1
Q
Primary headache
A
- More common
- Not symptomatic of another condition
2
Q
Secondary Headache
A
- Secondary to another underlying cause
- i.e. sinusitis, tumor, hemorrhage, temporal arteritis, or meningitis
3
Q
Tension Headache Facts
A
- Most prevalent type of HA
- Mild-moderate intensity; bilateral, non-throbbing HA w/o other clinical features
- 3 subtypes:
- Infrequent, episodic TTH: HA episodes 15 days/month
4
Q
Tension HA S/S
A
- Present most of day
- May start shortly after awakening (rarely awakens patient
- N/V NOT present
- Mild-to-moderate pain
- From minutes-to-hours in duration
- Not exacerbated by physical activity
- Stress is common trigger
- Pericranial tenderness: muscles around the head, neck or shoulders is exacerbated during TTH
- MRI, CT, spinal tap usually NL
5
Q
Tension HA descriptors
A
- Dull, pressure, head fullness, head feels large, like a tight cap, band-like, heavy weight on my head or shoulders
6
Q
Tension HA Tx
A
- Abortive therapy generally more effective
- Start with maximal dose (goal is to limit repetitive doses
- Use of triptans or OTC analgesics should be limited to <10 days/month
- Non-Pharmacologic: stress management, relaxation, biofeedback, aerobic feedback, Castor oil
7
Q
Tension HA Pharm
A
- Mild Analgesics:
- ASA 650mg q4hr
- APAP 325mg q4hr
- IBU 400-600mg q4-6hr
- Excedrin - (APAP 250mg, ASA 250mg, Caffeine 65mg) 2 tab at start of headache
8
Q
TTH Criteria
A
At least 2 of the following four:
- Pain is bilateral in head or neck
- Pain is steady (pressing, tightness) and non-throbbing
- Mild-to-moderate pain
- No aggravation of the headache by normal physical activity
In addition to these criteria there must be at least 10HA episode fulfilling all other ICHD-2 criteria:
- Duration of pain is b/n 30min-7d
- HA is not attributable to another disorder
9
Q
Cluster headache facts
A
- Occur in cyclical patterns or clusters: may last weeks to months
- VERY painful
- May awaken patient
- aka: “Alarm clock headache,” “suicide headache”
- Not life-threatening
- M > W (4.3:1)
10
Q
Cluster Headaches S/S
A
- Severe orbital, supraorbital, or temporal pain, accompanied by autonomic phenomena
- Can occur up to 8x/day; usually short-lived
- UNILATERAL
- Pt is restless: pace about or rock back and forth
- Can be so intense that patient is suicidal
- Risk decreases with increasing age
- May have autonomic Sx: ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion
- ** Ipsilateral to side of HA
11
Q
Cluster headache Risk factors
A
- Gender: Males more likely
- Age: 20-49yo
- Smoking
- ETOH use
- Family Hx
12
Q
Cluster HA: Circadian Periodicity
A
- Reaches max in about 15min; lasts about 90min-3hrs
- Described as sharp, penetrating, or burning
- May have: N/V, photo/phonophobia, aura
- Attacks often happen at same time of day
- Majority occur at night, usually 1-2hrs after bedtime
13
Q
Cluster HA Dx
A
- requires at least 5 HAs with these criteria:
1) Severe unilateral orbital, supraorbital, and/or temporal HA attacks, which last 15-180min
2) HA accompanied by: Ipsilateral conjunctival injection; ipsilateral nasal congestion/rhinorrhea; ipsilateral eyelid edema; ipsilateral forehead/facial sweating; ipsilateral miosis/ptosis; sense of restlessness/agitation
3) From 1 QOD to 8/day
14
Q
Cluster Tx
A
- SQ sumatriptan
- IN zolmitriptan (Zomig)
- O2 at 100% via NRB for 15min
15
Q
Cluster HA: Tx with Sumatriptan (Imitrex, Alsuma)
A
- Sumatriptan and zolmitriptan (Zomig) are used to treat
- SQ sumatriptan 6mg found typically effective (pain-free wthin 20min) in 75% of patients
- Imitrex may also be effective, but slower, when given IN
- IN Zomig 5-10mg has similar results
16
Q
Triptan Notes
A
- Side effects: non-iscemic chest pain; distal paresthesia
- AVOID in people w/Prinzmetal’s angina, CVD, CVA, uncontrolled HTN, or pregnancy
- SQ sumatriptan 6mg limited to no more than 2 doses in 24hrs
- IN triptans limited to no more than 3 doses in 24hrs
17
Q
Cluster HA: Other Tx
A
- Octreotide (Sandostatin LAR) 100mcg SQ
- Lidocaine 1mL given ipsilateral to the pain
- Ergots - More effective if given early
- ** 2mg SL: q 30 min with daily max at 6mg and weekly max at 10mg
18
Q
Cluster HA: Prevention
A
- Verapamil: TOC; 240mg PO qd
- Other choices: glucocorticoids, lithium, topiramate, & methysergide
19
Q
Migraine Facts
A
- 2 types: with aura, without aura
