Module 5.0 - Headaches Flashcards
1
Q
What are headaches?
A
Subjective sensation of pain involving any part of the head- scalp, face, sinuses, or cranium, with or without associated symptoms.
2
Q
What are the two categories of headaches?
A
Primary headaches - 3 types
a. Cluster
b. Migraine
c. Tension
Secondary headaches- 3 types
a. Acute new onset
b. Intermittent discrete
c. Chronic persistent
3
Q
What causes headaches?
A
- Caused by vasodilation/constriction of blood vessels due to cortical spreading
- They most commonly are benign
4
Q
What type of headaches are common in women? What type are common in men?
A
- Migraine headaches have a 3:1 female to male ratio
- Cluster headaches occur predominantly in men > 65 years of age
5
Q
What questions should be asked when taking a history of a patient with head pain?
A
- Prodromal symptoms (preceding symptoms)
- Time of peak and severity of symptoms
- Duration of symptoms
- Precipitating factors
- Associated symptoms
- Alleviating symptoms
- Review factors that predisposes patients to QT interval prolongation:
- History of unexplained syncopal episodes
- Structural heart disease
- Renal or liver disease-related altered drug clearanc
- History of cardioactive medications.
8. History of prior headaches
- Consistent headache history or different symptoms
- Family history of headaches or sudden death of family members
- Correlation or relationship of headaches to particular events/activities
6
Q
What are Red Flags when assessing patients with headaches?
A
- Acute onset, severe in nature, ‘worst headache of my life’; no previous history of headaches
- Possible Subarachnoid hemorrhage
- Constant, unrelenting headache not relieved with OTC meds
-
New onset headache after age 50; no previous history of headaches
- Increased risk of a serious cause (i.e. tumor, giant cell arteritis)
- ‘Ice pick’ headache
- Severe headache associated with meningeal signs- stiff neck (nuchal rigidity) and/or fever
- Possible: Meningitis, subarachnoid hemorrhage, subdural empyema
- Headache associated with mental status changes
- Possible: Encephalitis, subdural hematoma, subarachnoid hemorrhage, intracerebral hemorrhage, tumor, mass, increased ICP
- Persistent headache after trauma to head/neck
- Different presentation of headache from previous history of chronic headaches
- Headache most severe upon rising in am and with coughing, but improves later in day- indicative of increased intracranial pressure (ICP)
- Red eye and halos around lights
- Acute closed angle glaucoma
7
Q
What are some diagnostic tests used when diagnosing headaches?
A
- MRI – with or without contrast is the imaging procedure of choice for diagnosis of occult or organic disorders; in the case of renal disease withhold IV contrast.
- CT scan – screening tool for emergent detection of expanding mass lesions- (i.e. subdural and epidural hematomas, hemorrhagic stroke and large mass lesions) - less sensitive than MRI
- CT Angiography (CTA) or MR Angiography (MRA) – useful for imaging arteries and veins; must be administered with IV contrast
- Plain skull x-rays – identifies bony abnormalities (i.e. skull fractures or lesions); cannot identify intracranial abnormalities
- Lumbar puncture – invasive test; useful if CT or MRI is non-diagnostic
8
Q
What laboratory tests are useful when diagnosing headaches?
A
Consider CBC, erythrocyte sedimentation rate (ESR), basic metabolic profile to rule out infectious cause, anemia; Consider thyroid studies
9
Q
What are the 5 diagnostic criteria for migraine headaches without auras?
A
- Duration 4-72 hours.
- Must have at least 2 (two) of the following:
a. Unilateral location
b. Pulsating or throbbing quality
c. Moderate to severe intensity
d. Aggravated by routine physical activity
e. Interferes with activities of daily living - Must have at least 1 (one) of the following:
a. Nausea or vomiting
b. Photophobia, osmophobia, and/or phonophobia - At least 5 (five) attacks that fulfill the preceding criteria in 1, 2 and 3
- No evidence of organic disease.
10
Q
What is the diagnostic criteria for migraine headaches with auras?
A
- Pain is preceded by at least one of the following neurologic symptoms, which gradually develops over 5-60 minutes (auras may be visual, motor, sensory or verbal disturbances):
- Visual: (combination of field defects and luminous visual hallucinations) – most common
- Scintillating scotoma (visual migraine) - most common
- Fortification spectra – pattern resembling walls of a medieval fort)
- Unformed light flashes (photopsia)
- Hemianopsia (decreased vision or blindness in half the visual field)
- Geometric visual patterns
- Occasional hallucinations
- Somatosensory disturbance of face/arms
- Paresthesia
- Numbness
- Clumsiness
- Weakness in a circumscribed area
- Speech disturbances
- No evidence of organic disease
11
Q
What is the diagnostic criteria for tension headaches?
