Headaches (Ferguson) Flashcards
Cranial structures that are pain sensitive (5)
- Scalp
- Sinuses (periosteum)
- Meninges
- Pial arteries
- Arteries/ Major Veins
Cranial structures NOT sensitive to pain
- Ventricles
- Choroid
- Brain parenchyma
- Small parenchymal and dural veins
Which part of the brainstem can be activated to induce headache? What happens? What kind of headache is caused?
Activation of small area near dorsal raphe nucleus–> ^ 5-HT–> Migraine
What are the three types of headache?
- primary HA
- secondary HA
- cranial neuralgia
Which characteristic of migraines must be differentiated from pseudo tumor cerebri?
Exacerbation with exertion
Define migraine:
Which primary/secondary/neuralgia?
List associated symptoms (5)
Benign, recurring, primary HA
- photophobia
- phonophobia
- N/V
- worse with exertion
- Aura~
What is the current belief regarding pathophys of migraines? Where does it start? Which system is responsible for HA? Explain asstd. N/V, pallor, flushing, congestion?
Begins in brainstem with instability/ activation of cells–> spreads peripherally to stimulate trigenminal system
Involvement of chemoreceptors–> N/V
Involvement of ANS–> pallor, flushing, congestion
What is a migraine without aura (common migraine) and how does it present? How long does the HA last?
Unilateral deep, throbbing sensation Asstd. photophobia, phonophobia n/v worse with exertion better with rest
Most 30min-6hrs, possibly up to 72hrs
What is a migraine with aura and how does it present?
Common migraine proceeded by aura up to 30 min before HA onset, or 1 hr into HA
List 4 examples of an aura
- Visual disturbance (scintillating scotoma, central scotoma, monocular vision loss…)
- Focal paresthesia
- Focal weakness or paralysis
- Phonophobia (heightened sensitivity to sound) or other auditory disturbance
What is a complicated migraine and how is it diagnosed?
This is a migraine with a dramatic aura that lasts for an extended period of time–mimics stroke
DX by excluding stroke or other path
Describe the onset pattern of a basilar migraine. With which severe pathology might this HA be confused?
Vertigo/ Dysarthria/ Ataxia/ Diplopia (brainstem/ posterior cerebral circ. sx.) –> 30 min later throbbing occipital pain
Possible confusion with posterior circ. stroke
Wha tis a Bickerstaff Migraine? How does it present?
Most severe basilar migraine
Total blindness–> other postural cerebral circ. sx. –> throbbing occipital pain
List 5 Triggers of migraines
- Red wine
- Food: Chocolate/ Cheese/ MSG/ Nitrates
- Hunger
- Sleep deprivation/ disturbance
- Stress
When should patient take abortive tx for migraine? What are 4 classes of drugs used for abortive therapy?
Immediately, keep drugs handy
- NSAIDS
- 5-HT Agonists (Triptans, ergots)
- Dopamine Antagonists
- Combinations drugs
When do we generally pursue prophylactic therapy for patients with migraines?
> 4-6 migraines per dos, Pt missing work/ school with HA, Recurrent ED visits secondary to sx.
What are 5 classes of drugs used for migraine prophylaxis? How do we decide which to use?
- Beta blockers
- Ca++ channel blockers
- TCAs
- Anticonvulsants
- 5-HT
Decision made based on patient’s comorbidities
Which drug is used to treat skinny kids with migraines so they will gain weight?
Cyproheptadine (seritonergic drug)
Define Cluster HAs:
How long do they last?
In what pattern do they occur?
Episodic HAs occur in 1s-3s
Last 15min-3hrs
Severe unilateral stabbing pain is periorbital or temporal (facial pain > hemicranial HA) + asstd sx
Occur in clusters for 3-6 weeks at a time Circadian rhythm (occur at same time every day)
What are some associated sx. with cluster HA (4)
- conjunctival injection/ lacrimation
- Miosis/ptosis/eyelid edema
- rhinorrhea, nasal congestion
- Perspiration
Describe pathophys of cluster HAs
Derived from hypothalamus–> secondary activation of trigeminal autonomic reflex via trigeminal-hypothalamic pathway
What is the most effective abortive agent for cluster HAs?
