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Unit 3 Clin Med III > L16: Headaches > Flashcards

L16: Headaches Flashcards

1
Q

Vascular headaches

A

Migraine

Cluster headaches

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2
Q

Muscle contraction headaches

A

Tension headaches

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3
Q

Traction headaches

A

Organic diseases of the head such as intracranial mass

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4
Q

Inflammatory headaches

A

Meningitis, giant cell arteritis, etc

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5
Q

Primary versus secondary headaches

A

Primary: occur independently
Migraine, cluster, tension, chronic daily, primary stabbing, primary exertional, hypnic (“alarm-clock”)

Secondary: associate with another disorder

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6
Q

What is the most important factor in establishing headache diagnosis??

A

History

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7
Q

Migraine epidemiology

A

W>M
Common
Often genetic/familiar

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8
Q

Migraine duration

A

4-72 hours

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9
Q

Migraine symptoms

A

throbbing, pulsating , unilateral

photophobia, phonophobia, n/v
Movement worsens sx

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10
Q

Migraine triggers

A

Menstruation

Weekend following stressful work life

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11
Q

Common migraine=

A

Migraine without aura

Occurs without warning
More frequent form (75%)
Chronic and recurring
Unilateral pain 4-72 hours
Throbbing, pulsatile

Associated sx: nausea, confusion, blurred
vision, mood changes, sensitivity to light/sound
FHX

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12
Q

More common migraine type

A

Common

most ppl don’t get auras

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13
Q

Classic migraine=

A

Migraine with aura:
4 phases: Attack: prodrome, aura,
headache, postdrome

Aura occurs 10-60 min prior→ occur during the HA or no HA occurs, last less than 60 min

Triggers associated

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14
Q

4 phases of the classic (aura) migraine

A
  1. Prodrome (77%): 24-48 hours prior to HA
    • Food cravings, mood change, uncontrollable yawning, fluid
    retention, constipation, neck stiffness
  2. Aura (25%): prior to or concurrent with HA
    • Positive sx → visual/auditory /sensory /motor
    Negative sx→ loss of function /vision/hearing/sensation/motor
  3. Headache
    • Builds gradually in intensity
    • Unilateral pulsatile or throbbing pain
    • +/- NV, photophobia, phonophobia
  4. Postdrome→ Confused or exhausted
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15
Q

Examples of auras

A

Visual
• Classically small area of visual loss or bright spot, flashing or bright lights, shapes, visual heat waves

Sensory
• Follow or occur without the visual aura
• Unilateral Tingling (face, limb) or muscle weakness
• Abnormal sensations

Language
• Wording difficulties or dysphagia, Less common

Cutaneous Allodynia→ Abnormal pain response from things like
combing hair, shaving, wearing glasses, contact lens, earrings, tight fitting clothes

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16
Q

Red flags that warrant imaging for a migraine

A 
“Worst headache of my life”
Changes in presentation
New or unexplained neurologic symptoms
HA not responding to treatment
New onset after 50 or in pts with CA or HIV
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17
Q

If a migraine has a red flag and warrants imaging, what type of imaging should you get?

A

CT>MRI

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18
Q

Lifestyle changes to prevent migraines

A

Sleep
Routine meal schedule
Regular exercise
Avoidance of triggers

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19
Q

Beta blockers for migraine prophylaxis

A

propranolol
metoprolol
timolol

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20
Q

Antidepressants for migraine prophylaxis

A

amitriptyline (TCA)

venlafaxine (SSRI)

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21
Q

Anticonvulsants for migraine prophylaxis

A

Topiramate

Valproate

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22
Q

Other drugs for migraine prophylaxis

A 
Coenzyme Q10
Riboflavin
Calcitonin
Botox
Feverfew
CCB
*CGRP antagonists* (monthly or quarterly)
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23
Q

Mild to moderate abortive migraine treatment

A

Oral NSAIDs
acetaminophen,
OTC combination drugs (i.e. Excedrin, Midrin)

