Neuro- HA, facial pain Flashcards
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)
what are the new drugs out there for HA/facial pain?
CGRP drugs- calcitonin G-peptide
PE or history more important for HA/facial pain?
history!
if the HA effects activities of daily living, we are thinking it is…?
migraine
young w/ new HA =?
old (>40yo) w/ new HA=?
young- migraine
older- red flag!
what patterns do you want to ask about for HA?
varying during the day, menses, stress related, clusters
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?
what percentage of people who present to ER with HA are life-threatening?
1%
all types of HA may get better with ___ therapy but it doesnt mean that the HA was a _____
migraine therapy, migraine
HA- look for causes that need immediate treatment like…
CO poisoning (heating the house, others have the HA) preeclampsia intracranial mass infection vascular
two pts that NEED imaging even if physical is normal
- thundercalp HA, sudden onset - subarachnoid hemorrhage?
- HIV or elderly (esp w/ new HA) - infection?
temperature elevated with HA? think…
high BP with HA? think…
>50yo tender scalp w/ HA? think…
meningitis
HTN, preeclampsia, pheochromocytoma
temporal arteritis
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
HA and abnormality with visual or neuro test.. follow with?
imaging
who will you image scan urgently?
- first and worst HA
- abnormal neuro
- abnormal mental status
- abnormal fundoscopy- papilledema
- meningeal signs
- new HA - 50yo+
- HIV
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)
patterns of HA:
migraine, tension, cluster, brain tumor
migraine: sporatic pattern
tension: constant, consistent, low level
cluster: clustered groups
tumor: progressively worsening
triggers- anything that causes pain above the neck can cause a ___
migraine
HA that start in the the back and improves with physical manipulation
tension HA
neurokinin
pro-inflammatory relative of bradykinin that causes pain
anything that causes ____ can cause a HA
vasodilation
“periodic, debilitating HA assosciated w/ N/V” is often what?
migraine
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