What is a second agent that may be used for abortive therapy?
#1 = 12L/min O2 (high concentration O2) #2= Triptans
What are three categories of drugs that can be used for prophylactic treatment of cluster headaches?
- High dose steroids
- Ca++ channel blockers
- Lithium
What is the most common HA syndrome?
Tension HAs
How does a Tension HA present?
Squeezing pressure around head, possible photophobia or phonophobia
NEVER PRESENTS WITH N/V!
What are 4 non-pharm approaches to treating tension HA?
- Stress reduction
- Biofeedback
- CBT
- sleep hygiene improvement
What are 2 abortive pharm treatments for tension HA?
- Acetaminophen
2. NSAIDS
What is analgesic HA syndrome and with what HA syndrome might it be associated?
How is it treated?
Patient takes too many OTC analgesics, patient discontinues use and gets rebound HAs
May be associated with self medication for tension HAs
Tx: steroids for about a week
What are 2 prophylactic pharm treatments for tension HA? Do we commonly prophylactically treat tension HA?
- TCAs
- Anti-epileptics
Not commonly used because typically if you are doing prophylaxis for tension HA your patient actually has migraines and you’re just and idiot who didn’t take a good enough hx. to figure it out.
What is Idiopathic Intracranial Hypertension/ Pseudotumor cerebri? How does it present?
^^^ ICP w/o intracranial mass, hydrocephalus, or dural venous stenosis/thrombosis–> Sudden onset continuous, daily HA
WORSE: coughing, sneezing, supine
Which population most commonly gets IIH
young, obese females
What are some drugs that are associated with IIH? (3)
- Tetracycline
- OCPs
- Retinoic acid (hypervitaminousis A)
What are the three complications associated with IIH?
- vision loss
- diplopia
- pulsatile tinnitus
Should one do imaging for IIH workup? If so, which modality?
YES: MRI with venogram (MRV) to rule out posterior fossa tumor
When should you perform an LP to work up IIH? In what position should the patient be? How much fluid should you get to make the diagnosis?
- After MRV
- Lateral decubitus position for accurate opening pressure
- Both diagnostic and therapeutic
- *** > 25cm H2O
What is the most concerning complication asstd. with IIH and what should be done to monitor for this?
Irreversible vision loss–always get opt consult with formal visual field assessment
What is the most important non-pharm treatment for IIH?
weight loss
What are two pharmacological treatment steps to be taken when treating IIH?
- Remove offending agents
2. ~Admin drugs to decrease CSF absorption (carbonic anhydrase inhibitors)
What are 3 procedural treatments for IIH?
- Recurrent LP
- Optic N fenestration
- Shunting (ventriculoperitoneal)
What age group typically gets giant cell arteritis?
> 50 yrs
How does Giant Cell arteritis present? What are some common complaints?
Progressive unilateral throbbing HA + tenderness in temporal scalp area
Asstd. Complaints:
- jaw claudication
- diffuse joint pain
- visual disturbance (transient monocular vision loss)
What is the most severe complication asstd. with giant cell arteritis
*Causes untreated permanent blindness if untreated due to anterior ischemic optic neuropathy
How do we definitively diagnose giant cell arteritis?
Temporal artery biopsy w/ large segment (disease skips segments)
How do we treat giant cell arteritis?
Large dose corticosteroids (relief within 3 days)
Maintain on low dosecorticosteroirds for a few years after that
What are 9 worrisome symptoms that mandate imaging and further workup with acute onset HA?
- “worst” HA ever
- first severe HA
- Subacute, worse with time
- abnormal neuro exam
- fever/unexplained signs
- vomiting prior to HA
- Worse with positional change, coughing lifting,
- Sleep disturbance, present @ waking
- Onset after 55
When do we do LP for acute HA?
Fever, illness, immunocomp patient
Which imaging tests do we do for severe acute HA (2)
CT–> MRI
