Neuro- HA, facial pain Flashcards by Jacqui Joseph

what is common and what is scary? 3 of each

common: tension HA, migraine, chronic daily HA (rebound)

scary; inc. ICP (bleeds), pregressive HA (tumor), temporal arteritis (syst. vascular inflamm- threatens eyesight)

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what are the new drugs out there for HA/facial pain?

CGRP drugs- calcitonin G-peptide

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PE or history more important for HA/facial pain?

history!

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if the HA effects activities of daily living, we are thinking it is…?

migraine

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young w/ new HA =?

old (>40yo) w/ new HA=?

young- migraine

older- red flag!

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what patterns do you want to ask about for HA?

varying during the day, menses, stress related, clusters

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10 red flags for HA

progressive HA- tumor?
“Worst of my life” - bleed or inc ICP of other cause
changes in intensity, freq, etc
new HA in older person, new severe HA in adult
meningeal signs
temporal arteritis
HA that disturbs sleep or in morning (pink flag)
cough-induced
w/ focal neuro S&S affecting one side or one part of body
post-lumbar HA-leak?

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what percentage of people who present to ER with HA are life-threatening?

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all types of HA may get better with ___ therapy but it doesnt mean that the HA was a _____

migraine therapy, migraine

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HA- look for causes that need immediate treatment like…

CO poisoning (heating the house, others have the HA) 
preeclampsia
intracranial mass
infection
vascular

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two pts that NEED imaging even if physical is normal

thundercalp HA, sudden onset - subarachnoid hemorrhage?

- HIV or elderly (esp w/ new HA) - infection?

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temperature elevated with HA? think…
high BP with HA? think…
>50yo tender scalp w/ HA? think…

meningitis
HTN, preeclampsia, pheochromocytoma
temporal arteritis

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what two tests will you do for possible meningitis?

kernig’s - flex hip- extend knees and pain

brudzinski’s- flex neck, hand on chest, knee and hip flexion are a positive sign

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HA and abnormality with visual or neuro test.. follow with?

imaging

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who will you image scan urgently?

first and worst HA
abnormal neuro
abnormal mental status
abnormal fundoscopy- papilledema
meningeal signs
new HA - 50yo+
HIV

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CT vs MRI scan

CT for acute eval of “worst HA ever” (fresh bleed, w/in 24 hrs)
MRI- scan of choice for all others (MRA- (angiography) for select cases)

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patterns of HA:

migraine, tension, cluster, brain tumor

migraine: sporatic pattern
tension: constant, consistent, low level
cluster: clustered groups
tumor: progressively worsening

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triggers- anything that causes pain above the neck can cause a ___

migraine

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HA that start in the the back and improves with physical manipulation

tension HA

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neurokinin

pro-inflammatory relative of bradykinin that causes pain

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anything that causes ____ can cause a HA

vasodilation

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“periodic, debilitating HA assosciated w/ N/V” is often what?

migraine

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migraines have ____, often to multiple stimuli and in multiple systems like _____

hypersensitivities , GI/IBS

old migraine theory vs new migraine theory

old: vasoconstriction followed by reactive vasodilation
new: still partly vascular but brain is involved
- ->trigeminal hypersens, innervation of cranial vessels and dura w/ inflamm changes

migraine w/out aura: IHS criteria

HA 4-72 hours w/ 2-4 of ...unilateral pain, throbbing, moderatoe --> severe, worse w/ routine activity and 1 of ...N/V, photophobia/phonophobia -w/ 5 previous attacks

migraine w/ aura: IHS criteria

HA after aura, aura has 3 of the following.... - 1+ reversible symptoms indicating dysfunction - develops gradually w/ more symptoms - no symp >60min - HA w/in 60 min

w/out aura vs w/ aura: percentages

with aka classic = 20% | without aka common = 80%

location of pain for migraines and timing

usually lateral but can be bilateral, build up slowly and last hours

what is an aura?

