Migraine Headaches Flashcards
1
Q
why should a general dentist care about headaches
A
- the same nerve pathway (trigeminal) is involved and may show up as a toothache, gingival pain or facial pain in the pt
- being able to dx referred pain from headaches will allow you to refer your patient to proper specialist and avoid unneccesary dental tx
- headaches occur most frequently on arising in the morning therefore the DDS must differentiate in the head/facial pain is from migraine, bruxism or obstructive sleep apnea
2
Q
headaches can mimic acute dental disease if located in:
A
the lower half of the face (V2-3)
3
Q
what types of headaches can mimic dental disease and cause tooth pain
A
migraine, cluster headache, or paroxysmal hemicrania
4
Q
acute dental pain may spread:
A
unilaterally but unlike a headache it rarely crosses the midline of the face
5
Q
what are the dental pain characteristics
A
- intense, throbbing
- poorly localized
- generally provoked by stimulation of the offending tooth
6
Q
what the epidemiology of a migrane
A
- second most common neurological disorder
- affects more than 1 billion people worldwide
- 2-3 times more likely to be experienced by women
- prevalence peaks at 35-39 years in both sexes
7
Q
onset of migraine occurs in the ______ life decades then the frequency decreases
A
first four
8
Q
childhood gender distribution for migraines is:
A
equal
9
Q
what are the impacts of migraines
A
- 36 million americans are estimated to have severe migraine headaches
- migraine will affect 30% of women over a lifetime
- annual lost productivity in the US due to migraine costs over 1 billion $ per year
10
Q
what are the diagnostic criteria for headaches attributed to TMD
A
- any headache fulfulling criterion C
- clinical and/or imaging reveals evidence of TMD*
- evidence of causation demonstrated by 2 or more of the following:
- headahce has developed in temporal relation to onset of TMD
- either or both of: headache has significantly worsened in parallel with progression of TMD or headache has significantly improved or resolved in parallel with improvement or resolution of TMD
- headache produced or exacerbated by active jaw movements, passive movements through range of motion of jaw and/or provacative maneuvers such as pressure on TMJ and surrounding muscles of mastication
- headache when unilateral is ipsilateral to TMD
11
Q
what are the primary headache disorders
A
- migraine
- tension type headache
- trigeminal autonomic cephalgias (TACs): cluster headahce, paroxysmal hemocrania, hemicrania continua, SUNCT syndrome
12
Q
what are the orofacial pains resembling presentations of primary headaches
A
- orofacial migraine
- episodic orofacial migraine
- chronic orofacial migraine
13
Q
what are the diagnostic criteria for episodic orofacial migraine
A
- at least 5 attacks fulfulling critera B-D
- facial and/or oral pain without head pain lasting 4-72 hours (untreated or unsuccessfully treated)
- pain has at least two of the following 4 characteristics:
- unilateral location
- pulsating quality
- moderate or severe intensity
- aggravation by, or causing, avoidance of routine
- physical activity
- pain is accompanied by on or both of the following: nausea and/or vomitting and photophobia and phonophobia
14
Q
what are the chronic orofacial migraine diagnostic critera
A
- facial and/or oral pain without head apin on 15 days/month for more than 3 months and fulfilling criteria B and C below
- occurring in a patient who has had at least 5 attacks fulfilling criteria B-D for episodic orofacial migraine
- On 8 days/month for more than 3 months, fulfilling either of the following: criteria C and D for episodic orofacial migrane or believed by the patient to be orofacial migraine at onset and relieved by triptan or ergot derivative
15
Q
migraine headache may be ___ or _____
A
unilateral or bilateral
16
Q
episodes of migraines may occur when
A
at any time of day or night
17
Q
pain sensitive intracranial structures include;
A
the skin and blood vessels of the scalp; the head and neck muscles; the venous sinuses; the arteries of the meninges; the larger cerebral arteries; the pain carrying fibers of the fifth, ninth, and tenth cranial nerves; and parts of the dura mater at the base of the brain
18
Q
the brain itself is ____ to pain
A
insensitive
19
Q
what are the clinical characteristics of migraines
A
- scalp tenderness occurs in 2/3 of the patients during or after the headahce
- a genetic factor or familial history is present among. most
- more than 50% of people with migraines have less than two attacks per month
20
Q
