LG2.7/2.8 Headache Disorders Flashcards
What is a primary headache?
- Those in which there’s an intrinsic dysfunction of the Nervous System (often Genetic; predisposed to headache attacks)
- No underlying structural, infectious, toxic/metabolic cause.
What is an example of primary headache?
Migraine, cluster headaches, tension headaches.
What is a secondary headache?
- Those where headaches are Secondary to organic or physiologic or psychiatric processes (intracranially or extracranially)
- An identifiable underlying cause
- Examples: tumor, hemorrhage, meningitis
What are common symptoms of migraine?
- Usually one-sided. Throbbing. Incapacitating
- Nausea Vomiting
- Sensitive to light and sound.
- Worse with movement or straining.
- Duration of 4-72 hours
What is the Cortical Spreading Depression?
- Visual, Zig zag flashes(+), Scotoma (-)
* Sensory, weakness, trouble speaking, reversible, lasts 5 to 60 minutes
How do you differentiating migraine from ocular symptoms?
-one eye only, not scintillating scotomas
How do you differentiate migraine from detached retina?
-one eye, doesn’t improve but progresses
Differentiate migraine from stroke?
- Affects both eyes.
- Aura Spreads Slowly.
- Has positive features (of Aura).
- Recurring episodes follow a pattern.
- Reversible
- Other suspected clues.
What are increased risks of stroke related to Migraines?
- Migraine with Aura > Migraine without aura > No migraine history.
- Migraine + smoking increases risk of stroke 9x
- Migraine + Oral contraceptives (BCP’s) increases stroke risk 7x
What are the three simple screening questions for migraine patients?
DISABILITY, NAUSEA, PHOTOPHOBIA
What are the four specific questions for migraine patients?
1) Do you have headaches that interfere with work, social or family functions?2) Has your headache pattern been stable over the past six months?
3) How frequently do you experience headaches?
4) How effective is your current headache treatment?
Do brain tumors normally cause pain?
Brain cannot perceive pain within the brain, brain tumors rarely have headache as a presenting symptom.
Where does the pain in the brain come from?
- Cortex and meninges directly cause pain via blood vessels and stimulates the Trigeminal nerve which passes pain to the area of the cerebral cortex for processing
- Brainstem is center of sensory pain information passing to the brain
- Brainstem passes signals to cerebral cortex for CSD as well as pain.
- Genetic: Migraine patients have a abnormal sensory pain processing from trigeminal nerve/brainstem through the Thalamus. Lower threshold to produce migraine headache.
What is the action of serotonin?
- Vasoconstrictor
- Regulates mood, pain, appetite and sleep
What is found in low levels in Migraine sufferers?
• Low serotonin levels found in Migraine suffers
How do Triptans work?
Triptans work in acute treatment of migraine by blocking inflammatory chemicals in the meninges
What antidepressant may help with migraines?
SSRI’s
What perivascular vasoactive neuropeptides causes inflammation and is tied to migraines?
Calcitonin gene-related peptide (CGRP)
What is a Menstrual migraine?
Related to estrogen flux at time of menses
What is a Basilar Migraine?
Starts at the base of the skull, symptoms include vertigo, slurred speech, unsteadiness suspect CSD posteriorly perhaps in brainstem/cerebellar areas
What is an abdominal Migraine?
Children, family history of migraine, periodic attacks.
What is a Status Migrainosis?
very rare; lasts long, requires hospitalization
What is a Chronic Migraine?
Note on Secondary Headache part of Scheme; an overlap with tension headaches, and medication overuse headaches
Is a migraine a brain disorder?
Migraines are a brain disorder
What is allodynia?
-Painful reaction to otherwise non painful stimuli
What is Central sensitization?
Central amplification of pain response and threshold.
What is Neuronal sensitization?
Process where neurons become increasingly responsive to pain stimuli
What is sensitization?
Results in decreased response threshold, increased response magnitude, and expansion of receptive fields
What is the defining features of chronic or transformed migraine?
A progressive form of migraine intermittent attacks-eventally to 15 or more days per month
What are examples of comorbid conditions of migraines?
Depression, anxiety, panic attacks, bipolar disorder, fibromyalgia
What are nonphamacologic treatments for migraines?
- OMM
- Behavioral therapy
- Exercise
- Weight reduction
- Dietary
- Smoking cessation
- Establishing regular eating and sleeping patterns feverfew
- CoEnzyme Q 10
- Magnesium
- Riboflavi
What are interventional procedures for migraines?
- Neuroblockade (nerve, facet, epidural space)
- Neurotoxin treatment (Botox)
- Hospital/ rehabilitation programs
What are Acute abortive treatments for migraines?
Triptan, Ergotamine
What are acute symptomatic treatments for migraines?
Analgesic (ASA, NSAID) avoid Narcotic/Opioid agents
What are prophylactic treatments for migraines?
- Amitriptyline
- Propranolol/atenolol (beta blockers)
- Valproate (seizure medication)
- Botulinum toxin (Botox, injected every 3-4 mos.)
What are environmental treatments for migraines?
- Stress reduction
- Regular Sleep and Diet
- Avoid Food Triggers
- Behavior Modification
What is a tension type headache?
- Controversial title (some experts relate this to a variant form of migraine)
- USUALLY BILATERAL PAIN
- NOT DISABLING
- NO ASSOCIATED SENSORY SENSITIVITY
- NO ASSOCIATED NAUSEA
What are general characteristics of Cluster headaches?
- Male more common
- Related to hypothalamic disturbances and alterations in melatonin function.
What are clinical features of cluster headaches?
- Presence of headache cycles or bouts lasting weeks to months, occurring 1 or more times per year or less.
