Jaynstein - HA Flashcards
what do you think of when you see a HA with greatest intensity at the onset or HA that hurts intensely and then gets better
SAH
often missed PE exam with HA eval
fundoscopic
HA’s account for __% of ER visits
15
__% of HA’s occur in women
70
__% of HA’s are attributable to primary causes
80-90%
t/f: there is a genetic component to HA’s
t!
1st step in HA work up
differentiate primary cause vs secondary cause
3 types of primary HA
tension
migraine
cluster
mc overall primary HA
tension
mc type of HA seen in primary care
migraine
cluster HA’s account for __% of HA’s
0.4
cluster HA’s have __ predominance (gender)
male
4 causes of secondary HA
infxn
trauma
stroke syndromes
rebound
what type of HA is located on 1 or both sides of head
migraine
what type of HA is located on 1 or both sides of head OR neck
tension
what type of HA is located on the face, forehead, and between the eyes
sinus
what type of HA is located on one side of the head and extends from behind the eyes
cluster
duration of migraines
4-72 hr
duration of tension HA
2 hr - days
duration of sinus HA
days if untreated
duration of cluster HA
30-90 min
which type of primary HA is limited to mild-mod severity
tension
which primary HA is severe intensity
cluster
how intense are migraines
mild vs mod vs severe
how intense are sinus HA
mild to severe
tx for sinus HA
decongestants
abx
tx for cluster HA
100% O2
triptans
which type of HA requires the most preventive tx
migraines
t/f: migraines are overdiagnosed
t!
3 causes of HA due to infection
sinusitis
meningitis
encephalitis
4 causes of HA due to trauma
CVA/TIA
SAH
dissections
temporal arteritis
what 2 types of HA are related to CSF fluid abnormalities
spinal HA (30%)
pseudotumor cerebri
pregnancy-related HA
preeclampsia
t/f: you can simply dx a HA as “HA”
t!
don’t always need to specify type
what type of HA is always bad until proven otherwise
new onset HA’s in pt’s > 50 yo
historical/exam findings that indicate secondary cause of HA (10)
-systemic dz
-new/different pattern
-new HA in pt > 50 yo
-focal neuro sx
-seizure
-sx provoked by standing, lying down, valsalva, cough, or sex
-hx of neoplasia
-immunosuppression/HIV
-sudden onset
-papilledema
t/f: response to therapy is a good indicator of underlying HA pathology
f! -> level C
pt’s w. SAH can feel great after tx and then die
6 indications for further work up for HA
-age <5 or > 50 w. no prior HA hx
-progressive in frequency or severity
-HA awakens pt from sleep
-change in HA pattern
-systemic sx
-temporal artery tenderness
what do you think when you see a HA that is progressive in frequency or severity
-medication misuse
-subdural hematoma
-mass lesion
4 indications for ER with HA pt
-worst HA of life
-thunder clap HA - sudden onset reaching severe max intensity w.in minutes
-rapid onset w. strenuous exercise
-neuro deficits - LOC, AMS
2 underlying pathologies of thunderclap HA
ICH
meningitis
2 underlying pathologies of HA that has rapid onset w. strenuous exercise
SAH
carotid artery dissection
6 PE components of HA work up
bp -> elevated is bad
fundoscopy
bruits
temporal artery inspection/palpation
meningismus
neuro exam -> motor/sensory/gait
t/f: labs are helpful when diagnosing primary HA
f!
what should you be thinking about if you order labs for a primary HA
secondary HA
first line imaging for HA
CT without contrast
4 definite indications for CT w.o contrast for HA
focal neuro sx
onset of HA w. exertion or sex
worst HA of life
CHA (concussion HA) w. LOC
6 maybe indications for CT w.o contrast for HA
CHA w.o LOC
recent significant change in HA pattern
progressive worsening HA despite therapy
onset after 50 yo
cancer hx
unresponsive to tx
what is usually more helpful for HA dx than labs or imaging
HA diaries/logs
what type of HA is responsible for the most disability
migraine
are migraines mc in men or women
women
7 characteristics of a migraine
4-72 hr
unilateral
throbbing
worse w. exercise/activity
mod-severe pain
n/v
light/sound sensitivity
what %age of migraine pt’s have associated aura
30
mc type of aura/hallucination associated w. migraines
visual (lights/flashes/floaters/halos)
less common: sensory, linguistic, motor
__ is very uncommon w. migraines and should make you think about a psych disorder
auditory hallucination
criteria for migraine w. aura
at least 5 attacks fulfilling:
-lasts 4-72 hr (treated or untreated)
-has at least 2 of : unilateral, pulsating, mod-severe intensity (inhibits ADLs), aggravated by walking stairs or similar activity
-during HA at least one: n/v, photophobia, phonophobia
-H&P/neuro exam excludes underlying d.o
migraine w. aura criteria
at least 2 attacks fulfilling 3 out of 4:
-one or more fully reversible aura sx indicating focal, cerebral, cortical, and/or brain stem dysfxn
-at least 1 aura sx develops gradually over > 4 min
-2 or more sx occur in succession
-no aura sx lasts > 60 min
-HA follows aura w. free interval of < 60 min
PLUS:
H&P/neuro exam excludes underlying d.o
t/f: you can make the diagnosis of migraine before assessing if pt meets all the criteria
f!