- General Hx: ipsilateral, pounding/throbbing
- Moderate-to-severe
- Aggravated y activity
- Episodic: 4-72hrs
- cause uncertain: possible connection to serotonin and dopamine
- In childhood: M>W
- In adulthood: W>M
- Rare after 50yo
20
Q
Migraine Risks
A
- Genetics
- Overweight
- Certain foods/substances
- behaviors
- Environmental factors
21
Q
Migraine S/S
A
- Aura <20%
- Usually in front of head or on one or both sides of the temples
- N/V, Diarrhea, yawning, irritability, hypotension, feelings of anxiety or hyperactivity, photophobia, phonophobia, dark circles under eyes
22
Q
Phases of Migraine
A
- Onset of migraine can occur over the course of several hours to days
- Typical migraine with aura has 4 phases: prodrome, the aura, the headache, and the postdrome
23
Q
Migraine prodrome
A
- Occurs in up to 60% of patients
- Affective or vegetative symptoms that appears 24-48hrs before onset of HA
- Prodromal s/s: euphoria, depression, irritability, food cravings, constipation, neck stiffness, increased yawning
24
Q
Migraine aura: visual
A
- most often vsual, but may be sensory, verbal, or motor
- Classic aura begins as small area of visual loss or bright spot
- During the following 5min to one hr, thee visual disturbance expands to involve a quadrant of the visual field
- Following the margin are geometric shapes or zigzagging lines often appear (fortification spectrum)
25
Migraine aura: sensory
- another visual aura is a sickle or C-shape over visual field (scotoma)
- Sensory aura typically follow the visual aura within minutes (usually begins as a tingling in one limb or on one side of face; migrates across one side of face or down the limb; face and/or limb is numb and it may last up to an hour
- Slow spread of positive symptoms (scintillations or tingling) followed by negative symptoms (scotoma or numbness) is a classic migraine
26
Migraine aura: Language/motor
- May have language or dysphasic aura: from mild wording difficulties to frank dysphasia with paraphasic errors
- Motor aura is rare: Limbs and and face on one side of body become weak; classified as hemiplegic migraine
- Some patients experience migraines during HA
27
3rd Phase: Migraine headache
- Usually unilateral, throbbing, or pulsing
- Increases in severity over the course of one to several hours
- Often accompanied by n/v, photo/phonophobia
- relief sought in dark/quiet room
- Untreated, may last from hours to days
- Often resolves during sleep
28
Migraine Postdrome
- During this phase a sudden head movement transiently causes pain in the location of the antecedent headache
- Often feel drained, exhausted, or mild elation or euphoria
29
Migraine Treatment Goals
- Reduce the frequency of attacks
- Improve the response to therapy
- Restore the patient to normal functioning
30
International Headache Society (IHS) diagnostic criteria for migraine w/out aura
- HA last 4-72hr
- HA has at least 2 of the following: unilateral location; pulsating quality; moderate or severe intensity; aggravation by routine physical activity
- During HA at least 1 of the following: N and/or V; photo/phonophobia
- At least 5 HA filling the above criteria
- H&P and neuro exam do not suggest underlying organic disease
31
IHS diagnostic criteria for migraine w/ aura
- The migraine aura fulfills crteria for one of the subforms of aura with migraine HA
- The s/s are not attributed to another disorder
- 6 subforms of aura: Typical aura with migraine HA; typical aura with non-migraine HA; typical aura without HA; familial hemiplegic migraine; sporadic hemiplegic migraine; basilar-type migraine
32
Triptans: Basics
- Effective for relief of pain, nausea, & sensitivity to light/sound 2/t migraine
- Includes: sumatriptan (Imitrex); rizatriptan (Maxalt); almotriptan (Axert); naratriptan (Amerge); zolmitriptan (Zomig); frovetriptan (Frova); eletriptan (Relpax)
- Side effects: Nausea, dizziness, & muscle weakness
- Combo tab of sumatriptan/naproxen (Treximet) has proven more effective than either alone
33
Triptans: MOA
- Sumatriptan and 2nd-gen triptans are cerebral and coronary vacoconstrictors
* Act by vasoconstriction and inhibition of neurogenic inflammation
* 2nd-gen triptans have better
34
Migraine: Abortive therapy OTC
- ASA: 650-1000mg PO x 1 dose
- IBU: 400-1200mg PO x 1 dose
- Indomethacin: PR 50mg x 1 dose
- APAP 1000mg PO x 1 dose
