Headaches - Part II Flashcards
Clinical Manifestions: Onset - 3-40 y/o, usually puberty F:M - 3:2 Family Hx - (+) for 70% of cases Etiology - probably genetic; associated with a locus on chromosome 19
Migraine
Any transient neurologic disturbance lasting 15-30 minutes preceding the headache; may be visual, aphasia, vertigo, thick speech, tremor, unilateral numbness or weakness, auditory hallucinations, olfactory hallucinations
Aura (associated with classic migraine)
Spots in front of eyes
Scotomata
Luminous appearance before the eyes, with a zig-zag, wall-like outline; also called a fortification spectrum or scintillating scotoma
Teichopsia
Many migraine patients have feelings of size distortion, called ______ and ______.
…micropsia…macropsia…
Describe the headache portion of a migraine with aura.
Aura ends as throbbing headache begins. Onset is unilateral, but may spread to entire head. Commonly associated with nausea, vomiting, photophobia, sonophobia, pallor, tremors, perspiration, chills. Patient looks sick.
Constipation, diarrhea, cold extremities, local or general edema, speech difficulties, ataxia, dysuria, and impaired consciousness are all less common symptoms of what?
Migraine with aura
Apshasia, extremity weakness, and other focal neurologic deficits are all rare symptoms of what?
Migraine with aura
How long can a migraine with aura last?
Are there any variations to this?
4-24 hours
Variant called Status migrainosus can last up to 10 days
25% of patients will experience the following symptoms preceding what condition?
Elation, irratability, depression, hunger, thirst, drowsiness
Migraine with aura
Describe the post-headache stage of a migraine with aura.
Head on side of attack is tender to touch; brushing hair may be extremely painful. Patient feels exhausted and needs to avoid regtriggering of throbbing head pain. May experience euphoria when pain is gone.
Sudden sharp head pains the last only a second or two when between migraines with aura are called what?
Ice pick headaches or cephalgia fugax
No aura, throbbing character, hemicrania or generalized, and commonly associated with nausea, vomiting, photophobia, sonophobia, pallor, tremors, perspiration, chills. Patient looks sick. What is this?
Migraine without aura (common migraine)
What is the duration of a migraine without aura?
4-24 hours
Describe the post-headache stage of a migraine without aura.
Head on side of attack is tender to touch; brushing hair may be extremely painful. Patient feels exhausted and needs to avoid regtriggering of throbbing head pain. May experience euphoria when pain is gone.
Which cranial nerve is involved with migraines?
Trigeminal n.
Explain the trigeminal vascular reflex.
Afferent stimulation of pain centers in spinal nucleus of trigeminal nerve increases and perpetuates cycle of parasympathetic dilation of internal and external carotid arteries mediated via the facial nerve, resulting in stimulation of pain centers by trigeminal nerve afferents.
Where does the vascular theory of migraine come from?
During brain surgery a conscious patient observed the onset of a migraine and the surgeon observed the vasoconstriction then vasodilation accompanying the headache.
What are 4 problems with the vascular theory of migraine?
Fails to explain premonitory features of attack
Some drugs have no effect on vasculature
Not supported by new blood flow studies (no correlation to aura)
Most patients do not have aura
What is the serotonin theory?
Spreading wave of abnormal neural activity that creeps across the cortex, beginning in the occipital lobe, has been observed. Spread involves most or all of cerebral cortex.
What are the most effective abortive medications according to the serotonin theory? Where are they most active?
Triptans - active at 5-HT1 receptors
What appears to be the final common pathway for migrainous cephalgia?
Activation of 5-HT receptors
Auras have been found to stem from what? What is this?
Cortical spreading depression - a wave of excessive signaling across large areas of the brain, followed by abnormal silence in the previously overactive areas
Name 3 atypical migraines.
Ophthalmagic, hemiplegic, basilar artery
Patient presents with CN III palsy, paralysis of extraocular muscles, and ptosis & pupillary asymmetry lasting days (maybe weeks). What is this and what can it mimic?
