Neuro: Headaches Flashcards
The headache and associated symptoms are the disorder itself
Primary headaches
Types of primary headaches
Migraine Tension Cluster Paroxysmal Hemicrania Chronic Daily HA
Types of secondary headaches
Infection Mass Hemorrhage Temporal Arteritis Glaucoma
What are the four phases of migraine headache?
Prodrome
Aura (+/-)
Headache
Postdrome
Two categories of migraines
WIth aura and without aura
Euphoria, depression, irritibaility, food cravings, constipation, neck stiffness, and increased yawning are examples of what?
Prodromal symptoms
What are the four types of aura?
Visual
Sensory (tingling, numbness)
Verbal
Motor disturbances (weakness to hemiparesis)
Common migraine triggers
Glare Sounds Hunger Stress Physical exertion Stormy weather Hormonal changes Lack of sleep Alcohol/chemical stimulation
MIgraine pathophysiology
Cortical spreading depression (wave of depolarization that spreads across the cerebral cortex)
Neurovascular system becomes hyperexcitable
Activation of trigeminal nerve terminal
What happens as a result of activation of trigeminal nerve terminal in migraine headache?
release of CGRP, seratonin, and inflammatory cytokines
also substance P, neurokinin A, glutamate, and prostaglandin
What stage should migraines ideally be treated in?
When pain is at first generation neurons in trigeminal nucleus caudalis
What happens if migraines are not treated adequately in first stage?
2nd and 3rd generation neurons are activated. Cutaneous allodynia results
Meds are less effective here
What is important in treatment of acute migraines?
Activation of serotonin receptors
Vasodilator associated with migraines
CGRP
Who should get imaging studies with migraines?
Most patients don’t need it.
Recommended in pts atypical features, sudden severe HA (r/o SAH)
First or worst headache
unexplained neuro symptoms
New onset after 50
not responding to tx
sx suggesting meningitis or encephalopathy
Meds taken within first 1-3 hours of onset of migraine
Rescue meds NSAIDS (Toradol, advil, naproxen, diclofenac) Triptans Ergots Antiemetics
How many migraines warrents the need for prophylactic meds?
> 4 migraines/month
What are examples of preventative migraine meds?
antiepileptic drugs
Beta blockers
Antidepressants
What combination of meds is often used at migraine onset?
NSAID and triptan
MOA of triptan
serotonin agonist. Inhibit the release of vasoactive peptides, promote vasoconstriction, and block pain pathways. Inhibit transmission in trigeminal neuclus caudalis
Available triptans
SUmatriptan, zolmitriptan, naratriptan, rizatriptan, almotripan, eletriptan, frovatriptan
Who should NOT take triptans?
pts with stroke, heart disease, uncontrolled HTN, pregnancy, or in someone who used Ergotamine preparations within the last 24 hours
SE of triptans
paresthesia, dizziness, flushing, chest pain, diaphoresis, N/V, myalgias
What antiemetics are used in acute treatment of migraines?
Reglan, cholrpromazine, procholrperazine, droperiodl
What is sometimes given with antiemetics to prevent akathisia and acute dystonia side effects?
Benadryl
What should you always give when you are prescribing an Ergot (dihydroergotamine, DHE45)
Antiemetic
can cause severe nausea
MOA: alpha-adrenergic blocker that directly stimulates vascular smooth muscle to vasoconstrict peripheral and cerebral vessels
Dihydroergotamine (DHE45)
C/I of Dihydroergotamine
Uncontrolled HTN, heart disease, angina, hemiplegic migraine, PVD, sepsis, severe hepatic/renal function.
Cannot use within 24 hours of triptan
Used for migraines lasting longer than 72 hours (status migrainosis)
Steroids (Dexamethasone and Prednisone)
What are preventative treatments for migraines?
Antihypertensives (BB, ACEI, CCB, ARBs), Antidepressants, Anticonvulsants
You prescribe metoprolol for preventative treatment of migraines. One month later your pt is saying its not working and would like to switch. What do you say?
Takes at least 3 months of an effective dose before you can say the med is a failure
beta blockers used in preventative treatment of migraines
Metoprolol
Propanolol
Timolol
What antidepressants are given for migraine preventative treatment?
TCAs
SE of TCAs
anticholinergic SE tachy, palpitations Ortho hypotension weight gain blurred vision
What anticonvulsants are used to prevent migraines?
Valproate (Depakote) Topiramate (Topamax)
C/I of Valproate
pregnancy
do NOT use in women of child bearing age
C/I of Topiramate (Topamax)
Hx of kidney stones, GLAUCOOMA
Role of butterbur, feverfew, magnesium, and vitamin b12 with migraines
MAY be beneficial
most prevalent headache in the general population
Tension
What categorizes someones tension HAs to be infrequent? frequent? chronic?
Infrequent: <1 month
Frequent: 1-14 days/month x 3 months
Chronic: 15+ days/month
Difference in pathophys of tension HA vs migraine HA
Tension: primary d/o of CNS pain modulation alone
Migraine: generalized disturbance of sensory modulation
Feature that distinguishes tension from migraine
muscle contraction
Only proven treatment for tension headaches
Amitriptyline (Elavil)
Headaches in Trigeminal Autonomic Cephalgias
Cluster headaches
Paroxysmal hemicrania
SUNCT
Cluster headaches that occur daily (1-8x/day) for several weeks, followed by a period of remission
Episodic cluster headache
Cluster headaches that occur daily (1-8x/day) without remission
Chronic cluster headache
Autonomic clinical features of cluster headache
Ptosis, miosis, lacrimation
Conjunctival injection
Rhinorrhea
Nasal congestion
Theories of pathophys of cluster headache
- hypothalamic activation (trigeminal atuonomic reflex is then activated)
- inflammation of cavernous sinus that injures traversing sympathetic fibers of carotid artery
Neuroimaging in Cluster
suggested with MRI brain w and w/o contrast or CT to exclude brain and pituitary gland abnormalities
Treatment of choice to prevent cluster headaches
Verapamil (Calan)
Steroids, topamax, and lithium may also be used
First line acute rescue treatment of cluster ha
Oxygen inhalation AND
SQ or nasal Sumatriptan or Zolmitriptan
Complete line of acute rescue tx for cluster headaches
Oxygen inhalation and triptan (first line)
DHE
Lidocaine (IN)
Octreatide
