Module 13 - Headaches

Question 1

Red Flags*

Answer 1

SSNOOP
1. systemic symptoms (fever, lb loss)
2. Secondary headache risk factors (HIV, cancer)
3. Neurologic symptoms (confusion)
4. Onset (sudden, abrupt, split second)
5. Older (age >50 for new onset headache, should be worked up with GCA)
6. previous headache progression: 1st headache is different
(change in attack frequency, severity, clinical features)

Question 2

Duration of Headaches *

Answer 2

• Sudden onset: SAH or meningitis
• Gradual chronic: migraine, tension, cluster
• Recently developed over several days, weeks, months
• new onset migraine or tension type
• increased ICP
• temporal arteritis

Question 3

Sinus

Answer 3

Pain behind forehead or cheek bones

Question 4

Cluster

Answer 4

Pain is in and around one eye
more common in men
excruciating and explosive

Treatment: SQ sumatriptan and O2

Question 5

Tension

Answer 5

Band squeezing in temporal areas bilaterally
usually go away with rest or diversionary activities

Question 6

Migraine
Migraine with aura

Answer 6

Migraine: associated with two of the following pain characteristics:
-unilateral location
-pulsating quality
-moderate or severe intensity that either inhibits or prohibits daily activities, and aggravation by performing routine physical activity.

During an attack, at least one of the following symptoms is present:
-nausea or vomiting
-photophobia
-phonophobia

Aura: d/c BCP

Question 7

Diagnostics Tests*

Answer 7

• CT Head w/o: trauma, hemorrhage
• MRI ww/o of brain: infection inflammation, neoplasm
• Lumbar puncture: SAH, Meningitis, H/A
• CBC, ESR: Arteritis
• MRI w/o brain: brain screen, stroke, TIA, dementia

PE:
Kernigs + Brudzinski = Meningitis

Question 8

Pharmacologic Treatment *

Answer 8

Abortive
- early admin
- simple analgesics mild - mod attacks (ww/o caffeine)

TRIPTANS:
- Preferred 1st line for mod-sev !!!!!!!!!
- Take no more than 2 doses in 24hours
- or 2-3 doses per week
- or 10 days per mo
^ to prevent overuse headache
* combos with naproxen has good efficacy

Ergotamine, combos with caffeine, DHE
- first line for pts who cant use triptan
- have unfavorable side effects
- contraindicated taking CYPs
- may cause vasoconstriction

AVOID
narcotics, barbs, caffeine, benzos
=====================================
sumatriptan subcutaneously and ergotamine sublingually. Since she has not yet tried a triptan, it is the first choice. Ergotamine is for patients who cannot take a triptan

Question 9

Triptans **

Answer 9

AGENT OF CHOICE FOR MOD-SEV ATTACKS
S/E: fatigue, flushing, chest/throat/jaw tightness, pressure, heaviness or pain, paresthesia’s, dizziness, drowsiness
- use with caution in CAD, including men over 40yo and postmenopausal women
- cardiac eval rec’d for these patients

Take at onset of HA (but not with aura) and repeat after 2 hours if HA does not fully resolve

Question 10

Preventative Drugs *

Answer 10

• BB: propranolol, timolol, metoprolol
• TCA: amitriptyline (tension)
• Anti-epileptic: topiramate, divalproex, valproic acid
• Others:

Question 11

Diagnostics Tests and Treatment *

Answer 11

Acute Treatment
- NSAID or tylenol
- Combo analgesics containing caffeine
- avoid narcs and barbs

Preventative Treatment
- TCA
- Behavioral Treatment

Question 12

Diagnostics
Family history of brain tumor and migraines

Answer 12

CT head with and without

Question 13

Chronic migraines

Answer 13

15 a month