A
1. At least two (2) of the following:
- Vise-like or tightening and nonpulsatile pressure quality
- Bilateral mild to moderate pain- generalized
- Pericranial tenderness at back of head or neck
- Not aggravated by routine physical activity.
- Not associated with focal neurologic symptoms
2. Both of the following:
- No nausea or vomiting
- Photophobia and phonophobia absent or only one (1)
3. No evidence of organic disease
12
Q
What is the diagnostic criteria for cluster headaches?
A
- Severe, unilateral, periorbital, supraorbital, or temporal pain lasting 15-180 minutes
- At least one of the following on the headache side:
- Reddened conjunctive
- Facial sweating
- Lacrimation
- Miosis (constriction of the pupil)
- Ipsilateral nasal congestion
- Rhinorrhea
- Horner syndrome (ptosis of eyelid, miosis and anhidrosis)
- Bouts last 4-8 weeks and may occur severe times during the year
13
Q
What are the pharmacologic and non pharmacologic treatment options for tension headaches?
A
- Pharmacological: Acetaminophen, Aspirin, NSAID’s or Ketorolac IM
- Non-pharmacological: Heat, ice, massage of neck/temples, rest, regular sleep, f/u 2 weeks, consult with MD if conservative treatment fails.
- Prevention: 1st line treatment: nortriptyline (Elavil) daily at bedtime
14
Q
What are 5 pharmacologic treatment options for migraine headaches?
A
For acute attacks:
- A simple analgesic, such as aspirin, acetaminophen, ibuprofen or naproxen taken immediately may abort the headache
- Butorphanol tartrate nasal spray (Stadol NS) 1 mg (1 spray) in one nostril, repeat 2nd dose in 60 minutes.
- Cafergot combination (ergotamine maleate) - Contains (1mg + caffeine 100mg), 1-2 tablets at onset, may repeat 1 tab q 30 minutes up to 6 tabs (comes in suppository, inhaler and sublingual forms- refer to individual type dosage instructions)
- Dihydroergotamine mesylate (DHE 45), 0.5-1 mg IV, or 1-2mg SC/IM; repeat every hour prn to maximum of 3 mg. (comes in nasal spray form-see dosage instructions); NOTE *Serious life-threatening peripheral ischemia on black box warning
- Triptans include: sumatriptan, zolmitriptan, naratriptan, risatriptan, almotriptan, eletriptan and frovatriptan
15
Q
What are 2 common triptans prescribed?
A
- Sumatriptan (Imitrex), 6 mg, SQ to rapidly abort headache, may repeat once in 2 hours; max 12mg/24 hours (comes in oral and transdermal form- refer to dosing recommendations for each)
- Zolmitriptan (Zomig), 1.25-5mg po; may repeat after 2 hours, max 10mg/24hours (comes in nasal form- refer to dosing recommendations)
21
Q
What causes Subarachnoid Hemorrhage (SAH)?
A
- Cerebral aneurysm rupture
- Cerebral arteriovenous malformation
- Bleeding from a tangle of blood vessels called an arteriovenous malformation (AVM)
- Bleeding disorder
- Bleeding from a cerebral aneurysm
- Head injury
- Unknown cause (idiopathic)
- Use of blood thinners
22
Q
What are the signs and symptoms associated with subarachnoid hemorrhage?
A
- ‘Worst headache of my life’ with sudden onset, no precipitating factors, no relief with OTC pain meds
- Altered consciousness
- Mental status changes, confusion and irritability
- Nuchal rigidity
- Nausea and vomiting (due to increased ICP)
- Photophobia
- Seizures
- Cranial nerve deficits
- Motor or sensory deficits
23
Q
How is a Subarachnoid Hemorrhage (SAH) diagnosed?
A
- Obtain a noncontrast CT head ( high sensitivity within 6 hours of onset of symptoms)
- If CT head negative, but clinical evidence of SAH exists, then obtain lumbar puncture (RBCs 100-10,000 in final tube generally correlates with a diagnosis of SAH )
- Consider CT angiography (CTA) if noncontrast CT head negative and an LP is unable to be performed (overweight patient, uncooperative or history of lumbar spine surgery). Sensitivity 100% if performed within 6 hours of onset of symptoms