what is the pathophysiology of migraines
A
- migraines and trigeminal autonomic cephalgias cause activation of the trigeminovascular system causing relapse of inflammatory chemical mediators in the brain known as neuropeptides
- the serotonin receptor (5-HT) gets activated. serotonin acts as a NT in the CNS and is a potent vasoconstrictor. it is found in the brain, platelets and intestine
- CGRP is believed to play a major role in migraine pathogenesis
21
Q
a small group of migraineurs transform into chronic daily headache which is now classified as:
A
daily persistent migraine- headaches occur 15 or more times per month
22
Q
previous classification of daily persistent migraines was:
A
medication overuse or rebound headache since use of analgesics and migraine abortive medications more than 2 days a week can trigger daily headaches in some individuals
23
Q
what is the tx for daily persistent migraines
A
onabotulinum A
24
Q
_______ of migraineurs have a parent with the disorder and up to _____ have at least one first degree relative with migraine
A
50-60%; 80%
25
what chromosome is linked to migraines
18
26
_____ headaches rarely occur within the same family
cluster
27
______ of tension type headaches sufferers have family members with similar headaches
40%
28
migraine is comorbid with:
stroke
- epilepsy
- depression
- anxiety disorders
29
in patients with migraine, anxiety disorders and major depression the onset of anxiety generally _____ the onset of migrane
precedes
30
the onset of major depression usually ____ the onset of migraine
follows
31
what are the international headache society classifications of migraines
- migraine with aura (classic migraine)
- migraine without aura (common migraine)
- many pts have both forms
32
aura can _______ the actual headache attack
precede, accompany or follow
33
what is the aura prevalence
male to female 1:2
34
what is an episodic migraine frequency
15 migraines per month
35
what is chronic migraine frequency
15 or more migraine days per month
36
describe a migraine without aura diagnostic criteria
- at least 5 attacks fulfilling criteria B-D
- headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
- headache has 2 or more of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity
- during headache 1 or more of the following: nausea/ vomitting and/or photophobia/phonophobia
37
what are the migraine attack phases and describe each
- prodrome: occurs hours to days before the headache
- aura: immediately precedes or accompanies the headache
- headache
- headache resolution: may take days
38
describe prodrom
- change in mood or behavior- depressed, hyperactive, euphoric, talkative, drowsy, restless, irritable
- neurological: sensitivity to light and noise; difficulty concentrating; yawning, hypersomnia
- general: stiff neck, food cravings, cold feeling, anorexia, sluggish, thirstry
39
approximately ____ of migraine attacks are with aura
30%
40
the aura consists of gradually spreading neurological symtpoms that usually precede the headache by:
5-60 minutes
41
what are the most common symptoms of aura
visual disturbances such as flashing lights or a zigzag pattern (fortification spectra)
42
what are the sensory auras- parasthesias
- parasthesias
- the second most common aura
- numbness in the hand which migrates up the arm and then involves the face, lips, tongue
- may involve the leg
- may incude loss os position sense
- may be bilateral
- rarely occur in isolation; usually follow a visual aura
43
what do sensory auras present as
- motor symptoms - weakness or atonia - 18% prevalence
- hyperkinetic movement disorders- chorea
- speech abnormalities (aphasia- absence of language of dysarthria- poorly articulate speech) - 17-20% prevalence
44
describe a migraine with typical aura
- at least 2 attacks fulfilling criteria B and C
- aura of visual, sensory and/or speech/language symptoms, each fully reversible, but no motor, brainstem, or retinal symtpoms
- 2 or more of the following 4 characteristics: 1 or more aura symptom spreads gradually over 5 minutes and/or more than 2 symptoms occur in succession
- each symptom lasts 5-60 minutes
- 1 or more aura symptom is unilateral
- aura accompanies or followed by headache in less than 60 mins
45
describe typical aura without headahce
- fulfulls criteria 1.2.1 migraine with typical aura
- no headache accompanies or follows the aura within 60 mins
46
describe the headache phase
- location: may be bilateral (40%) or start on one side and become generalized
- pain: intensity varies, however average rating is 5/10
- anorexia is common although food cravings may occur
