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HEENT > Primary Headache > Flashcards

Primary Headache Flashcards

1
Q

chronic headaches

A

-new, severe, or acute is more likely related to intracranial disorder than chronic headaches
-may be primary or secondary to another disorder

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2
Q

primary headache syndromes

A

-migraine (with or without aura)
-tension type headache (episodic or chronic)
-cluster headache (episodic or chronic)
-no demonstrable structural abnormality

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3
Q

secondary causes of headaches

A

-intracranial lesions
-head injury
-cervical spondylosis
-dental disease
-ocular disease
-temporomandibular joint dysfunction
-sinusitis
-hypertension
-depression
-etc
-sleep disturbance, substance withdrawal

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4
Q

migraine

A

-pulsating or throbbing
-lateralized throbbing headache
-occurs episodically following its onset in adolescence or early adult life
-can be associated with anorexia, nausea, vomiting, photophobia, phonophobia, osmophobia, cognitive impairment, blurring of vision
-gradual buildup and last hours or longer
-focal disturbances of neurological function may precede or accompany
-scotoma- visual disturbances; field defects
-photopsia- unformed light flashes
-scintillating scotomas- some combination of field defects and luminous hallucinations

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5
Q

tension headache

A

-sense of tightness or pressure
-band like pain

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6
Q

neuritic caused headache

A

-sharp lancinating pain

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7
Q

migraine or cluster headache

A

-ocular or periorbital icepick-like pain
-lateralized headache

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8
Q

intracranial mass lesion

A

-dull or steady headache
-may be focal or generalized

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9
Q

ophthalmologic disorder

A

ocular or periocular pain

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10
Q

sinusitis

A

-tenderness of overlying skin and bone

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11
Q

trigeminal or glossopharyngeal neuralgia

A

-localized pain to one of the divisions of the trigeminal nerve or to the pharynx and external auditory meatus respectively

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12
Q

precipitating (triggering) factors

A

-recent sinusitis
-dental surgery
-head injury
-systemic viral infection
-SARS-CoV-2
-emotional stress
-fatigue
-foods containing nitrite or tyramine
-menstrual period
-alcohol
-temporomandibular joint dysfunction (chewing)
-cough

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13
Q

timing of headaches

A

-headaches are worse awakening in pts with intracranial mass or sleep apnea
-cluster headaches occur at the same time each day
-tension headaches are worse with stress / end of day

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14
Q

headaches that requires MRI or CT scan

A

-progressive headache disorder
-new onset in middle or later life
-disturb sleep
-related to exertion
-neurologic symptoms or a focal neurologic deficit

-rules out intracranial mass lesion
-CSF exam to exclude subarachnoid hemorrhage or meningeal infection

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15
Q

essentials of migraine diagnosis

A

-headache, usually pulsatile, lasting 4-72 hours
-usually unilateral pain
-nausea, vomiting, photophobia, and phonophobia
-aggravated with routine physical activity
-aura of transient neurologic symptoms may precede head pain
-commonly occurs with no aura

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16
Q

general consideration of migraines

A

-neuronal dysfunction in trigeminal system
-results in release of vasoactive neuropeptides such as calcitonin gene (peptide that leads to neurogenic inflammation, sensitization, and headache)
-aura is hypothesized to result from cortical spreading depression- wave of neuronal and glial depolarization that slowly moves across the cerebral cortex
-autosomal dominant inheritance sometimes- familial hemiplegic migraine

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17
Q

initial process

A

-life threatening?
-old or new? chronic? sudden?
-epidemiology
-ALWAYS consider serious causes of headaches
-history- OLDCARTS
-physical exam- you dont need a physical exam to diagnosis a primary (tension, migraine, cluster)
-working diagnosis
-reassure pt if no evidence of serious underlying causes & initiate treatment

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18
Q

3 main primary headaches

A

-tension (most common)
-migraine
-cluster (least common)