N/V→ Antiemetic

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24
Q

Moderate to severe abortive migraine treatment

A

Triptans (oral, or combination with NSAID, naproxen)

Ergots

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25
Triptan sensation
Injection site reaction, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, malaise, feeling of warmth, paresthesia→ Resolve in 30 minutes
26
Contraindications for triptan or ergotamine use
``` vasoconstriction: uncontrolled HTN pregnancy hx of MI PVD cerebrovascular disease ```
27
Aura vs TIA: onset
Aura: gradual onset TIA: rapid onset
28
Aura vs TIA: duration
Aura: <1 hour TIA: maximal intensity within a few minutes lasting up to 24 hours
29
Aura vs TIA: symptoms
Aura: Aura types may overlap and ebb and flow TIA: Multiple deficits occur simultaneously
30
Episodic tension headaches
1. Infrequent: < 12 days/year and lasting < 1 day/month 2. Frequent: 1-14 days/month lasting 30 min to several days Not disabling
31
Chronic tension headaches
> 15 days/month, Lasts hours to days, may be | unremitting
32
Tension headache background
Most common type, F>M
33
Tension headache symptoms
Muscle contraction HA: Bilateral pressure, band-like, Non-throbbing Start in morning, worsen during day Mild-moderate in intensity Duration: 30 min - 7 days •Associated sx: anorexia, head/neck pain with muscle tenderness, bruxism (Phonophobia, photophobia rare, no aura, no N/V)
34
Tension headache triggers
``` Stress jaw clenching missed meals depression too little sleep head/neck strain ```
35
Tension headache management
Clinical diagnosis Treat underlying cause→ corrective devices for jaw/mouth, sleep study, less stressful environment Acute: NSAIDs, acetaminophen, aspirin, combination → High initial dose +/- Preemptive treatment Hot shower or heat to back of neck
36
Avoid these meds in tension headaches
*Avoid opioid/barbiturates→ high potential for medication overuse HA
37
Refer patients with headaches if....
``` Patient requests a referral Provider has low comfort level with dx Diagnosis is questionable Patient does not respond to treatment Condition worsens or changes Unable to treat as outpatient ```
38
Cluster headaches are more common in
Males
39
Trigeminal autonomic cephalgias
Cluster Headaches Sharp, boring unilateral, periorbital HA with autonomic sx Excruciating→ *One of the worst pain syndromes known to man (suicidal) Duration: brief, 15-180 minutes
40
When do cluster headaches occur
Similar time of day/night x several weeks with period of remission • Attacks: every other day - 8x/day • Clusters: typically 6-12 weeks • Remission: up to 12+ months • Chronic: clusters lasting >1 year or remission < 1 month
41
Presentation of cluster headaches
Restless, paces, sits and rocks Pain: severe orbital, supraorbital, or temporal Autonomic sx: conjunctival injection, lacrimation, eyelid edema, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis→ Ipsilateral to pain, Parasympathetic hyperactivity and sympathetic impairment Associated sx may be similar to migraine sx: aura, sensitivity to light, sound, smell
42
Triggers for a cluster headache
Alcohol Smoking Smells Stress
43
Diagnosis for a cluster headache
MUST DO IMAGING *MRI with and without contrast or plain CT* Evaluate brain and pituitary gland for potential secondary cause
44
ACUTE management of a cluster headache
*O2*: nonrebreathing face mask 100% O2 at >12L/min Sitting upright Continue x 15 min even if attack ends in less time
45
Contraindications to oxygen therapy
severe COPD: risk of hypercapnia and CO2 narcosis
46
Triptan can treat _____
Migraine headaches AND Cluster headaches (subcutaneous sumatriptan, intranasal sumatriptan or zolmitriptan, oral zolmitriptan)
47
Other options for acute cluster headache treatment
intranasal lidocaine | ergots
48
Preventative therapy for cluster headaches is started ______
At the onset of a cluster episode Goal to suppress attacks and minimize need for abortive medicines