- nausea (90%), vomitting (33%)
- phot/phonophobia cause patient to seek a dark, quiet room
- exercise will usually worsen migraine
47
what are the systemic symptoms of headache phase
- blurry vision
- nasal stuffiness
- anorexia
- hunger
- diarrhea
- abdominal cramps
- polyuria
- pallor
- sensations of hot/cold
- sweating
- scalp tenderness
48
headache phase affective alterations include:
- impairment of concentration (common)
- impairment of memory (less common)
- depression
- fatigue
- anxiety
- nervousness
- irritability
49
describe the resolution phase
- pain diminishes
- fatigue, irritability, listlessness, impairment of concentration or mood change may occur
- some migraine sufferers report euphoria following an attach while others report depression and malaise
50
what are the aggravating or precipitating factors for headache
- menstruation or pregnancy due to estrogen level changes
- stress
- smoking
- relaxation after stress
- fatigue
- inadequate or excessive sleep
- missing a meal
- weather change
- high altitude
- sunlight/glare
- perfumes or chemical fumes
- physical activity
- coughing
- exposure to flickering lights
- loud noise
51
what are the food triggers for migraines-
- chocolate
- caffeine
- cheeses (aged cheddar)
- alcohol (especially red wine)
- foods containing MSG, nitrates and aspartate
- citrus fruits
52
ask pt about for past headache hx:
- previous meds prescribed
- non pharmacological therapies
- current meds
- withdrawal and rebound headache- produced by excessive use of NSAIDs, babrituates, triptans, narcotics and ergots- limit usage to 2days/week
53
what social hx needs to be taken
- identify source of stress
- recent major life changes
- job satisfcation
- exposure to drugs/toxins in workplace
- habit history (alcohol, tobacco, caffeine)
- sleep habits (keep bedtime and awakening time the same each day. depression, anxiety, sleep apnea produces morning headaches
54
what are the migraine maangement categories
- psychotherapy
- non pharmocologic methods
- pharmocologic methods: abort migraine, prevent migraine
55
what are the non pharmacologic methods (behavioral modifications) that are likely to help
- regular sleep
- regular exercise
- regular meals
- avoid chocolate
- avoid tyramine/MSG
- limit caffeine
- eliminate alcohol
- biofeedback/stress managment
56
what are the non pharmacologic methods to manage migraines-
- encourage good sleep
- stress management: decreases autonomic nervous system responsiveness
- psychotherapy
- neurostimulators for migraine and cluster headache treatment
- migraine treatment with occipital and TN neurostimulation
- nervio
57
migraine attacks frequently begin in the ____ house of sleep when sleep has been lengthened
last
58
what are the forms of psychotherapy
- relaxation training
- biofeedback
- hypnosis
- cognitive behavior therapy
59
what is the goal of migraine treatment with occipital and TN neurostimulation
to evaluate the efficacy and safety of concurrent non invasive stimulation of occipital and trigeminal nerve treatment of migraine with and without aura
60
what is nervio
a neurostimulator is a cuff worn on the upper arm that delivers electrical pulses to nerves, aiming to trigger a natural pain response in the brain to help treat migraine pain, both acutely and preventatively *
61
what is the transcutaneous supraorbital neurostimulator
- uses electrodes for stimulation
- pt places electrodes on their forehead and connects the device to the electrodes and turn it on
- stimulatees the supraorbital nerves which transmit that signal to the brain
62
what does the single pulse transcranial magnetic stimulator do
stimulates using a magnet rather than electrical pulses
63
describe the onabotulinum toxin type A treatment
- potent neurotoxin
- weakens painful muscles
- inhibits muscle contractoins
- FDA treatment option for chronic migraines
- interrupts pain cycle and may alter NT secretory function in both afferent and efferent motor nerves
- therapeutic injections have an average duration of 12 weeks before re injection is neeeded*
64
onabotulinum A toxin is used for:
chronic migraine headache not responsive to medications
65
onabotulinum A toxin is injected in____ sites
32
66
onabotulinum A toxin is repeated every:
3 months
67
research has demonstrated effectiveness of onabotulinum A toxin treatment of:
headaches and muscle pain
68
what are the advantages of onabotulinum A toxin
no drug interactions and no systemic side effects
69
what are the potential side effects of onabotulinum A toxin
risk of weakness at injection site
70