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19
Q

history of adult with headache

A

-age at onset
-presence or absence of aura and prodrome
-frequency, intensity, and duration of attack (# per month)
-time and mode of onset
-quality, site, and radiation of pain
-associated symptoms and abnormalities
-family history of migraine
-precipitating and relieving factors
-exacerbation or relief with change in position
-effect of activity on pain
-relationship with food/alcohol- chocolate, cheese, caffeine
-response to any previous treatment
-review of current medications
-any recent change in vision
-association with recent trauma
-any recent changes in sleep, exercise, weight, or diet
-state of general health
-change in work or lifestyle (disability)
-change in method of birth control (women)
-possible association with environmental factors
-effects of menstrual cycle and exogenous hormones

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20
Q

physical examination for adult with headache

A

-blood pressure
-pulse
-listen for bruit at neck, eyes, and head for clinical signs of arteriovenous malformation
-palpate the head, neck, and shoulder regions- tension -> tension headache
-check temporal and neck arteries- temporal arthritis- headaches forms due to inflammation of temporal artery -> urgent -> patient can go blind
-examine the spine and neck muscles
-Neurologic exam:
-mental status testing, cranial nerve exam, funduscopy (exam optic nerve/vein for papillae edema) and otoscopy, and symmetry on motor, reflex, cerebellar (coordination), and sensory tests
-gait exam -> getting up from seated positing without any support and walking on tiptoes and heels, tandem gait, and romberg test (stand with eyes closed to see if the pt sways)

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21
Q

classification of headache

A

-primary vs secondary
-acute vs chronic
-urgent / emergent vs nonurgent

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22
Q

primary headache

A

-associated features are the disorder itself
-often result in considerable disability and a decrease in the pts quality of life
-no underlying cause
-tension, cluster, migraine
-trigeminal autonomic cephalalgias
-benign cough headache
-benign exertional headache
-headache associated with sexual activity
-benign thunderclap headache
-idiopathic intracranial hypertension (pseudotumor cerebri) (IITCH)

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23
Q

secondary headaches causes

A

-caused by exogenous disorders
-can be mild secondary or life threatening
-ex. subarachnoid hemorrhage is causing a headache
-due to trauma, cranial/cervical vascular disorder, non-vascular intracranial disorder, substance/withdrawal, infection, disorder of homeostasis, disorder of cranium, neck, ears, eyes, nose, sinus, teeth, mouth, or other facial structure, psychiatric disorder

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24
Q

chronic headaches

A

-primary or secondary to another disorder
-frequency of 15 or more days a month for longer than 3 months in the absence of organic pathology
-common primaries -> migraine, tension, cluster
-common secondary causes -> intracranial lesions, head injury, cervical spondylosis, dental or ocular disease, temporomandibular joint dysfunction, sinusitis, hypertension, depression, etc.
-sleep disturbance, substance withdrawal

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25
Q

acute headaches

A

-rapid onset
-age > 40 years
-severe intensity
-thunderclap, trauma, exercise onset
-fever
-vision changes
-nuchal rigidity
-HIV infection
-current or past hx of hypertension
-neurologic findings (mental status changes, motor or sensory deficits)

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26
Q

chronic headache subtypes

A

-chronic migraine headache
-chronic tension type headache
-medication overuse headache (opioids 10, NSAIDS 15)
-hemicrania continua- one sided, persistent, responds to indomethacin (NSAID)
-new daily persistent headache
-chronic daily headache (CDH) is not a specific headache type but a syndrome that encompasses other primary headaches

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27
Q

examples of secondary headaches

A

-subarachnoid hemorrhage
-meningitis
-subdural hematoma
-temporal arteritis
-CNS tumor
-posttraumatic
-primary cough headache
-sinusitis
-toothache
-medication overuse

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28
Q

etiologies that require urgent investigation/treatment

A

-vascular causes
-infections
-intracranial masses
-preeclampsia (frontal)
-CO poisoning
-headache brought on by cough, exertion, or sexual activity

