Module 6 Headaches Flashcards
What is the difference between Primary and Secondary Headaches?
Primary headaches are more common and are NOT a symptom of an underlying condition. Types: Tension, Migraine, Cluster
Secondary headaches are less common and a result of an underlying condition.
Discuss the pathophysiology of headaches
- Still debated
- Familial history of migraine
- Vascular and chemical changes in the brain
- Changes are in response to stimulus or trigger
Differential diagnosis of Headaches
•Primary headache
•Secondary headache
•Headache + neurological signs/symptoms,
systemic symptoms and history of acute onset
or age >50 with a new headache =
EMERGENCY
Red Flags of Headaches
–Systemic symptoms
•Fever, chills, weight loss, HIV infection, history of cancer
–Neurologic signs or symptoms
•Confusion, change in mental status, seizure, asymmetric reflexes
–Onset
•Acute, sudden or split second
–Older patient
•>= 50-years-old with new or progressive headache
–Previous headache history
•First headache or different (change in frequency, severity, features)
Diagnostics for Headaches
•Not very helpful
•Guidelines
–should be avoided if it will not change the
management
–Not indicated if the patient not more likely to have abnormality
–May make sense in an excessively concerned patient
•Imaging
Treatment of Headaches
- Depends on type of headache
- Nonpharmacologic
- Pharmacologic
- No cure only control
- Pregnancy
What is a Migraine Headache
•Lasts 4 hours to several days
•Associated with a trigger
•Migraine with or without aura
–Aura is typically visual. Can be jagged lines, spots, shimmering bright light or even a loss of vision in a particular area. Somatosensory aura is tingling or numbness of the fingers, motor disturbances and cognitive disorders.
–Aura typically occurs before the onset of the headache and can last 5-60 minutes.
What are triggers for Migraine Headaches
- Are different for everyone
- Medication overuse
- Certain foods – chocolate, cheese, alcohol
- Weather changes
- Altitude changes
- Skipping meals
- Hormonal changes
Subjective Data for Migraines
- Throbbing pain on one or both sides of the head
- Photophobia and/or phonophobia
- Nausea or vomiting
- Fatigue
- Difficulty concentrating or communicating
- History is the most important part of the evaluation of headaches.
- Duration, quality and location
Objective data for Migraine Headaches
•Necessary to rule out secondary headache •Typically normal with primary headache •Vital Signs •General appearance •Head & Neck –Fundoscopic & pupillary exam (eyes) –Auscultation carotids & vertebral arteries –Palpation of head, neck & temporal arteries –Evaluate for neck stiffness •Respiratory •Cardiac •Complete neurological exam –Include evaluation for focal weakness –Sensory loss –Gait •Mental status exam
Classification requirements for Migraine
•5 attacks lasting 4-72hr •At least 2 of these: –Unilateral –Pulsating –Moderate to severe –Aggravating physical activity •At least 1 of these: –Nausea and/or vomiting –Photophobia and phonophobia
Classification requirements for migraine with aura
•2 attacks with 3 of the following: –One or more reversible aura symptom –develops gradually over 4 minutes –No aura symptom lasts >60” –Migraine occurs within (or at start of) 60 minutes of aura •No other cause
Treatment of Migraines
- Abortive therapy
- Preventative therapy
- Antiemetics
- Over the counter
- Lifestyle changes
Abortive treatment for Migraines
•NSAIDS, Excedrin Migraine, Acetaminophen
•metoclopramide (Reglan) – helps potentiate absorption and effect. CAUTION in elderly!
•TRIPTANS – caution! Do not use in those with HTN or ASCVD. MOA-
cranial vasoconstriction. Serotonin receptor agonist (5-HT1B and 5-HT1D).
•ERGOT – not first line, cause nausea and potential for rebound headache
•CGRP Inhibitors (GEPANT) – new drugs you may have seen on commercials. Very
expensive and many insurances do not cover.
•Corticosteroids – refractory headache, recurrent headaches, severe headaches. May be given orally in single dose or short-taper dose
Preventative therapy for Migraines
- Unable to deal with headache
- More than 4 headaches per month
- Headaches are prolonged and refractory to medicine
Medications:
•Anticonvulsants – divalproex sodium (Depakote)
•Calcium channel blockers – diltiazem (Cardizem)
•Beta blockers – propranolol (Inderal)
•Tricyclic antidepressants – amitriptyline (Elavil)
•OnabotulinumtoxinA (Botox)
Education for Migraines
- Nonpharmacologic options
- Avoid triggers
- Medication side effects
- No cure but treatable
What is a Tension Headache
•Frequent and infrequent tension headaches
•Acute - nagging and occurs <15 days per
month occurring most of day.
•Chronic – similar to acute but occurs >15 days
per month
Subjective data for Tension Headache
- Bilateral
- Pressing or tightening feeling
- Mild to moderate intensity
- No nausea or vomiting
- Photophobia or phonophobia maybe present
- Activity does not worsen headache
- Trigger - Stress
Classification requirements for Tension Headache
•10 episodes on 1 or less days per month (<12days per year) •Last 30 minutes to 7 days 1. bilateral 2. pressing or tightening 3. mild or moderate intensity 4. not aggravating to activity •No n/v** AND..... •Only one – photophobia or phonophobia**
Treatment of Tension Headache
•Acetaminophen (Tylenol)
•Ibuprofen or NSAIDs
•May use a Triptan as abortive therapy with
caution. Can cause rebound headache if used
too much
•Antidepressants may be used for preventative
therapy
What is a Cluster Headache?
