ICS-Headache

Question 1

What type of headaches present with papilledema, meningeal irritation, cranial nerve disturbances and peripheral weakness or sensory changes?

Answer 1

Secondary headaches will present with associated neurological symptoms. Examples include tumors, infections (meningitis), hemorrhages, stroke and arteritis.

Question 2

Historical red flags for secondary headache disorders.

Answer 2

Thunderclap headache, progressive headache, new daily persistent headache, abnormal neurological exam, change in headache pattern, awakens from sleep and exertional headaches.

Question 3

Past medical history red flags for secondary headaches.

Answer 3

Cancer, HIV, extracranial infection, Tb, Sarcoid, new headache during pregnancy or after delivery.

Question 4

Physical exam red flags for secondary headaches.

Answer 4

Fever, stiff neck, nausea, vomiting, papilledema, cognitive impairment, personality changes, seizures

Question 5

What are the 3 types of primary headaches?

Answer 5

Migraine, tension, cluster

Question 6

Criteria for migraine w/o aura.

Answer 6

5+ attacks, each lasting 4-72 hours. At least 2: unilateral, pulsating, moderate to severe intensity, aggravated by routine activities. At least 1: nausea, vomiting, photophobia, phono phobia. Finally, exam does not suggest secondary headache.

Question 7

Criteria for migraine w/ aura.

Answer 7

2+ attacks. At least 3: aura is reversible, develops gradually over 4 min., terminates by 60 min., headache follows aura by < 60 min. Finally, exam does not suggest secondary headache.

Question 8

Which type of migraine is most common?

Answer 8

W/o aura.

Question 9

What are common migraine triggers?

Answer 9

CN I (odors), CN II (lights), CN V (temperature & pressure changes), CN VIII (motion).

Question 10

Types of acute treatment for migraines

Answer 10

Abortive (triptans & ergots, but never used together) & symptomatic (antiemetics, NSAIDs, muscle relaxants and rarely opioids)

Question 11

Types of preventative treatment for migraines.

Answer 11

Beta blockers, TCAs, Ca channel blockers, BONT and anticonvulsants.

Question 12

When should you think about prescribing someone preventative migraine therapy?

Answer 12

2+ per week, significant interference w/life

Question 13

Why guard a patient from rebound headache when treating them?

Answer 13

It can be more difficult to abort

Question 14

Triptan site of action

Answer 14

5-HT1 agonist

Question 15

Why can you try a different triptan on a patient that had no success with a previous triptan?

Answer 15

There is no class effect with triptans. You can also change the three F’s: fast vs. slow, formulation and formulary.

Question 16

Slow acting triptans

Answer 16

Naratriptan and frovatriptan. All the others are fast acting.

Question 17

Why prescribe triptans over ergots?

Answer 17

Acts on many receptors and has many side effects.

Question 18

Tension headache criteria

Answer 18

At least 2: tight quality, mild/moderate intensity, bilateral, no aggravation w/daily activities. Both: nausea or vomiting and photophobia or photophonia

Question 19

A patient comes to see you complaining of daily headaches. He says that he has to take tylenol every single day or else he will get one. What might this guy have?

Answer 19

Medication overuse headache. The brain produces a headache in order to get the medication it has become accustomed to get daily.

Question 20

Criteria for cluster headache

Answer 20

5+ attacks, unilateral eye or temporal pain lasting 15-180 min untreated. At least 1: conjunctival injection, lacrimation, nasal congestion, sweating, miosis, ptosis, eyelid edema. 1-8x per day.

Question 21

Acute treatment for cluster headache

Answer 21

Oxygen, subQ triptan, intranasal lidocaine, DHE, prednisone.

Question 22

Preventative treatment for cluster headache

Answer 22

Verapamil, lithium, ergotamine.

Question 23

Drug given at high dose for 7-10 days to abort ongoing cluster attack.

Answer 23

Predisone

Question 24

Diagnostic treatment for cluster attacks if symptoms resolve after 10-15 min.

Answer 24

Oxygen