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29
Q

tension headache

A

-duration- 30mins to 7 days
-exacerbated by: emotional stress, fatigue, noise, or glare
-pain characteristics: pressing or tightening; band like tightness, mild to moderate severity, bilateral location, peri-cranial tenderness, poor concentration, NO aggravation by routine physical activity*
-associated symptoms: (all must be met)- no vomiting, no more than one of: nausea, photophobia, phonophobia, and no family hx
-management: oral analgesics (NSAIDS, acetaminophen), treat anxiety and depression, alternative therapies
-prophylaxis (prevention)- TCA’s (tricyclic antidepressants)

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30
Q

migraine types

A

-without aura- most common
-classic migraine (with aura)
-migraine in children
-basilar artery migraine
-ophthalmoplegic migraine- can cause temporary blindness - artery constricts cutting of blood
-chronic migraine
-atypical migraine
-status migrainosus
-hemiplegic migraine

31
Q

migraine screen

A

-photophobia?
-incapacity? does it limit you?
-nausea?
-if yes, to 2-3 questions -> migraine

32
Q

brief headache screen

A

-how often do you get severe headaches (without treatment it is difficult to function)
-how often do you get other (milder) headaches
-how often do you take headache relievers or pain pills (overuse?)
-has there been any recent change in your headaches

33
Q

migraine disability assessment score (MIDAS) questionaire

A

-questionnaire regarding the past 3 months
-how many days did you miss work/school because headaches
-how many days was your productivity reduced by half or more bc of headaches
-how many days did you not do household work bc of headaches
-how many days was your productivity in household work reduced by half or more bc of headaches
-how many days did you miss family, social, or leisure activities bc of headaches
-how many days did you have a headache
-on a scale of 1-10 how painful were these headaches
-Grade 1- minimal or infrequent disability 0-5
-Grade 2- mild or infrequent diability 6-10
-Grade 3- moderate disability 11-20
-Grade 4- severe disability >20

34
Q

POUND

A

-pulsatile quality of headache
-one-day duration (4-72 hours)
-unilateral location
-nausea or vomiting
-disabling intensity
-92% probability of migraine in pts with at least 4 POUND criteria

35
Q

migraine without aura

A

-most common subtype of migraine
-higher average attack frequency
-usually more disabling than migraine with aura
-triggers: smell, taste
-often have strict menstrual relationship
-most prone to accelerate with frequent use of symptomatic medication, resulting in a new headache
-medication overuse headache

36
Q

migraine without aura criteria* IHS diagnostic criteria

A

-at least 5 attacks fulfill B-D
-B. headache lasting 4-72 hours (treated or not)
-C. headache has >2 of the following:
-unilateral location (usually frontotemporal)
-moderate or severe pain intensity
-aggravation by or causing avoidance of routine activity (walking, climbing stairs)
-D. during headache > 1 of the following:
-nausea $/or vomiting
-photophobia/phonophobia
-E. not attributed to another disorder (primary)

37
Q

migraine with aura

A

-classic migraine
-at least 3:
-1 or more fully reversible aura symptoms
-at least 1 aura symptom develops gradually over >4 mins or 2 or more symptoms occur in succession
-no single aura symptom lasts > 60 mins
-headache begins within 60 mins of aura onset
-H&P and diagnostic tests do not suggest any underlying organic disease

38
Q

aura

A

-precede the migraine 5-60mins
-simmering spots or stars
-zigzag lines that gradually float across your field of vision
-loss of vision in one eye
-blurred vision
-blind spots (scotomas)
-objects in your surroundings that appear as if they are shimming in heat
-flashes of light
-feelings of numbness
-tingling
-dizziness (vertigo)
-difficulty with speech
-altered sense of smell or taste
-can mimic a stroke!