49
Preventative therapy for cluster headaches includes
CCB: *Verapamil* (DOC) Other options: glucocorticoids, lithium, topiramate Extreme chronic cases: electrical stimulation or glucocorticoid injections of occipital nerve, deep brain stimulation of hypothalamus, or surgery targeting trigeminal nerve or autonomic pathways
50
Chronic daily headache (4 types)
> 15 days/month during 3+ months Moderate pain on sides or top of head 1. Chronic Migraine 2. Chronic Tension-type 3. Hemicrania continua: 4. New daily persistent headache (NDPH)
51
Hemicrania continua
continuous, fluctuating pain on same side of face/head lasing minutes to days Associated sx: tearing, irritated eyes, rhinorrhea, swollen eyelids Dx and Tx: Indomethacin
52
New daily persistent headache (NDPH)
"Chronic benign headache" Abrupt onset and does not remit Pain: range mild to severe: throbbing/tightening on both sides of head Associated sx: light/sound sensitivity +/- occur following infection, medication use, trauma, or other condition with no previous hx of HA TX: muscle relaxants, antidepressants, anticonvulsants
53
Primary stabbing headache
“ice pick”, “jabs and jolts” headache Pain is intense and strikes without warning Lasts 1-10 seconds Usually around eye but may occur anywhere along trigeminal nerve Daily to yearly Often associated with other headaches TX: Indomethacin or abortive medications if multiple episodes occur, avoid trigger
54
Primary exertional headache
Trigger: coughing, sneezing, intense activity Last minutes to days Associated sx: N/V +/- FHX of migraines Imaging: MRI/MRA to r/o vascular abnormalities Risk increases > 40 yo and focal neuro sx TX: warm-up exercises, NSAIDS, Indomethacin (prior to exercises or daily use)
55
Alarm clock headaches aka
Hypnic Headache
56
Hypnic headaches
“Alarm-clock” Headaches Later in life (>50 yo) Develops during sleep and awakens people at night Disorder of REM sleep? > 10 episodes/month lasting 15 min- 3 hours Pain: mild-moderate throbbing, both sides of head Associated sx: nausea, sensitivity to light/sound Imaging for new presentation: MRI TX: caffeine at night > indomethacin > lithium
57
Get imaging for these headaches the first time they present:
``` Cluster HA (MRI with and without contrast or plain CT) Hypnic HA (MRI) Primary Exertional HA (rule out vascular) (MRI/MRA) ```
58
Secondary headaches management
Refer
59
"Alerts" For secondary headaches
First HA in patient over 50 Sudden intense HA without previous hx of HAs Nuchal rigidity, + Kernig or Brudzinski signs Diplopia Papilledema or retinal hemorrhage Persistent or new neurological signs Fever Excessive BP elevation Hx of head trauma, malignancy, coagulopathy Change in previous HA presentation
60
SNOOP means
Systemic illness/sx → HIV, CA, infection, sinusitis, meningitis, vasculitis Neurologic→ Mass/lesion, vascular malformation, stroke, Substance abuse/ withdrawal Onset sudden→ Subarachnoid hemorrhage, mass, lesion, vascular malformation Older→ Mass, lesion, temporal arteritis Previous hx→ Subdural hematoma, medication overuse, mass/lesion, meningitis
61
A medication overuse headache is....
Primary HA develops or worsens with medication overuse HA results from frequent use of analgesics and HA often occurs when analgesic is withheld (morning awakening) • Vary in severity and location • Chronic daily headache Typically preceded by an episodic HA disorder
62
What medications can cause a medication overuse headache?
Any symptomatic medications
63
Low risk meds medication overuse headache
opioids, barbiturates, and aspirin or acetaminophen combinations Medium-High: triptans
64
Medication overuse headache management
NSAIDS (not including ASA)
65
Treatment of medication overuse headache
withdrawal of medications with NSAIDS, preventative medication for underlying headache disorder

Unit 3 Clin Med III (3 decks)

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