•Can be acute or chronic
•Usually awakened during sleep
•Reaches maximum intensity in approx. 15
minutes
•Lasts approximately 90 minutes
•Can occur several times a day
•Headache occurs in clusters for days or weeks
Subjective data for Cluster Headache
- Severe, unilateral pain
- Retro-orbital pain
- Agonizing
- Feelings of restlessness
Classification requirements for Cluster Headache
•5 attacks lasting 15-180 minutes
•Severe orbital pain
•Either or both of the following:
–at least one of the following symptoms or signs, ipsilateral to the headache:
1) conjunctival injection and/or lacrimation
2) nasal congestion and/or rhinorrhea
3) eyelid edema
4) forehead and facial sweating
5) miosis and/or ptosis
–a sense of restlessness or agitation
•Occurring with a frequency between one every other day and 8 per day
Treatment of Cluster Headache
Preventive -
•Verapamil
•Lithium
Abortive –
•Parenteral or nasal
•Oxygen – 10-15L/min using non-rebreather mask.
•Triptans – watch for overuse
Warning signs of Headaches
- Sudden vision changes or double vision
- Sudden numbness or weakness
- Changes in speech
- Cognitive changes
- Fever, weight loss
- Onset that is acute, sudden or split second
Referral for Headaches
- Primary care
* Neurology
What is Bells Palsy
Injusry to facial Nerve CN VII affecting motor, sensory, and parasympathetic functions. Affects tears, salivation, taste, and facial expression.
Subjective data of Bells Palsy
- Acute onset (sudden & severe), progressive usually 48-72-hours
- Paralysis may be preceded by pain behind ear
- c/o facial drooping, drooling, inability to smile, tearing
- Inability to close eye
- Dysguesia, hypoesthesia, postauricular pain, tinnitus, hyperacusis, and mild hearing deficit are also common.
Objective data for Bells Palsy
- Observe for smooth forehead, widened palpebral fissure, flattened nasolabial fold & asymmetric smile.
- Full physical exam, including neurological exam
- Evaluate all cranial nerves
- Include both motor & sensory of CN VII
Differential for Bells Palsy
- Central nervous System (Stroke, Tumor, Multiple sclerosis)
- Lyme disease
- Guillain-Barre’
Treatment of Bells Palsy
- Protection of the eye is the single most important goal. (Glasses during day, Tape at night, Lubricating eye drops q 2-hours / eye ointment at night)
- Massage of facial muscles
- Acupuncture
- Physical Therapy
- Corticosteroids within 72-hours of symptom onset (Increase probability of nerve recovery)
- Consult if pregnant
What is Dizziness?
A nonspecific term used by patients encompassing several disorders.
What is Vertigo?
A spinning sensation accompanied by nystagmus and ataxia
- Problems in labyrinths of inner ear, peripheral lesions of CNIII or
- Lesions of the central pathways or nuclei of the brain.
What is Disequilibrium?
unsteadiness or imbalance when walking
What is Presyncope?
a near faint / feeling faint / lightheaded
Differential for dizziness
Vertigo
Presyncope
Disequilibrium
Psych condition
What is Benign Paroxysmal Positional Vertigo/Benign Positional Vertigo?
- BPPV is the most common cause of vertigo.
* Intense and brief but false sense that you’re spinning or moving.
What symptoms are associated with BPPV?
- Nausea / vomiting
- Diaphoresis
- Disequilibrium
- Blurry vision
How are BPPV episodes triggered?
By a rapid change in head movement:
• Such as when you turn over in bed.
• Sit up or experience a blow to the head.
What exams should be included when assessing for BPPV?
- Otologic exam, including Rinne & Weber
- Neurologic exam: Cognitive, CN, Gait, Motor & Sensory, Balance & Romberg
- Cardiac
- Hallpike-Dix Maneuver
What is the Hallpike-Dix Maneuver
- Observe for spontaneous nystagmus
- Patient from seated to supine quickly, with head extended beyond table and head tilted 30 to 45 degrees to side, so ear points to floor.
- Repeat initial step to other side, then a third time to first side.
- Observe for nystagmus latency, duration, direction & fatiguability in both down and upright positions.
What are the hallmarks of a peripheral cause of BPPV?
- Nausea
- Normal neurologic exam
- Symptoms are position related
Differential for BPPV
Viral Infection
Meniere’s
Migraine
Treatment of BPPV
- BPPV may remit in a few days or weeks without treatment
- Canalith repositioning procedure is first line treatment
- No lying flat for 48-72-hours after
- Teach the Epley maneuver in case of recurrence
- Vestibular rehabilitation
Symptoms of a stroke
- Contralateral weakness of face, arm or leg or both
- Contralateral paresthesia of face, arm or leg or both
- Transient blindness (ipsilateral)
- Lack of self-awareness (of illness or deficit)
- Aphasia, alexia, anomia, agraphesthesia
What would we see during a physical exam of Stroke?
- Eye droop, motor or sensory deficits, speech disturbances
* + Carotid bruits