Ophthalmagic migraine - mimics carotid artery aneurysm (requires angiography or MRA)
Patient presents with sudden hemiparesis and confusion accompanying sudden onset of headache (other symptoms can include hemiplegia and aphasia). Headache lasts less than an hour. What is this and what can it mimic?
Hemiplegic migraine - mimics transient ischemic attack (TIA)
What is the familial incidence of hemiplegic migraine?
98% of cases (chromosome 19 locus)
20 y/o female patient presents with vertigo, tinnitus, visual blurring, and bilateral paresthesias accomanying headache (other symptoms can include diplopia, dysarthria, ataxia, syncope, stupor, and unilateral paresthesias). What is this and what can it mimic? What work up does it require?
Basilar artery migraine - mimics Wallenberg Syndrome
Requires work-up for vertebral basilar artery insufficiency
How can you prevent migraines?
Identify and remove triggers
Consider prophylactic pharmeceutical treatment if >2 headaches/month
Remember that migraines = neurological events associated with high risk of stroke now and later in life
What are some locations of somatic dysfunction associated with migraine triggers?
Upper 4 thoracic/costal segments - often T4ERrSr or rib 4 (inhaled or exhaled)
Less commonly - cranial somatic dysfunction (occipitomastoid suture dysfunction with partial internal jugular obstruction)
What are the principle sympathetic levels fore vasomotor control of the head and neck?
T1-T4(6)
What techniques should you avoid during an acute migraine attack?
HVLA & ME
What techniques may be useful during an acute migraine attack?
Indirect techniques & cranial (CV-4)
What effect should you treat for somatic dysfunction between headaches?
Prophylactic
How does weight factor in as a risk factor for migraines?
Severe headaches are nearly twice as prevalent if your weight is very high (BMI above 30 kg/m^2) or very low (BMI below 18.5 kg/m^2)
What is it about food that can cause a headache?
Chemical content - often high in the amino acid tyramine
What are some general categories of food that may serve as migraine triggers?
Ripened cheeses (e.g. chedder, brie), chocolate, dairy, yeasty breads/cakes, MSG-containing food, onions, fermented food, caffeinated beverages, citrus, bananas, cured meats, alcohol
What hormonal changes can trigger a migraine?
Menses, ovulation, menopause, birth control pills & devices
What are some non-food, non-hormonal triggers for migraines?
Stress Blood-glucose changes Febrile illness Light Allergens Medications Weather changes Sports Sleep
How many levels of treatment are there for migraines?
5
How are the levels of pain for migraines delineated?
Mild-moderate: 1-6
Severe: 7-10
What non-pharmacologic measures can you use for a level I migraine?
OMT
Acupuncture
Biofeedback
How should you treat a level II migraine (mild-moderate pain)?
Caffeine-free NSAIDs
How should you treat a level III migraine (mild-moderate pain)?
Triptans
Dihydroergotamine
Other Ergots
How should you treat a level IV migraine (mild-moderate pain)?
Mixed analgesics
Class III opoids
What level(s) do you bypass when dealing with a migraine with severe pain?
Level I
How do you treat a level II migraine (severe pain) that presents with nausea or vomiting?
Non-oral abortive migraine medications
Antiemetic, e.g. procholrperazine suppository
How should you treat a level II migraine (moderate to severe pain)?
Triptans
Dihydroergotamine
Other Ergots
How should you treat a level III migraine (moderate to severe pain)?
Mixed analgesics
Class III opoids
How should you treat a level IV migraine (moderate to severe pain)?
IM/SC DHE
SC sumatriptan
How should you treat a level V migraine (moderate to severe pain)?
IV DHE
IV/IM neuroleptics
IV/IM corticosteroids
IV/IM opoids
What is the name for antipsychotic drugs that produce a state of apathy, lack of initiative, and limited range of emotion? In psychotic patients, they reduce confusion and agitation and normalize psychomotor activity.
Neuroleptic
What optiates, administered orally, can you take to kill a headache?
Morphine Codeine Hydromorphone Hydorcodone Oxycodone Meperidine Methadone
What opiates, administered intramuscularly, can you take to kill a headache?
