Headaches (Week 2--Charles) Flashcards
Primary vs. secondary headache
Primary: intrinsic to brain without any underlying structural, infectious, toxic/metabolic cause (migraine, tension headache, cluster headache)
Secondary: identifiable underlying cause (tumor, hemorrhage, meningitis)
Reasons to consider neuroimaging for headache
Abnormal unexplained neurological exam
Onset of headache over age 55
Associated fever
Headache with extremely abrupt onset
Headache refractory to aggressive treatment
First or “worst” headache ever experienced
Increasing frequency and/or severity of headaches
Change in headache clinical features
Headaches that don’t “fit” primary headache criteria
Studies for investigating primary headaches
Space occupying lesions: brain scan, preferably MRI with contrast
Hemorrhage: brain scan, consider lumbar puncture with negative scan
Increased intracranial pressure: brain scan, lumbar puncture if scan is negative
Toxic/metabolic, inflammatory: lab studies
Does cutting brain parenchyma cause pain?
No!
That’s why you can do awake neurosurgery
Is it blood vessels (vasodilation/constriction) that cause migraine symptoms?
No!
Dilation of blood vessels is neither necessary nor sufficient for causing migraine pain
Migraine is primarily a disorder of brain excitability
Vasodilation may occur as part of disorder but is not required for migraine pain
What can cause headache?
Lesions or electrodes in the periaqueductal grey region in the brainstem
Head pain can be evoked by stimulation of insular cortex
LIfetime cumulative incidence of migraine
43% of women have had a migraine, and 18% of men
Approach to treatment of headache patient
Diagnose patient and reassure them that they do not have a brain tumor
Identify and change exacerbating environmental factors, medications
Establish regimen for acute therapy of headache
Determine if preventive therapy is appropriate
ICHD criteria for migraine w/o aura
At least 5 attacks fulfilling the following:
Headaches lasting 4-72 hours
During headache at least one of: nausea and/or vomiting, photophobia and phonophobia
At least 2 of: unilateral location, pulsating quality, moderate or severe intensity, aggravated by physical activity
ID migraine validated screener
Has a headache limited your activities for a day or more in the last 3 months?
Are you nauseated or sick to your stomach when you have a headache?
Does light bother you when you have a headache?
Migraines can be mis-diagnosed as being what?
Sinus headache
TMJ
Tension headache/cervicogenic headache
Common headache triggers
Irregular meals
Irregular caffeine, chocolate, nuts, bananas
Irregular sleep (particularly excessive sleep)
Stress or “let-down” from stress
Any combination of the above
Medications that may make migraines worse
Oral contraceptives
Hormone replacement
SSRI antidepressants
Steroids (tapering)
Decongestants
Benzodiadepines (maybe?)
Bone density medications (maybe?)
Acute therapy for migraine
Triptans: selective serotonin 1B/1D agonists (sumatriptan, rizatriptan, etc)
DHE nasal spray
Migraine prophylaxis drugs
Beta blockers
Tricyclics
Ca2+ channel blockers
Serotonin uptake inhibitors
MAO inhibitors
NSAIDs
Methylsergide
New: valproic acid, divalproez sodium, memantine?, topiramate, BoTox