- Repetitive stereotyped intense attacks of short duration.
- Focal orbital or temporal pain, always unilateral with lacrimation, nasal discharge, pupillary changes, conjunctival injection
- Can occur during sleep, often triggered by alcohol ingestion
What are preventative agents for cluster headaches?
- Steroids (prednisone)
- Lithium carbonate
- *Verapamil
- Valproic acid
- Melatonin
- Indomethacin
- Antidepressants generally of little benefit here. (c.f.; migraine)
What are acute treatments of cluster headaches?
o Limited, due to short duration of individual attacks
o Oxygen inhalation
o Triptans/dihydroergotamine (limit 1-2 doses per day, 2-3 days per week)
o Occipital nerve blocks
What are the typical presentation of cluster headaches?
- Male
- Conjunctival injection
- Lacrimation
- Congestion
- Rhinnorhea
- Ptosis; Eye edema; Patients won’t Stay still; writhing,In pain, pound head, etc.
What activity greatly increases likelihood of cluster headaches?
Heavy smokers
When do you consider neuro-imaging?
- Abnormal unexplained neurological exam (learn and practice).
- *Onset of headache over age of 55.
- *Associated fever.
- *Headache with extremely abrupt onset.
- *Headache refractory to aggressive treatment.
- *First or “worse” headache ever experienced.
- *Increasing frequency and/or severity of headaches.
- *Change in headache clinical features.
- *Headaches that don’t “fit” primary headache criteria.**
What are the reasons to consider neuro-imaging in children?
o morning/nocturnal headache (especially 3 y.o. or less).
o *explosive onset headache.
o *progressive worsening over time.
o *declining school performance/personality changes.
o *altered mental status.
What are the defining features of an intracranial hematoma?
Recent head trauma with acute changes in mental status, headache or focal neurologic deficit
What are the defining features of a chronic subdural hematoma?
- Blunt head trauma: over weeks/months (slow); elderly
- on anticoagulants, alcoholic}
- Normal space between skull and brain is ¼ inch, Increases with age
What do you do with a patient that has head trauma, headache, altered mental status, or focal finding on exam?
GET UNENHANCED CT HEAD SCAN, ASAP, FOLLOWED WITH FREQUENT NEUROLOGICAL EVALUATIONS
What nerve is a common cause of facial pain?
Trigeminal Neuralgia
What are the symptoms of Trigeminal Neuralgia?
A paroxysmal sharp intense stabbing, electric like pain in a distribution of the Trigeminal (Cr. N. V) nerve.
What is the most common cause of compression of the Trigeminal nerve root?
Aberrant loop of Artery or vein
What are other less frequent causes of Trigeminal Neuralgia?
- Demyelinating nerve lesion of Multiple Sclerosis
- Post herpetic neuralgia (especially V1 subdivision)
- Compression from schwannoma (acoustic neurona)
- Vascular compression from an aneurysm (secondary TN)
What are triggers of Trigeminal Neuralgia?
Touching face, chewing, talking, smiling, cold air on face, brushing teeth.
What are the characteristics of facial pain due to Multiple Sclerosis?
Characterized by unilateral or bilateral facial pain attributed to demyelination of the Trigeminal Nerve (Cr. N. V).
What is Neuralgias?
-Paroxysmal pain in the distribution of a particular nerve
What is Glossopharyngeal Neuralgia?
- Paroxysmal pain in areas innervated by Cr N (IX) and Cr N (X) (Glosspharyngeal and Vagus Nerves)
- Back of throat (stabbing pain in tonsillar fossa, base of tongue, beneath the angle of the jaw, behind ear)
What are triggers of Glossopharyngeal Neuralgia?
Chewing, swallowing, yawning, touching the neck
What are the causes of Glossopharyngeal Neuralgia?
- Demyelinating lesions
- Cerebellopontine angle tumors
- Peritonsillar abscess
- carotid aneurysm
What imaging do you do for Glossopharyngeal Neuralgia?
Get MRI/MRA to rule out mass lesion or vascular pathology
What does post herpetic neuralgia do?
- Shingles
- Facial pain affecting V1 (trigeminal nerve)
What is Carotidynia?
Pain that eminates from the carotid artery
What is Giant Cell Arteritis?
- Temporal Arteritis
- 55 y/o+
- Vasculitis of the large and medium sized arteries; temporal artery distended, tender, jaw chewing fatigue or claudication.
What tests/treatment would you give to the patient?
- Get ESR/ inflammation blood study)
- Treat with steroids (prednisone)
What is TMJ?
- Temporomandibular Joint Disorder
- TMJ disorder is often a secondary headache disorder
What are common elements that contribute to TMJ disfunction?
- Muscle dysfunction
- TMJ issues
- Cervical spine dysfunction
What are the most common presenting signs and symptoms of TMJ?
- Pain (96%)
- Ear discomfort (82%)
- Headache (79%)
- TMJ discomfort or dysfunction (75%)
What are criteria for Hospialization?
- Moderate to severe intractable headache
- Not responding to appropriate/aggressive outpatient or ER treatments
- Continuing N/V/D
- Need to detoxify or treat toxicity.
- Frequent emergency department treatments
- Other comorbid conditions
When do/don’t you administer opiods for headaches?
- NO chronic headache pop.
- Acute setting, no other options, limit use
- Give when all els fails
- When standard agents are contraindicated
- In the elderly or during pregnancy.
What is the best choice for opioids use?
*Best to refer to specialists and /or centers where complex regimens can be offered *
What is the main point of primary headaches?
-Are considered potentially life long disorders and require not only aggressive treatment but maintenance therapy that changes over the course of the patient’s life.
