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