MDT Headache

Question 1

Headaches are one of the __________ at 12 to 16% of the population in north America

Answer 1

most common medical complaints

Question 2

Differential Diagnosis / Danger Signs
Sudden onset or “thunderclap” headache could be

Answer 2

subarachnoid hemorrhage (SAH)

Question 3

Differential Diagnosis / Danger Signs
Absence of prior headache/s similar to present one Could be

Answer 3

CNS infection

Question 4

Differential Diagnosis / Danger Signs
Focal neurologic signs other than auras

Answer 4

Could be stroke or tumor

Question 5

Differential Diagnosis / Danger Signs
Other physical symptoms like fevers

Answer 5

Could be meningitis

Question 6

Differential Diagnosis / Danger Signs
Rapid onset with exercise Could be

Answer 6

intracranial hemorrhage associated with brain aneurysm

Question 7

Differential Diagnosis / Danger Signs
Associated with nasal congestion

Answer 7

Could be sinusitis

Question 8

Differential Diagnosis / Danger Signs
Associated with papilledema

Answer 8

Could be increased intracranial pressure

Question 9

Reasons for What
(1) Recent change in pattern, frequency, or severity of headaches
(2) Progressive worsening despite therapy
(3) Focal neurological deficits or scalp tenderness
(4) Onset of headache with exertion, cough, or sexual activity
(5) Visual changes, auras, or orbital bruits
(6) Onset of headache after age 40
(7) History of trauma, hypertension, fever

Answer 9

imaging

Question 10

Overview and presentation of what?
1) Most prevalent headache
2) Bilateral headaches
3) Often occurs daily
4) Characterized as “vice-like” in nature
5) Often exacerbated by emotional stress, fatigue, noise, glare
6) May be associated with hypertonicity of neck muscles.

Answer 10

Tension Headaches

Question 11

Do you need to do any diagnostic tests for Tension headaches?

Answer 11

no

Question 12

What meds can you use to treat a Tension headache

Answer 12

Abortive
-NSAIDS
(1 Ibuprofen (Motrin) 400- 800 mg PO q 4- 6 hours, Max
2400mg/24 hours
(2 Naproxen (Naprosyn) 250- 500 mg PO q12 hours
-Tylenol
(1 Dose: 325-1000 mg PO q 4-6 hours, max 4 grams/24 hours
Contraindications: Hepatic or renal impairment, chronic alcohol
abuse

Question 13

Overview and presentation of what?
1) Usually affects middle aged men but can also affect women
2) Intense unilateral pain that starts around the temple or eye
3) Patients is often restless and agitated due to the pain
4) Episodes often occur 15 minutes to 3 hours
5) Usually occur seasonally and attacks are grouped together
6) Other associated symptoms
a) Ipsilateral congestion or rhinorrhea
b) Lacrimation and redness of the eye
c) Horner syndrome (Ptosis, miosis,
anhidrosis)
7) After resolution of attacks there is a hiatus of several months

Answer 13

Cluster headache

Question 14

Oral treatment for ______during an attack is generally _______

Answer 14

Cluster headache
unsatisfactory

Question 15

Treatment for cluster headache initial treatment of choice

Answer 15

Inhaled 100% oxygen for 15 minutes is initial treatment of choice

Question 16

Treatment for cluster headache
Subcutaneous Sumatriptan (Imitrex)
Dose:
MOA:
Adverse reactions:

Answer 16

Dose: SubQ Initial: 6 mg; may repeat if needed ≥1 hour after initial dose
MOA: Selective agonist for serotonin causes vasoconstriction and reduces neurogenic inflammation
AR: Tingling, dizziness/vertigo, feeling hot

Question 17

Treatment for cluster headache
Oral Zolmitirptan (Zomig)
Dose:
MOA:
AR:

Answer 17

Dose: Initial: 2.5 mg, may repeat if needed ≥ 2 hour after initial dose
(maximum single dose: 10 mg per 24-hour period).
MOA: causes vasoconstriction and reduce neurogenic inflammation associated
with antidromic neuronal transmission correlating with relief of migraine
AR: Gastrointestinal unpleasant taste, chest pain,
weakness, dizziness/vertigo, feeling hot.

Question 18

How long do cluster headaches usually last?

Answer 18

15 min to three hours?

Question 19

Overview and presentation of what?
1) Gradual build-up of a throbbing headache, that may be unilateral or bilateral
2) Duration of several hours
3) Aura may or may not be present
a) Visual disturbances such as visual
field deficits or visual hallucinations
(stars, light slashes, zigzags, etc)
b) Other focal disturbances such as
aphasia or numbness, tingling,
clumsiness, or weakness in a
circumscribed distribution
4) Family history often positive for headaches
5) May have associated nausea and vomiting

Answer 19

Migraines

Question 20

Migraine management

Answer 20

1) Avoidance of precipitating factors, together with prophylactic or symptomatic
pharmacologic treatment if necessary.
2) During acute attacks - rest in a quiet, darkened room until symptoms subside.

Question 21

Migraine Abortive Treatment

Answer 21

a) Simple analgesics/NSAIDS: Ibuprofen, Naprosyn, Aspirin, Acetaminophen, Ketorolac (Toradol) 30mg IV/IM once or every 6 hours or 60mg IM once (max 120mg/day)
b) Sumatriptan (Imitrex) Oral dose of 25, 50 or 100mg. repeat in 2 h if needed. REC 50mg and 100mg initial more better
c) Zolmitriptan (Zomig) 2.5 mg q>2H (max 10 mg)

Question 22

Migraine Prophylaxis

Answer 22

1) Preventative treatment indicated when migraines occur more than 2-3 times per month or associated significant disability.
2) Antihypertensives: Beta-blockers such as Propranolol, Metoprolol
3) Antidepressants, amitriptyline
4) Anticonvulsants: topiramate
5) Treatment for concurring symptoms like nausea and vomiting antiemetics: promethazine

Question 23

Overview and presentation of what?
1) After head injury, it is common to have headaches
2) Symptoms occur within 1-2 days of injury, and subside within 7-10 days
3) Often accompanied by impaired memory, poor concentration, emotional
instability, and increased irritability

Answer 23

Post-Traumatic Headache

Question 24

Post-Traumatic Headache
Treatment

Answer 24

1) No special treatment required
2) Simple analgesics are appropriate first line therapy

Question 25

Overview and presentation
1) Present in about 50% of patients with chronic daily headaches
2) Patients typically present with chronic pain or with complaints of headache unresponsive to medication
3) History will often reveal heavy use of analgesics

Answer 25

Medication Overuse Headache

Question 26

Medication Overuse Headache
Treatment

Answer 26

1) Treatment is to withdraw medications….
a) Expect improvement in months, not days