OnlineMedEd+-Headaches Flashcards
Headache Red Flags
S
N
O
O
P
Systemic symptoms: fever (meningitis), weight loss, risk factors such as HIV, malignancy, pregnancy, and anticoagulation
Neurological: focal neural deficits (abcess with fever) newly acquired confusion, impaired alertness/consciousness, nuchal rigidity, HTN, papilledema, cranial nerve dysfunction, abnormal motor function
Onset: sudden, abrupt, split-second (SAH), thunderclap, or onset with exertion, sexual activity, coughing, or sneezing.
Onset: age > 50 or younger than 5 years
Previous headache hx change. First headache in adults; the primary pattern is usu on teens or young adults. New onset of a different.
Pain should NOT be worse upon awakening and improve during the day. Sign of ^ ICP and possible 2ndary ha with most likely diagnosis being a tumor
Tension Headaches
Description:
Presentation:
Should NOT be present:
Treatment:
Tension Headaches
Description: This is a regular headache that you get from time to time. It’s the most common cause of headaches.
Presentation: bilateral, vice-like pain that radiates from the front to the back/neck. aggravated by exercise. pressing non-pulsing.
Should NOT be present: nausea/vomiting, photophobia, or phonophobia.
Dx: clinical. The absence of other headache features defines tension.
Treatment: is usually with acetaminophen or NSAIDs. even butalbital
Cluster
Description:
Pt:
Presentation:
What are two names for this headache
Dx: What important imaging should be done & rationale
Treatment: non pharm? 1st line Pharm? prophylaxis?
Cluster
This is the most common “trigeminal autonomic cephalgia”
Pt: @ 1:3 to 1:8 male to female
Presentation: It’s characterized by severe unilateral pain (often behind one eye - hot poker). that has autonomic symptoms (rhinorrhea, lacrimation, conjunctival injection, Horner’s).
Clusters of headaches occur in periods of weeks and are often symptom-free for months (attacks “cluster” together). Can have a very regular onset time. Can awaken from sleep 3-4 am. (alarm clock headaches) VERY painful = suicide headache. Can’t be still.
Dx: clinical When cluster headache is diagnosed, an MRI should be obtained to rule out other diseases that mimic Cluster.
Tx: high flow oxygen is the first-line treatment and is often sufficient to abort attacks. eliminate triggers
Sumatriptan, (avoid with CAD, hx of stroke, MI etc.; within 24 hours of ergot, 2 weeks from an MAO i).
high dose NSAIDs, can be used if oxygen fails.
Prophylaxis is with calcium channel blockers such as verapamil. (not very effective)
Migraines
Etiology:
Pt:
Presentation:
Dx:
Treatment: Mild? Severe? Chronic?
POUND mnemonic (# for diagnosis?)
Migraines
Etiology:
Migraines are generally poorly understood; they’re thought to have vascular pathogenesis (arterial vasodilation)
Pt:
women: men 3:1
presentation: Multiple
- usu unilateral pounding/pulsing headache.
- The pain is usually disabling causing 1 or more sx phonophobia, photophobia, nausea/vomiting,
- lingering malaise even after the headache is aborted (“hangover”).
- If the patient manages to fall asleep it’s sufficient to abort the migraine,
- pain may last for 4-72 hrs without intervention.
- Migraines have triggers (nitrites, caffeine, chocolate, menstrual cycle, stress, etc)
Treatment
- active dynamic migraine mild (use NSAIDs)
- severe, initiate therapy immediately (early intervention decreases the need for back up medications). Start with a Triptan or an Ergot (caution if CAD as these drugs cause vasospasm).
Who must ergots not be give to?
pregnant, breastfeeding, his if ischemic heart heart, prinzmetal angina, PVD, any new CP, elevated BP, within 24 hours of any other ERGOT, basilar migraine: diplopia, dysarthria, tinnitus, vertigo, hearing loss, mental confusion. CVD
chronic migraines use
- cognitive feedback,
- trigger avoidance,
- prophylaxis with Beta Blockers (propranolol is best), Calcium Channel Blockers (verapamil or diltiazem), or Anticonvulsants (valproic acid, topiramate).
POUND Mnemonic for Migraines
P O U N D
(Any 3 is diagnostic)
- Pulsatile
- One day in duration (4-27 hours)
- Unilateral
- Nausea and Vomiting
- Disabling intensity
What is an aura
Pt: how many migraine sufferers have an aura?