pt must meet criteria
treating migraines in what time period leads to better outcomes
w.in the first 2 hr of attack
t/f: HA’s are overtreated
f!
they are undertreated -> leads to chronic HA syndromes
what is the goal of HA tx (6)
treat promptly
limit HA to 2 hr or less
optimize op tx
reduce ER visits
minimize s.e of meds
minimize use of narcotics
effective HA tx should reduce # of HA related doc visits to __
2/mo
4 preventive migraine meds
antidepressants
anticonvulsants
bb
ccb
ccb are most effective for what type of HA
cluster
4 abortive meds for HA (this excludes narcotics bc… just don’t)
NSAIDs/APAP/ASA
triptans
combos: butalbital/apap/caffeine
DHE
t/f: OTC analgesics should not be first line tx for migraines in the hospital setting
f!
always start w. first line, even in hospital setting
go to first line tx for migraines
400 mg IBU
there is no clinical benefit to IBU over __ mg
400
what is the ceiling for toradol:
max age for toradol:
15 mg
65 yo
black box warning for toradol
no more than 5 days dt risk of renal failure
admin of toradol must first be __ before you can give it PO
IM or IV
2nd line abortive tx for migraines if pt does not respond to OTC analgesics
sumatriptan (imitrex)
t/f: you can’t give a pt imitrex unless you have diagnosed them with a migraine
f!
give it early
OTC analgesics/caffeine combo are very effective for migraines, but what is the risk of this combo
rebound HA
benefit of ASA over NSAIDs for migraines
ASA is cardioprotective, whereas NSAIDs increase risk for CVA
be cautious prescribing ASA for migraine if you suspect
SAH
migraine w. aura increases risk for (2)
stroke
heart attack
you should consider preventive migraine tx if (3)
> 1 HA/week
miss work
associated complex sx
preventive migraine tx takes __ weeks to be effective
8-12 weeks
3 very effective OTC preventive migraine tx options
petadolex (butterbur)
Mg supplement
coenzyme Q10
t/f: petalodex is safe for kids
t!
good for kids and adults
Mg supplements are esp effective for what type of migraine,
and can also help with __
migraine w. aura
sleep quality
coenzyme Q has an added benefit of
lowering bp
what class of med can be used for migraine prevention, but is not first line dt s.e profile
antiepileptics:
divalproex sodium
gabapentin
topiramate
what 3 antidepressants are effective for migraine prevention
amitryptiline
nortriptyline
fluoxetine
what 3 bb are effective for migraine prevention
propranolol
timolol
atenolol
what 2 ccb are best for migraine prevention
diltiazem
verapamil
what type of stroke is associated w. migraines w. aura
occipital
what increases risk for heart attack and stroke with aura migraines
estrogen-based OCP
consider progesterone only OCP
recurring HA that is induced by repetitive and chronic use of acute meds
rebound HA
t/f: tx for rebound HA’s is ineffective until meds have been withdrawn and washout or med withdrawal occurs
t!
3 other names for rebound HA
medication/drug induced/misuse
analgesic rebound
ergotamine rebound
what HA meds can lead to rebound HA
all of them!
but esp opioids and caffeine
5 lifestyle migraine triggers
emotional stress
dpn
too little sleep
exercise/overactivity
skipping meals/fasting
6 food triggers for migraine
chocolate
nuts/nut butters
dairy
red wine/etoh
processed meats
MSG
2 physical triggers for migraines
menstrual cycle
other hormone changes
4 environmental triggers for migraines
weather/seasonal changes
time travel :)
odors/pollution
bright light
3 common tx pitfalls for HA’s
misdiagnosing migraines
overtreating HA and causing rebound
undertreating HA
abortive HA cocktail that Jaynstein likes
Compazine + Benadryl +/- Toradol
Reglan as alternative to Compazine
caution w. Toradol
compazine treats (2)
HA
nausea
route of admin for HA cocktail
PO
IM -> lasts longer, easier admin
IV
preventive migraine tx that Jaynstein likes
Propranolol + SSRI
PLUS
Excedrin or Triptan for acute episodes
