Neuro - HA's Flashcards
what are the 3 primary HA syndromes?
Migraine, tension-type HA, Cluster HA
what 5 characteristics should you ask your patient about their headache?
(1) quality
(2) intensity
(3) location
(4) mode of onset
(5) relationship to biologic events
what is the MOST IMPORTANT info to obtain about the quality of the pts HA?
if the HA is pulsatile (characteristic of a migraine)
migraine is usually what type of quality?
pulsating, throbbing, lateral
what is the quality of tension HAs?
tightness and pressure, band-like
what is the quality of Neuritis?
sharp, lancinating
what is the quality of cluster HA’s?
ice pick
what is the quality of intracranial lesion?
dull or steady
what is the quality of ophthalmologic d/o?
peri-ocular pain
descriptors of intensity of a HA?
Degree to which the pain has incapacitated the patient
Awake from sleep
- Meningitis, Subarachnoid hemorrhage
- Cluster headache
what is the location of migraine HAs?
unilateral
inflammation of an extra cranial artery in HA causes pain to localize where?
to the site of the vessel
intracranial lesions in the posterior fossa cause pain where?
in the occipitonuchal region and usually are lateral if the lesion is one-sided
supratentorial lesions induce pain where?
frontotemporal pain or approximate the site of the lesion
subarachnoid HaA vs meningeal HA in terms of onset?
subarachnoid bleed HA -> abrupt
meningeal HA -> gradual
what is “ice-cream” HA caused by?
pharyngeal cooling (cold constricts the blood vessels going to the head)
what HA’s are worse with wakening?
sleep apnea HA’s or intracranial mass
HA that is same time each day or night describes what type of HA?
cluster HA
when are tension HA’s the worse during the day?
at the end of the day
migraine, cluster HA and intracranial tumor onset is how long?
mins to hours
meningitis and tension HAs onset is how long?
hours to days
what are catamenial migraines?
migraines that occur in the premenstrual period
when are HA’s that originate in cervical spine disease are intense after what?
period of inactivity, such as a night’s sleep, and the first movements of the neck are stiff and painful
sinus HA’s have what regularity? worsened when?
clock-like regularity - upon awakening or in midmorning
worsened by stooping and changes in atmospheric pressure
if a HA is made worse by sudden movement or coughing or straining, what is the source?
intracranial source
when do migraines usually occur after?
after a period of intense activity and stress (“weekend” migraine)
what are tension HAs?
tension or spasm w/in the pain-sensitive muscles of the neck or temples
-strained muscle in the head
what is the M/C type of primary HA d/o?
tension HAs
what sx’s do you NOT have with tension HAs that you do with migraines?
photophobia, phonophobia, N/V
tension HAs worsen with?
stress, noise, and glare
typical-sounding tension HAs in pt >60-65 y/o could be what?
giant cell arteritis (have elevated ESR rate, visual changes, jaw claudication)
for dx of tension HAs must have how many in previously?
10
must have tension HAs lasting how long?
30min - 7 days
tension HAs must have 2 of the following characteristics…
(1) Pressing or tightening (nonpulsating) quality
(2) Mild to moderate intensity (nonprohibitive)
(3) Bilateral location
(4) No aggravation from walking stairs or similar routine activities
tension HAs must have both of the following…
(1) No nausea or vomiting
(2) Photophobia and phonophobia absent, or only one is present
what’s the difference b/w chronic tension HA vs regular tension HA?
chronic tension HA is at least 15 days per month for at least 6 months
tension HAs must be less than ___ per year or ___ per month
less than 180 per year or 15 per month
tension HA tx?