S/sx:
Concerns
Focal dysfunction of cortex causing visual or olfactory symptoms
Pt: 80% don’t have aura but do have prodrome
s/sx: REVIEW. Prodrome: dread, fatigue, anxiety, unusual fatigue, nervous, excited, GI upset,
sx lasting more than 1 hour
What are some lifestyle migraine triggers?
Dietary Migraine Triggers
MRI vs CT
Rational for oral, injectible, nasal
Abortive Therapies Med class/MOA/use/contraindications
HA medications
Oral:.5-1 hr. for slowly developing with minimal GI distress acetaminophen, ibuprofen, aspirin
Injectible: 15-30 mins sumatriptan (imitrex) dihydroergotamine (migranal). for rapid progression with GI distress;
Nasal: 15-30 mins sumatriptan ( imitrex ); zolmetriptan , (Zomig) dihydroergotamine ( migranal ). rapid progression with GI distress;
Triptans: 5-HT1D - serotonin receptor site agonist,
vasoconstrictor effects: avoid in prinzmetal angina or with CAD, pregnant women, or if recent ergot use. caution with MAOs, SSRIs, can be used with migraine or tension
Ergots: 5-Ht1A and 5-Ht1D agonists. do not alter cerebral blood flow. migraine only no TT HA
vasoconstrictor. avoid in pregnancy and CAD
NSAID: prostaglandin and leukotriene inhibition of synthesis. The first sign of HA without GI issues. Naproxyn sodium is quickest onset.
Fiorocet: caffeine, butalbital, acetaminophen. enhance neurotransmitter action migraine and TT occasional use.
GI distress: Neuroleptics: promethazine (Phenergan), perchlorpromazine , ( compazine ). sedating with EPM effects.
zofran. expensive;
metoclopramide (prokinetic) also EPM
Corticosteroids - no more than once a month.
Meningitis
first time most severe HA
brain abscess
Tumor
subarachnoid Hemorrhage
Idiopathic intracranial hypertension
trigeminal neuralgia
Secondary HA
- For meningitis
look for fever and a headache. Do an LP with Cx, give Abx (CT?).
? do a CT
- For abscess l
ook for fever, headache, and Focal neurologic Defect. Do a CT scan then drain, give Abx.
- For tumor
look for a progressively worsening headache worse in the AM. Do a CT / Bx, give Radiation / Chemo /
- For SAH l
look for a patient with a sudden onset headache that’s the worst headache of their life. Do a CT, get neurosurgery, control BP and HTN.
Idiopathic Intracranial Hypertension
IIH is also called pseudotumor cerebri. It is pseudo-tumor – the intracranial pressures are elevated but there’s no tumor. Almost all patients are women, obese, and of childbearing age. There’s a strong board association with ocps but other things can do it like vitamin A, isotretinoin, and glucocorticoid withdrawal. You’ll see all the classic signs of intracranial hypertension (like papilledema). A lumbar puncture will reveal an opening pressure >25cmH2O and the tap will relieve the headache.
First line treatment is acetazolamide. Refractory disease is treated with VP shunts or serial LPs.
Trigeminal neuralgia
Trigeminal neuralgia is essentially a seizure of the trigeminal nerve presenting with lancinating pain across or down the jaw and ear. They are often brought on by cold things in the mouth. It is a clinical diagnosis, though an MRI should be obtained to rule out compressive myelopathies. The treatment iscarbamazepine.
PROPHYLAXIS HA MEDS
PROPHYLAXIS MED
Reduce vasodilators: estrogen, progesterone
Betablockers: metoprolol and propranolol (atenolol, nadolol)
CCB: not supported by evidence
AntiEpileptic Drug: divalproex, valproate, topiramate not lamotrigine
TCA: amitriptyline; nortriptyline
SNRI: venlafaxine
Herbal: Petasites (butterbar); riboflavin, magnesium, feverfew. CoQ10, estrogen during the premenstrual week.
What is analgesic Rebound HA
Tx?
Analgesic Rebound
Analgesic rebound can be any type of pain that occurs in a patient on chronic analgesics (opiates, ergots, triptans, OTC, taken 2-3 times/week) who suffers from frequent headaches (10x/month).
Withdrawing the offending medication may initially make the headaches worse, but this is simply a withdrawal symptom it’ll pass if drugs are withheld.