* ** Found to be highly effective for treating pain, functional disability, photophobia, phonophobia
- Excedrin: Combo of ASA+APAP+caffeine; found to relieve migraine pain
35
Migraine: Other drugs
- Ergot: ergotamine + caffeine combos (Migergot, Cafergot); less expesive, but also less effective than triptans
- Anti-emetics: Metoclopramide (Reglan); prochlorperazine (Compazine)
- Opiates: Usually only used as last resort
- Dexamethsone: Used in conjunction with other meds to improve pain relief; should not be used frequently due to risk of steroid toxicity
36
Migraine: Prophylaxis BB
- General rule: If HAs are interfering with work or other activities more than once/wk, it is reasonable to consider prophylactic medications (>3-4 days/month)
- Most prophylactic drugs require several weeks to several months to establish efficacy; give 2mo trial for each meds
- First line for prophylaxis: Beta-blockers - capable of reducing the frequency and severity of attacks by 50%
- For patients who cannot tolerate beta-blockers: CCBs (AVOID in pts with CHF or heart block)
37
Migraine: Prophylaxis Others
- ACE/ARB: Reduction of HA in ~30%
- TCA: Nortriptyline/amitriptyline
* Consider relationship b/n migraine and depression
- NSAIDS: ASA, IBU, Naproxen
- Antiepileptics: Valproate, toprimate
- Vitamins: Possible prophylactic role for high-dose riboflavin (VB12) in doses of 400mg/day
38
Migraine: Beta-blockers
- Propanolol (Inderal): 20mg PO q12hr; 40-160mg/day
- Metoprolol (Lopressor): 50mg PO q12hr; 100-200mg/day
- Timolol (Blocadren): 10mg PO q12hr; dose range 20-30mg/day
- Nadolol (Corgard): 80mg PO qd; 80-240mg
- Atenolol (Tenormin): 100mg PO qd
* Improvement can take several weeks
* * Doses should be titrated and maintained for 3mo before considering med a failure
39
Migraine: CCBs
- Verapamil (Calan, Verelan, Isoptin): 40mg PO q8hr; 120-240mg/day
* Often 1st choice due to low side effects
* TID can cause non-compliance
- Tolerance can develop with CCBs
* 42% treated with nifedipine (Procardia), 49% treated with verapamil developed tolerance
* Tolerance can be overcome by increasing dose or changing to different CCB
40
Migraine: ACE/ARB
- Lisinopril (Prinivil) 10mg PO qd x 1wk then 20mg PO qd made significant difference in duration & severity
- Candesartan (Atacand) 16mg PO qd gives similar results
- Not used often
- BB show better results
41
Migraines: Antidepressants
- TCA --> Amitriptyline (Elavil): 10mg qhs; 20-50mg/day
* Other TCAs: nortriptyline, doxepin, protriptyline
* Side effects: sedation, dry mouth, constipation, tachycardia, palpitations, orthostatic hypotension, weight gain, blurred vision, urinary retention, confusion
- SNRI --> Venlafaxine (Effexor) 37.5mg PO qd; 75-150mg qd
42
Migraines: Anticonvulsants
- Valproate (Depakote): May cause nausea, somnolence, tremor, dizziness, weight gain, alopecia; Contraindicated in pregnancy
- Topiramate (Topamax): 25mg PO qd; Max 100mg PO q12hr; may have residual benefit for up to 6mo after discontinuation
43
Migraines: Others
- Botulinum toxin: Ineffective for EPISODIC migraines; effective for CHRONIC migraines
- Butterbur: Effective and well tolerated; Forewarn patients that butterbur contains pyrolizidine alkaloids (potential carcinogens)
- Coenzyme Q10: 100mg TID; 50% reduction; well tolerated
- Feverfew: Mixed evidence; unknown safety
44
Migraines: Magnesium
- Many patients w/migraines found to have low Mg
- Current popular drug
- Mixed results in RCTs
- Most common side effects: diarrhea, GI discomfort
45
Migraines: NSAIDs
- Naproxen: Found to be more effective in prevention than placebo; strongest evidence of NSAIDs
- Fenoprofen (Nalfon), IBU, ketoprofen (Orudis): May also be effective
- Indomethacin: may help prevent; available in suppository
46
Migraines: Non-pharmacological
- Wellness programs: avoid triggers (cheese, chocolate, citrus fruit, nuts, red wine); supportive psychotherapy
- HA diary: Document the number of HA, triggers, and treatment successes/failures
- Behavior mod.: relaxation, stress mgmt.; biofeedback; acupressure; wellness
47
Secondary HA: Brain tumor
- Can mimic TTH
- IC tumors are associated with HA at initial presentation 20% of time but present in course of DZ 60% of time
- Worse unilaterally, worse when bending over, associated with significant N/V