NSAIDs, APAP
treat comorbid anxiety or depression
behavioral therapy, relaxation training (dark room, relax)
massage
pts with migraines should keep a ___
diary to tease out what their triggers are
pts with migraines usually describe ___ before the migraine occurs
an aura
what’s the aura like before a migraine?
aura affects vision, or could also have numbness or tingly in their hand
what’s the most important question to ask when considering migraine in a pt?
if they’ve ever had a HA like this before
serious migraines can have what sx’s?
mimics such as stroke or transient ischemic attacks usually present with loss of function (weakness, lack of sensation, impaired vision, and language dysfunction)
migraine WITHOUT aura dx criteria
At least 5 attacks fulfilling following criteria:
- Headache attacks lasting 4–72 hours (untreated or unsuccessfully treated)
- Headache has at least two of the following characteristics:
a) Unilateral location
b) Pulsating quality
c) Moderate or severe intensity (inhibiting or prohibits daily activities)
d) Aggravation by walking stairs or similar routine physical activity - During headache at least one of the following:
a) Nausea and/or vomiting
b) Photophobia and phonophobia
No evidence of contributing underlying disorder
migraine WITH aura dx criteria?
At least 2 attacks fulfilling the following:
- At least three of the following four characteristics:
(a) One or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain stem dysfunction
(b) At least one aura symptom developing gradually over more than 4 minutes or two or more symptoms in succession
(c) No aura symptom lasting more than 60 minutes. If more than one aura symptom is present, accepted duration is proportionately increased
(d) Headache following aura with a free interval of less than 60 minutes. It may also begin before or simultaneously with the aura.
No evidence of contributing underlying disorder
migraines have a relation to neuronal dysfunction in what nerve? what occurs?
in trigeminal nerve, release vasoactive substances leading to inflammation, sensitivities and headaches
what is a basilar artery migraine?
blindness or vision changes occurs bilaterally and followed by pareasthesias, disequilibrium, confusional states and occipital migraine
what is an ophthalmoplegic migraine?
lateralized pain in the eye, accompanied by nausea, vomiting, diplopia due to transient external ophthalmoplegia.
Should refer to an ophthalmologist
avoid ___ factors in migraines tx
avoid precipitating factors
tx of acute migraine attacks
Rest in a dark quiet room
Simple analgesic -> Advil and Tylenol
what are ergotamines? avoid when?
tx for migraines
Cafergot – combination of Ergotamine tartrate (1mg) and Caffeine (100mg)
Avoid in pregnancy, CV disease, and if on CYP3A4 inhibitors
what anti-nausea med is good for migraine tx?
Prochlorperazine (Compazine)
which analgesics for migraine tx are habit forming and cause rebound HAs?
Butalbital Containing Analgesics
these are like being on speed
what is Sumatriptan used to treat and what is it? greater benefit when given with what other med? cause what sx’s?
it’s a Triptan and it’s used to treat migraines
-high affinity for 5-HT1 receptors and can quickly abort a migraine
greater benefit when given with Naproxen
cause N/V
when do you avoid Sumatriptan?
Avoid in pregnant women
Avoid in hemiplegic or basilar artery migraine
Uncontrolled HTN, risk factors for strokes
Sumatriptan is C/I in who?
C/I in pts with coronary or peripheral vascular disease
when is preventative therapy indicated for migraines? what meds are used for the ppx?
if migraines occur >2-3x month
use any of the triptans
Botox tx for what HA?
migraine HA
acupuncture is as effective as what drug tx for migraines?
ppx drug tx
what are cluster HAs?
Cluster headaches abruptly reach maximum intensity on one side of the head, last 1 to 2 hours, and have associated ipsilateral autonomic signs such as tearing, miosis, ptosis, or rhinorrhea
comes very acutely
when do you get cluster HAs in the day? for how long and then what?
get one attack daily at same hour -> for about 8-10 weeks/year then be pain free for about 1 year
what’s the pain like in cluster HAs?
- deep
- usually retro-orbital
- often excruciating in intensity
- nonfluctuating
- explosive in quality
what is a core feature of cluster HAs?
periodicity
patients with cluster HAs should NOT have what sx’s?
focal neurologic signs or symptoms
what is the dx criteria for cluster HAs?
At least five attacks fulfilling the following
-Severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes untreated
- Headache associated with at least 1 of the following signs, which must be present on the pain side:
(1) Conjunctival lacrimation
(2) Lacrimation
(3) Nasal congestion
(4) Rhinorrhea
(5) Forehead and facial sweating
(6) Miosis
(7) Ptosis
(8) Eyelid edema
-Frequency of attacks from one every other day to eight per day
No evidence of contributing underlying disorder
tx of individual cluster HA with what oral agents are often what?
ineffective
what are some non-oral meds for individual cluster HA tx?
