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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
Q

Triptan sensation

A

Injection site reaction, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, malaise, feeling of warmth, paresthesia→ Resolve in 30 minutes

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26
Q

Contraindications for triptan or ergotamine use

A 
vasoconstriction: uncontrolled HTN
pregnancy
hx of MI
PVD
cerebrovascular disease
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27
Q

Aura vs TIA: onset

A

Aura: gradual onset
TIA: rapid onset

28
Q

Aura vs TIA: duration

A

Aura: <1 hour
TIA: maximal intensity within a few minutes lasting up to 24 hours

29
Q

Aura vs TIA: symptoms

A

Aura: Aura types may overlap and ebb and flow

TIA: Multiple deficits occur simultaneously

30
Q

Episodic tension headaches

A
  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
Q

Chronic tension headaches

A

> 15 days/month, Lasts hours to days, may be

unremitting

32
Q

Tension headache background

A

Most common type, F>M

33
Q

Tension headache symptoms

A

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
Q

Tension headache triggers

A 
Stress
jaw clenching
missed meals
depression
too little sleep
head/neck strain
35
Q

Tension headache management

A

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
Q

Avoid these meds in tension headaches

A

*Avoid opioid/barbiturates→ high potential for medication overuse HA

37
Q

Refer patients with headaches if….

A 
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
Q

Cluster headaches are more common in

A

Males

39
Q

Trigeminal autonomic cephalgias

A

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
Q

When do cluster headaches occur

A

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
Q

Presentation of cluster headaches

A

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
Q

Triggers for a cluster headache

A

Alcohol
Smoking
Smells
Stress

43
Q

Diagnosis for a cluster headache

A

MUST DO IMAGING
MRI with and without contrast or plain CT

Evaluate brain and pituitary gland for potential secondary cause

44
Q

ACUTE management of a cluster headache

A

O2: nonrebreathing face mask 100% O2 at >12L/min
Sitting upright
Continue x 15 min even if attack ends in less time

45
Q

Contraindications to oxygen therapy

A

severe COPD: risk of hypercapnia and CO2 narcosis

46
Q

Triptan can treat _____

A

Migraine headaches
AND
Cluster headaches
(subcutaneous sumatriptan, intranasal sumatriptan or zolmitriptan, oral zolmitriptan)

47
Q

Other options for acute cluster headache treatment

A

intranasal lidocaine

ergots

48
Q

Preventative therapy for cluster headaches is started ______

A

At the onset of a cluster episode

Goal to suppress attacks and minimize need for abortive medicines

49
Q

Preventative therapy for cluster headaches includes

A

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
Q

Chronic daily headache (4 types)

A

> 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
Q

Hemicrania continua

A

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
Q

New daily persistent headache (NDPH)

A

“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
Q

Primary stabbing headache

A

“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
Q

Primary exertional headache

A

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
Q

Alarm clock headaches aka

A

Hypnic Headache

56
Q

Hypnic headaches

A

“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
Q

Get imaging for these headaches the first time they present:

A 
Cluster HA (MRI with and without contrast or plain CT) 
Hypnic HA (MRI) 
Primary Exertional HA (rule out vascular) (MRI/MRA)
58
Q

Secondary headaches management

A

Refer

59
Q

“Alerts” For secondary headaches

A

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
Q

SNOOP means

A

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
Q

A medication overuse headache is….

A

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
Q

What medications can cause a medication overuse headache?

A

Any symptomatic medications

63
Q

Low risk meds medication overuse headache

A

opioids, barbiturates, and aspirin or acetaminophen combinations

Medium-High: triptans

64
Q

Medication overuse headache management

A

NSAIDS (not including ASA)

65
Q

Treatment of medication overuse headache

A

withdrawal of medications with NSAIDS, preventative medication for underlying headache disorder

Unit 3 Clin Med III (3 decks)

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