- Be vigilant about possibility when patient presents with new, subacute, or progressive HA suggestive of TTH
48
Secondary HA: Medication overuse HA (MOH)
- Should be suspected in pt with c/o frequent or daily HA depite, or b/c of, regular HA meds
- MOH diagnostic criteria: HA >14d/mo; regular overuse for >3mo of 1+: ergotamine, triptans, opioids, or combo analgesics >9d/mo on a regular basis for >3mo; HA has developed or markedly worsened during med overuse
- Must wean pt off of meds (Detox)
- Patients suffer high withdrawal symptoms
49
Secondary HA: sinus HA
- Many pts presenting with sinus HA turn out to have Migraine, MOH, or TTH
- Occurrence of nasal symptoms with HA should neither trigger Dx of siuns HA nor exclude Dx of other primary HA
50
Secondary HA: Cervicogenic HA
- Consider if HA is STRICTLY unilateral
- Caused by referred pain from upper cervical joints
- Characterize by: unilateral, nonthrobbing, nonlancinating head pain of mod-to-sev intenity; variable duration; increased by movement of the head; radiates from occipital to frontal regions
- Muscle tenderness in posterior head and upper neck in a primary diagnostic criterion of cervicogenic HA; is common in TTH as well
- Dx established using controlled anesthetic blocks of cervical structures or their nerve supply
51
What is Dementia?
- An acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert patient
- Progressive and disabling
- Not an inherent aspect of aging
- Different from normal cognitive lapses
52
Dementia: Facts
- General term to describe various disesaes that damage brain cells
- Alzheimer's (Most Common): progressive disorder that damages and eventually destroys brain cells, leading to memory loss and changes in thinking and other brain functions; develops slowly; gradually worsens; ultimately fatal
- Other types: vascular dementia, mixed dementia, Lewy body dementia, fronto-temporal dementia
53
Dementia: RIsk factors
- Age, Family Hx, Head injury, female gender
- Head-Heart connection: Growing evidence links brain health to heart health
- Risk of ALZ or Vasc dementia increased by cond. that damage the heart or blood vessels
- African-Americans and Hispanics have higher rates of CVD, thus increased rates of ALZ or Vasc. Dementia
54
Dementia: Warning signs (Memory, planning)
- Memory loss that affects daily life: esp. in early stages -> forgetting recently learned info.; forgetting important dates or events; asking the same questions over
- Challenges in planning or solving problems: changes in their ability to develop and follow or work with numbers; trouble following familiar recipes or keeping track of monthly bills; difficulty concentrating and take much longer to do things than previously
- Difficulty completing tasks at home, work, or leisure: Often find it hard to complete daily tasks; trouble driving to familiar locations, managing a budget at work or remembering the rules of games
55
Dementia: Warning signs (time, space)
- Confusion with time or place: People with ALZ can lose track of dates, seasons, and the passage of time, trouble understanding something if it is not happening immediately
- Trouble understanding visual images and spatial relationships: may have difficulty reading, judging long distance, determining color/contrast
* May not recognize own reflection
56
Dementia: Warning signs (Language, remembering locations)
- New problems with words in speaking or writing: trouble starting/joining conversation, may stop in middle of conversation, struggle with vocabulary, have problem finding the right word
- Misplace things and lose the ability to retrace steps: put things in unusual places, accuse others of stealing
57
Dementia: Warning signs (Judgment, withdrawal, mood)
- Decreased or poor judgment: May experience changes in judgment or decision making (i.e. dealing with money, grooming
- Withdrawal from work or social activities
- Changes in mood/personality: may become easily upset, confused, suspicious, fearful, depressed, or anxious
58
Normal Aging
- No consistent, progressive deviations on testing of memory
- Some decline in progressing and recall of new information: slower, harder
- reminders at work: visual tips, notes
- Absence of significant effects on ADLs or IADLs due to cognition
59
Distinguishing signs of delirium
- Acute onset
- Cognitive fluctuations over hours or days
- Impaired consciousness and attention