- SC or intranasal sumatriptans effective
- 100% O2, 12-15 L/min for 15 minutes via non-rebreather
- Zolmitriptan nasal spray -> better effects on cluster HAs
- Dihydroergotamine IM or IV
- Viscous Lidocaine 1mg 4-6% solution Intranasally -> on the side of the HA
ppx agents for cluster HAs?
Lithium Carbonate
Verapamil - check ECG PR interval
Topiramate
when does a post-traumatic HA occur? when does it get worse?
1 day to week after injury and may worsen in ensuing weeks
anyone with a new HA that wakes them up at night or is bad enough to bring them into, needs what?
CT w/out contrast to look for intracranial mass lesions/bleeds!!!
what is the HA like post LP?
dull throbbing HA
why can post LP HA occur?
HA can happen because of slow leak afterwards, or because the procedure dehydrated the meninges
Pt needs to LAY FLAT for an hour
what sx’s w/HA should pt be referred for urgent evaluation?
- Thunderclap onset
- Increasing HA unresponsive to simple measures
- History of trauma, HTN, fever, visual changes
- Presence of neurologic signs and scalp tenderness
what is pseudotumor cerebri?
Idiopathic intracranial hypertension is a syndrome characterized by:
- papilledema
- incr ICP (with normal CSF) >250mmH2O
- nonspecific brain imaging study demonstrating normal or small-sized ventricles
what people are most commonly affected by pseudotumor cerebri?
obese women (one tx is to lose weight)
what’s the presenting sx of pseudotumor cerebri?
diffuse HA
Complaints of diplopia and blurred vision or transient visual obscuration occur in more than 60% of cases
when is dx of pseudotumor cerebri?
- the patient has symptoms of increased intracranial pressures
- no localizing symptoms
- a nonspecific or normal imaging study
- CSF pressures are elevated >250 mmH2O with otherwise normal CSF findings
pseudotumor cerebri is critico to differentiate from what?
space-occupying intracerebral mass lesions by CT scan
tx’s for pseudotumor cerebri?
- repetitive lumbar punctures
- carbonic anhydrate inhibitors (acetazolamide)
- thiazide diuretics
- corticosteroids for visual complaints
what are some surgical maneuvers for pseudotumor cerebri tx?
- lumbar-peritoneal shunting
- optic nerve sheath decompression, may be required
who does post-herpetic neuralgia develop in?
pts who have herpes zoster (shingles)
when does post-herpetic neuralgia seem to occur in elderly or immunocompromised persons with herpes zoster (shingles)?
when the rash is severe, and when the first division of the trigeminal nerve is affected
what aids in dx of post-herpetic neuralgia?
hx of shingles and presence of cutaneous scarring resulting from shingles
what correlates with the intensity of post-herpetic neuralgia?
severe pain with shingles
what is post-herpetic neuralgia characterized by?
constant, severe, stabbing or burning, dysesthetic pain
what division of the trigeminal nerve is most commonly affected in post-herpetic neuralgia? where is pain localized?
the first division (V1) - ophthalmic division
so pain is localized to the forehead on one side
how can you test for decreased cutaneous sensitivity to the painful area in post-herpetic neuralgia?
with a pinprick
what is the major complication of herpes zoster in the trigeminal nerve?
decreased corneal sensation with impaired blink reflex, which can lead to corneal abrasion, scarring, and ultimately loss of vision
“cotton whisp test”
tx for post-herpetic neuralgia
Anticonvulsants (Carbamazepine, Oxcarbazepine, Gabapentin)
Antispasmodic Agents (alone or in conjunction with anticonvulsants)
Botox Injections
Surgery (Microvascular decompression)
Brain Stereotactic radiosurgery (use a focused dose of radiation on the trigeminal nerve)
Glycerol injection (damages ganglion to nerve)
Balloon compression (compresses the nerve)
