Headaches - Neuro Flashcards
Origin
- Extracranially: Skin, Muscle, Blood vessels, Periosteum
- Intracranially: Venous sinuses/arteries, Dura, Falx cerebri
- Brain parenchyma itself incapable of producing pain
Migraine Headache
- Affects 12% of the population
- 70% have family history
- 3x more common in women than men
- Usually begins in adolescence or young adulthood
- May begin in childhood
Common Migraine (migraine without aura)
-Represents vast majority of migraines
-Usually lasts 4-72 hrs.
-Characteristics:
Unilateral
Pulsating
Intensity: moderate to severe
Aggravated by physical activity
Nausea/vomiting
Photophobia/phonophobia
-Pt. should have at least 5 attacks before dx. made
Classic Migraine(migraine with aura)
-15% of those with migraine
-Has similar characteristics as common migraine
-Aura comes on gradually, usually lasts <60 minutes, followed by HA
-Types of aura
Visual most common (e.g., scotoma)
Sensory (unilateral paresthesias, numbness)
Motor aura (unilateral weakness, speech difficulty)
Migraine Precipitants
- Menstruation
- Too little/too much sleep
- Fasting
- Physical activity
- Stress
- Tyramine-containing foods: Red wines, Hard cheeses, herrring
- Phenylethlamine: Chocolate
- Nitrites: Processed meats
- Caffeine withdrawal or excess
- Medications: OCP’s, antihypertensives
Migraine prophylaxis
- Beta-blockers: Propranolol
- Calcium-channel blockers: Verapamil
- SSRI’s: Paroxetine (Paxil), Fluoxetine (Prozac)
- Tricyclic antidepressants: Amitryptaline. Nortryptaline
- Anti-seizure meds: Valproic acid (Depakote), Gabapentin (Neurontin)
Cluster Headaches
- A “cluster”, or series of HA’s over a period of 2-3 months
- These clusters usually occur every 1-2 years
- Much less common than migraines
- Males affected 4-9x more frequently than females
- Onset usually in late 20’s
- May be triggered by alcohol, nitroglycerine, histamine
- Pain always unilateral
- Excrutiating
- Penetrating, usually non-throbbing
- Location: trigeminal nerve distribution, usually behind eye
- Often with autonomic features: Lacrimation, Conjunctival injection, Nasal congestion/rhinorrhea, Ptosis/miosis
- Mechanism: Dilation of retro-orbital blood vessels and inflammation of trigeminal nerve branches
Treatment of cluster headaches
- Similar to migraine treatments
- Exception: beta-blockers generally not used
- Oxygen inhalation
- 5-8 liters/min administered for 10 min.
- Effective in ~70%
Tension Headaches
- Most common type of HA
- Duration: 30 min.-7 days
- Features
- Pressing/tightnes/band-like (usually non-pulsating)
- Mild-moderate intensity
- Unaffected by physical activity
- Possibly associated with photo-/phonphobia
- Usually without nausea/vomiting
- Tx: Mild analgesics, ASA, Acetaminophen, NSAID’s, Stress reduction, Relaxation techniques
Extra-cranial Sources of HA
- Sinusitis: Acute or chronic infection of sinus cavities, Usually stabbing or aching, Worse with bending forward, coughing, Better when supine, Percussion over sinus produces pain
- Acute glaucoma: Orbital pain, Often associated with nausea/vomiting, Cornea is edematous, Conjunctiva injected, Decreased vision
- Temporal arteritis: A vasculitis involving branches of external carotid artery, usually temporal artery, Usually in pts. > 50 , 4x more common in women, Jabbing, excrutiating pains over temple, Usually unilateral, but may be bilateral, Visual loss may be present, May have systemic sx. (fevers, malaise), Temporal artery tender to palpation, Elevated ESR is highly suggestive, Definitive dx. with biopsy
- TMJ: Usually due to spasms of muscles around TMJ, May be due to overbite, previous dental work, grinding teeth, Unilateral or bilateral pain in TMJ, tender to palpation, May feel clicking in joint
- Trigeminal neuralgia: Brief, severe attacks in distribution of branch or branches of trigeminal nerve, Due to partial demyelinization of trigeminal nerve, possibly due to compression, Pain is lancinating, “electric shock” pain, May be triggered by eating, talking, washing face
Life Threatening Headaches
- Subarachnoid hemorrhage
- Meningitis
- Brain tumors
- Subdural/Epidural hematoma
- Hypertensive headache
Subarachnoid Hemorrhage
-Bleed from ruptured aneurysm (or less commonly, an AVM)
-Sudden onset of severe HA
-“Worst headache of my life”
-LOC ,focal neuro signs, or seizure possible
-May have nuchal rigidity
-CT scan ~90% sensitive for dx.
-If CT negative, must do lumbar puncture!
TX: Nimodipine: a calcium-channel blocker, decreases cerebral vasospasm
-Phenytoin: seizure prophylaxis
-Urgent neurosurgical consultation
Subdural Hematoma
- HA, often with confusion, obtundation
- Often seen in elderly after previously forgotten minor head injury
- Dx: CT
Epidural Hematoma
- Hx. of trauma
- Brief LOC, then awake with HA, then deteriorating mental status
- May rapidly progress to herniation
- Dx. by CT
- Urgent neurosurg. consultation
Hypertensive Headache
- Diastolic BP usually >130
- Overdiagnosed: Did high BP cause HA or did HA cause high BP? Any HA may cause BP to rise
- HA should be alleviated by BP control with antihypertensives
