack?

A

NSAIDS!!

Excedrin migraine: ASA, caffeine, acetaminophen

+/- antiemetic

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25
Q

What are the abortive tx options for a moderate to severe attack?

A

triptains or combo of sumatriptan/naproxen

+/- antiemetic agents

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26
Q

What is an medication overuse HA? What is the limit to PRN meds in 1 month?

A

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

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27
Q

With regards to NSAID, what should you tell your pt if one does not work?

A

If one does not work, may try another or a combo

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28
Q

_____ 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?

A

Triptans - Serotonin (5-HT1b/1d) Agonists

proinflammatory neuropeptide

SubQ-> fastest route
nasal
oral

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29
Q

**What are first line therapy for mild/mod migraine HA? mod/severe?

A

mild/mod: NSAIDs are first line

mod/severe: triptan or triptan plus naproxen

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30
Q

Which -triptans provide the highest likelihood of consistent success?

A

Rizatriptan (Maxalt)
Eletriptan (Relpax)
Almotriptan (Axert)

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31
Q

What are the CI for -triptans?

A

CAD or PAD

Have not been studied in patients >65 years of age - so avoidance best option

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32
Q

What are the cautions associated with -triptans?

A

Patients who are taking meds to lower heart rate (CCB, BB, MAOI’s)

Patients taking SSRI’s or SNRI’s = Serotonin Syndrome

pregnant pts

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33
Q

What is the pregnancy category associated with triptans?

A

Was listed as Preg Cat C – best to avoid breastfeeding for 12 hrs after tx

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34
Q

**What are two important pt education points for triptans?

A

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

35
Q

_____ 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?

A

Ergotamine (Ergots)

vasodilation!

36
Q

What are the pt instructions for ergots?

A

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)

37
Q

What are the SE of ergots? CI and caution?

A

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

38
Q

**What is the BBW for ergots?

A

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

39
Q

What are the top 3 antiemetics listed in lecture?

A

Ondansetron (Zofran)

Promethazine (Phenergan)

Metoclopramide (Reglan)

40
Q

What is the new emerging ABORTIVE therapy? What drug class? What makes this drug class special?

A

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

41
Q

**What migraine medication is safe for pts with CAD/PAD? What is the drawback?

A

ditan

but expensive!!

42
Q

**_______ is the only medication that can be used for prophaxylaxis and abortive therapy

A

CGRP ends in -gepants

43
Q

_____ MOA blocks the CGRP protein that carry pain signals along nerve endings that cause the pain associated with migraines

A

Calcitonin Gene-related Peptide Antagonists - CGRP

-gepants

Rimegepant (Nurtec) is the commonly used one

44
Q

_______ do NOT cause medication overuse HA

A

-gepants

45
Q

**if your pt has CAD and migraine HA, what is the tx?

A

start with tylenol then move to -ditan

46
Q

What are 4 factors that would indicate the need for prophylaxis tx? **What is the major one?

A

**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

47
Q

What is the prescribing train of thought when it comes to prescribing preventative therapies for migraine HA?

A

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

48
Q

What are the preventive therapy medication options?

A

Topiramate (Topamax)

Valproic acid (Depakote)

Beta-blockers

Amitriptyline (Elavil) 10 – 150 mg QHS

Venlafaxine

botox injections

Riboflavin

Calcitonin Gene-related Peptide Monoclonal Antibodies- emerging!

49
Q

What are the first line preventive therapy options for migraines?

A

antiepileptic:

topiramate and valproic acid

50
Q

How do you choose the best preventive medication for migraine HA?

A

Think similar to psych meds!
Prior experiences
Response to relative
Pattern of headache
Comorbid conditions

51
Q

______ is the MC type of HA. Describe the classic presentation. What is the MC trigger?

A

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

52
Q

**What is the tx for a tension HA? What do you need to pay special treatment to?

A

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

53
Q

What is the pathophys behind a cluster HA?

A

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

54
Q

What are 3 classic signs that the HA is a cluster HA?

A

ptosis
tearing
running nose

ONLY ON 1 SIDE!!!

55
Q

**What are the risk factors for a cluster HA? what are the 2 highlighted ones?

A

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

56
Q

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?

A

cluster HA

15-180 minutes

occur at night and will wake the pt up

alcohol is a common trigger

57
Q

What is the preferred imaging for a cluster HA? Why?