focal disturbances of neuro function- preceding or accompanying pain - visual: field deficits and flashing lights, often side opposite the pain - aphasia, numbness, tingle, clumbsy * generally resolves before or with pain

rarely get ____ and no migraine

aura

aura equals double risk for what?

stroke - but baseline risk is usually low

critical parts of PE for migraine

vitals, neuro, vision w/ fundoscope -most likely a normal exam

what migraine will you do labs for?

the first one

TXT for migraine HA

- NSAIDs (naproxen) > APAP (tylenol) - sleep - vasoconstrictors (ergots, caffeine) - Triptans (1st LINE! ) - antipsyc-related Rx

triptans for migraines

- expensive - sumatriptan: shortest onset but most ADRs (short 1/2 life = rebound HA) - injected IV/SC better than oral or nasal - work better if used in prodrome

how to take triptans

take as soon as you know its going to be a migraine - GOAL: headache is GONE not reduced - if HA not gone in 2 hrs, take another dose, repeat every 2 hours up to max daily dose

which triptan has the longest half life?

fovatriptan

when do you use prophylaxis for migraines?

if >4 in one month

what to use for prophylaxis for HA?

``` #1- amitriptyline @ 10mg (TCA)- it lowers BP (careful w/ older people) any anti-HTN (beta or ca+ blocks) -gabapentin, anti-convulsants -SSRIs -avoid triggers and excercise ```

new mab drugs for migraine - what do they target and how often do you take?

3 new ones, target either CGRP or its receptors - infusions every 3 months * b/c they are antibodies, you can develop an immune response to them and then it wont be effective

tension HA: how do they present, what are they caused by, what do you treat them with

- band-like from muscle tension w/ vasodilation secondary to inflamm mediators - worsen throughout the day txt: triptans for severe, prophylaxis, fix stress

chronic use of sinus medication may cause...

rebound HA

"scary" sinus HA

erosion of sinuses into CNS --> brain abscess | need immediate attention

cluster HA

men, unilateral, transient , severe-incapacitating - may pound on their head - not throbbing - ipsilateral nasal congestion, redness, tearing, horner's syndrome (ptosis- interruption of sympathetic tone)

cluster vs migraine: prevalence, gender, onset, location, duration, time of day, activity

prevalence: C- low, M-higher gender: C- males M-females onset: C- sudden M-gradual location: C- retro-orbital, M- uni or bilateral duration: C-short M-4-72 hours time of day: C- night M-any activity: C-pacing, pounding on head, M-bedrest

Txt for cluster HAs

usually ineffective - 100% O2 - triptans, ergots - Ca+ channel blockers (verapamil) - indomethacin

horner's syndrome is due to impaired...

sympathetic innervation to the eye and nearby skin glands

what is a transformed migraine?

chronic daily HA that started as a migraine, can originate as a tension HA -usually w/ daily HA drug use (from any drug used to treat HA including decongestants)

txt for transformed migraine

``` #1- stop daily meds #2- prophylaxis, may take a month -never will get complete reliefe ```

anticonvulsants for neuropathic pain- trigeminal neuralgia and chronic pain/diabetic neuropathy/postherpetic ?

tegretol (carbamazepine) for trigeminal neuralgia | low dose amitryptyline for chronic pain/DM/postherpetic

what drug is like amytriptyline but expensive?

neurontin (gabapentin)

what causes neuropathic pain?

excessive neural activity esp. on SNS pathways

what CN is affected by post-herpetic neuralgia?

CN V branch 1 (superior branch)

temporal arteritis

syst. vascular inflamm condition of an unknown cause - tenderness in arteries, esp temporal - hypercoag - can cause retinal occlusion and blindness - wont really see in anyone younger than 50yo

what may you see unliteral HA and jaw claudication with ? what is jaw claudication?

temporal arteritis | -dec arterial flow to jaw muscles = ischemia

temporal arteritis management

oral prednisone w/ slow taper- monitor ESR/CRP (inc sed rate- erythrocyte and c-protein) - opthamology consult- urgent - temporal artery biopsy before steroids take effect