- Altered sleep cycles
60
Depression vs. Dementia
- In depression:
1) demonstrate decreased motivation during cognitive testing
2) express cognitive complaints that exceed measured deficits
3) Maintain language and motor skills
- Treatment of depressive symptoms may improve cognitive function
61
ALZ: S/S
- Onset: Gradual
- Cognitive symptoms: primarily memory
- Motor symptoms: rare early, apraxia later
- Progression: gradual, 8-10yr on average
- Labs: NL
- Imaging: Possible global atrophy, small hippocampal volumes
62
Apraxia
- Adisorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked, even though:
* The request or command is understood
* They are willing to perform the task
* The muscles needed to perform the task work properly
* The task may have already been learned
63
AD: Diagnosis
- Development of cognitive deficits manifested by: Impaired memory AND aphasia, apraxia, agnosia, disturbed executive function
- Significantly impaired social, occupational function
- Gradual onset, continuing decline
- Not due to CNS or other physical conditions (i.e. PD, delirium)
- Not due to Axis I disorder (i.e. schizophrenia)
64
Agnosia
- A rare disorder characterized by an inability to recognize and identify objects or persons
- May have difficulty recognizing the geometric features of an object or face
- May be able to perceive the geometric features but not know what the object is used for
- May not know whether a face is familiar or not
- May be limited to 1 sensory function such as vision or hearing
- May retain cognitive abilities in other areas
65
Vascular Dementia: S/S
- Onset: May be sudden/stepwise
- Cognitive symptoms: depend on anatomy of ischemia
- Motor symptoms: correlates with ischemia
- Progression: stepwise with further ischemia
- Labs: NL
- Imaging: cortical or subcortical changes on MRI
66
DSM-IV criteria for vascular dementia
- Develpment of cognitive deficits manifested by: Impaired memory AND aphasia, apraxia, agnosia, disturbed executive function
- Significantly impaired social, occupational function
- Focal neurologic symptoms and signs or evidence of cerebrovascular disease
- Deficits occur in the absence of delirium
67
Lewy Body Dementia: S/S
- Onset: gradual
- Cognitive Symptoms: Memory, visuospatial, hallucinations, fluctuations
- Motor symptoms: Parkinsonism
- Progression: Gradual but faster than AD
- Labs: NL
- Imaging: Possible global atrophy
68
Fronto-Temporal Dementia
- Onset: Gradual, usually >60yo
- Cognitive symptoms: executive; disinhibition; apathy; behavior changes
- Motor symptoms: none; may be associated with ALD in rare cases
- Progression: gradual but faster than AD
- Labs: NL
- Imaging: Atrophy in frontal and temporal lobes
69
Dementia Tx: Acetylchilnesterase Inhibitors
- Cholinesterase inhibitors:
* Donepezil (Aricept): approved for ALL stages
* Galantamine (Razadyne): approved for mild-to-moderate AD
* Rivastigmine (Exelon): Approved for mild-to-moderate AD
* Tacrine (Cognex) - 1st of the class; high side effects; no longer used
- Prevent the breakdown of acetylcholine -> supports communication among nerve cells
- Delay worsening of symptoms for 6-12mo for about 1/2 people who take them
- Are generally well tolerated
- Side effects: N/V; loss of appetite; increased bowel movements
70
Dementia Tx: N-Methyl-D-Aspartate Receptor Antagonist
- Memantine (Namenda): Prescribed to improve memory, attention, language, and the ability to perform simple tasks
* regulates activity of glutamate (messenger chemical involved in learning and memory)
- Delays worsening of symptoms for some people
- May be used alone or with other AD Tx
* ** some evidence shows benefit of memantine + cholinesterase inhibitor for severe AD
- Side effects: HA, constipation, confusion, dizziness
71
Dementia Tx: Vitamin E
- Antioxidant
- Delays loss of ability to carry out daily activities and placement in residential care
- May slightly increase risk of death from CAD
72
Dementia: Accompanying S/S
- Sundowning
- Psychoses (delusions, hallucinations)
- Sleep disturbances
- Aggression, agitation
- Hypersexuality
73
Dementia: Other meds
- Antidepressants for mood and irritability: SSRI, SNRI
- Anxiolytics for anxiety, restlessness, disruptive behavior: Lorazepam, oxazepam
- Antipsychotics for hallucinations, delusions, aggression, agitation, hostility, uncooperative