A

MRI w/ and w/o contrast for the initial evaluation

concerned about a tumor, stroke or aneurysm

58
Q

**What is the management for a cluster HA?

A

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

59
Q

What is benign intracranial hypertension? What is another name for it?

A

Defined as a syndrome of increased intracranial pressure without a space occupying lesion

Pseudotumor Cerebri

60
Q

Who is the MC pt type for BIH? What is a major risk factor?

A

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!!!

61
Q

What are 3 factors that potentially contribute to BIH? What will the ventricles look like on imaging?

A

Excessive cerebrospinal fluid (CSF) and extracellular edema

Increased venous sinus pressure

Defective CSF absorption

ventricles will appear NORMAL on imaging

62
Q

When are children more likely to develop increased cranial pressure?

A

after thrombosis of 1 or more dural sinuses, usually after otitis media or mastoiditis causing increase in venous sinus pressure

63
Q

What are some medications associated with BIP?

A

Retinoic acid

Antibiotics - tetracycline, nitrofurantoin, fluoroquinolones

Hormones - steroid use, OC, thyroxine

Vit A

Lithium

Immunizations - DTaP

64
Q

What is the presentation of BIH? What are the 2 highlighted one?

A

Throbbing headache - worse on straining

Visual disturbances - unilateral or bilateral; diplopia, Abducen’s Nerve Palsy

Tinnitus

Nausea and/or vomiting

Papilledema on fundoscopic exam

65
Q

What is abducen’s nerve palsy? What disorder is it associated with?

A

inability to pull eye laterally

BIH

66
Q

What imaging should be ordered initially in BIH? why? what will the test show?

A

MRI or CT scan usually initial test

need to r/o mass or sinus obstruction

will show normal ventricles

67
Q

**What is the gold standard dx test for BIH? What will the test show? Is it required for dx?

A

lumbar puncture to check CSF pressure

lumbar puncture opening pressure >250 mmHg is a positive result

required for true dx

68
Q

What is the pharm tx for BIH? What is the MOA? What adjunct medication is used when?

A

Acetazolamide (Diamox) - diuretic

Reduces formation of CSF

+/- corticosteroids used only with visual changes to improve symptoms

69
Q

**What is the other treatments for BIH? What is the highlighted one?

A

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

70
Q

What is the MC cause of Subarachnoid Hemorrhage?

A

trauma but may be spontaneous

71
Q

What is the cause of a spontaneous Subarachnoid Hemorrhage? What is another name for it?

A

Spontaneously caused by rupture of arterial saccular (‘berry”) aneurysm or A-V malformation

*berry aneurysm

72
Q

what are the mc pt demographics for a subarachnoid hemorrhage?

A

Older, female, non-Caucasian, HTN, tobacco use, excessive alcohol use

73
Q

**THUNDERCLAP HEADACHE - “WORST HEADACHE” OF THEIR LIFE. what should you instantly think?

A

Subarachnoid Hemorrhage

74
Q

What is the Ottawa Subarachnoid Hemorrhage Rule?

A

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)

75
Q

How do you dx a Subarachnoid Hemorrhage?

A

CT scan (with angiography if available)

if CT scan negative, immediate LP to Looking for presence of blood or xanthochromia in the spinal fluid

76
Q

What is the basic tx for Subarachnoid Hemorrhage?

A

Hospitalize with bedrest and no exertion for at least 2 weeks

Neurology consult - urgent

77
Q

How will a mass occupying lesion present? What is the imaging? tx of choice?

A

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!

78
Q

What is temporal arteritis? What is the trend?

A

Chronic vasculitis of large and medium sized vessels

Incidence steadily rises with age

79
Q

______ is found in nearly 75% of the temporal arteries of affected patients. What are the s/s? What is the highlighted one?

A

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!

80
Q

What labs do you want to order in temporal arteritis? How do you CONFIRM dx? What will it show?

A

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)

81
Q

What is the tx for giant cell arteritis?

A

High dose corticosteroids

82
Q

**What are the classic triad for a CNS infection? How do you dx it? What is the tx?

A

fever
HA
nuchal rigidity

dx: lumbar puncture
also want to order: WBC, plts, blood culture

tx: admit with IV abx +/- steroids

83
Q
A

Neuro (13 decks)

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