Morphine
Hydromorphone
Meperidine
What is the minimum dose of Morphine that should be administered intramuscularly to kill a headache?
10mg
How often should you use acute migraine treatment?
No more than 2 or 3 days in any given week and never more than 2 days in a row - this could result in rebound headaches
What causes rebound headaches?
Overuse of analgesic medications
What do rebound headaches result in?
Recurring daily headaches
How can you stop rebound headaches?
They will not stop until medication is discontinued
How long can continuous headaches last after discontinuing medication?
Medication withdrawal can last up to 3 months
What can rebound headaches result in if they get really bad?
Hospitalization, sedation, and IV ergotamine
What is a chronic daily headache?
Transformed migraine
Describe the chronic daily headache.
Daily/almost daily (>15 days/month) head pain for >1 month
Untreated headache lasts >4 hours/day on average
Has one of the following: Hx episodic migraine, Hx increasing headache frequency with decreasing migrainous features over at least 3 months, headache at some point meets migraine criteria other than duration
Does not meet criteria for new daily persistent headache or hemicrania continua
Has at least one of the following: no suggestion of other disorders as cause, other disorders are ruled out, disorder is present but 1st attacks do not occur in close temporal relation to them
What has research shown to be superior to medications in improving headache intensity, frequency, and response rate?
Needling acupuncture
What treatment has been successfully used in reducing the number and duration of chronic daily headache? How often is treatment given?
Botox injection into hypertonic muscles associated with chronic daily headache; injections are given every 12 days
What is the name of a continuous, unilateral headache that varies in intensity, waxing and waning without disappearing completely?
Hemicrania continua
What painful exacerbations associated with autonomic disturbances may occur with hemicrania continua?
Ptosis
Meiosis
Tearing
Sweating
Does hemicrania continua alternate sides?
Rarely
What is hemicrania frequently associated with?
Jabs & jolts - idiopathic stabbing headache or cephalgia fugax
Is hemicrania reliably triggered by head motion?
No, but tenderpoints in neck may be present
What symptoms may the patient with hemicrania continua experience?
Photophobia
Phonophobia
Nausea
The following criteria are for which type of headache?
Headache present for at least 1 month
Strictly unilateral
Pain is continuous but fluctuating, is of moderate intensity, and lacks precipitating mechanism
Absolute response to Indomethacin or exhibits a facial autonomic feature with severe pain exacerbations
Has one of the following: no suggestion of other disorder, disorders have been ruled out, no temporal relationship between disorder and 1st attacks
May be associated with idiopathic stabbing headache
Hemicrania continua
What type of OMT may be used to treat hemicrania continua?
No data, but presence of cervical tenderpoints suggests the possibility of a therapeutic trial of manipulative treatment
What drugs may be used to treat hemicrania continua?
Indomethacin 50-300 mg/day or ibuprofen, piroxicam, or rofecoxib if indomethacin unsuccessful
What medications do no work for hemicrania continua?
Sumatriptan
Naratriptan
Other triptans
What type of pain relief is diagnostic of hemicrania continua?
Complete pain relief within 2 hours of IM injection of 50 mg indomethacin
Tension type headaches and headache/facial pain associated with disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial/cranial structures are known as what?
Muscle contraction headaches
What can trigger a secondary muscle contraction headache?
Any other source of head and neck pain
A muscle contraction headache can serve as a trigger for what?
Migraine or cluster headache
What kind of headache has the following characteristics?
Age of onset: any
F:M - 4:1
Family Hx - non-contributory
Characteristics: pain in muscle belly or at muscular insertions, commonly at forehead, temples, occiput, neck, shoulders; band-like/tight pain, tenderness upon palpation of involved muscles, and may be eased by head rolling or alcohol consumption
Muscle contraction headache
What type of headache may be associated with chronic depression, stress, or anxiety; is commonly a daily headache which may assume a twice daily pattern; and occurs more frequently than 15 days/month?
Chronic tension type headache
How might you treat stress-induced (chronic tension type) headaches?
Eliminate source of stress Cognitive behavioral therapy Coping techniques Use of non-narcotic analgesics Use of OMT (judiciously)