39
Q

migraine in children

A

-attacks may last 1-72 hours
-commonly bilateral
-occipital (unilateral or bilateral) is rare and calls for diagnostic caution -> many cases are attributable to structural lesions

40
Q

atypical migraines

A

-headaches are typical of migraine but at least one diagnostic criterion is missing
-uncommon

41
Q

status migrainosus

A

-defined as a migraine attack lasting > 72 hours that has been refractory to treatment
-constant with no relief
-often associated with pernicious nausea, vomiting, dehydration, and despair
-oxygen, ergotamine (vasoconstrictor)

42
Q

basilar migraine

A

-severe headache preceded by visual aura and brain stem signs of ataxia, vertigo, tinnitus, diplopia, nystagmus, dysarthria
-level of consciousness and cognition are affected

43
Q

hemiplegic migraine

A

-familial syndrome with hemiplegia and alteration in level of consciousness varying from confusion to coma

44
Q

ophthalmologic migraine

A

-associated with acute attacks of third cranial nerve palsy with dilated pupil and unilateral eye pain

45
Q

chronic migraine

A

-migraine like or tension type like headache on greater than or equal to 15 days/month for >3 months that fulfill criteria B and C
-B. Occurring in a pt who has had at least 5 attacks fulfilling criteria for migraine without aura and/or criteria for migraine with aura
-C. on greater than of equal to 8 days/month for > 3 months
-criteria C and D for 1.1 Migraine without aura
-criteria B and C for 1.2 Migraine with aura
-believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
-D. not better accounted for by another diagnosis

46
Q

criteria of migraine status migrainosus

A

-A. headache attack fulfilling criteria B and C
-B. in a pt with migraine without aura and/or migraine with aura, and typical of previous attacks except for its duration and severity
-C. both of the follow characteristics:
-unremitting for >72 hours
-pain and/or associated symptoms are debilitating
-D. not better accounted for by another ICHD-3 diagnosis

47
Q

goal for acute migraine treatment

A

-rapid and consistent freedom from pain and associated symptoms, especially the most bothersome symptoms, without recurrence
-restored ability to function
-minimal need for repeat dosing or rescue medications
-optimal self care and reduced subsequent use of resources (ER, dx imaging, clinician and ambulatory infusion center visits)
-minimal or no adverse events
-cost considerations

48
Q

management of migraines

A

-lifestyle modification and education
-identify migraine symptomatology that allow for intervention as early as possible
-proper nutrition, regular exercise, adequate hydration, proper sleep, stress management, and maintaining a migraine diary
-instruct in the proper use of their medications- duration, CI, AE
-mild to moderate attacks
-moderate to severe attacks
-rescue/abortive treatment
-non pharmacologic- relaxation, thermal biofeedback, acupuncture
-pharmacologic- triptans
-neuromodulation
-prophylactic management- if occurs more frequently than 2-3 times a month or debilitating -> associated with attacks
-frequency, intensity, variants, patient preference, lowest effective dose, adequate trial, long acting preparations

49
Q

otc medication

A

-start medication immediately
-Tylenol, ibuprofen
-can prevent / abort
-earlier the better
-educate patient

50
Q

symptomatic therapy

A

-simple analgesic (aspirin, acetaminophen, ibuprofen, naproxen)
-limit to 15 days or less per month, and combination analgesics should be limited to no more than 10 days per month

51
Q

ergotamines

A

-cafergot- combination of ergotamine tartrate and caffeine
-1 or 2 tablets are taken at the onset of headache or warning symptoms, followed by 1 tablet every 30 minutes (if needed)
-up to 6 tablets per attacked (per 24 hours)*
-no more than 10 days per month*
-suppository, intravenously or subcutaneously or intramuscularly
-contraindications: pregnancy, cardiovascular disease or its risk factors, pts taking potent CYP 3A4 inhibitors
-constricts the blood vessels -> affects fetus, coronary artery disease

52
Q

serotonin agonists

A

-triptans
-5-HT 1b/1d receptor agonists
-at least 7 different medications

53
Q

sumatriptan

A

-subcutaneously by an auto injection
-may repeat once after 2 hours if needed
-nasal and oral preparations
-zolmitriptan is available in oral and nasal formulations (if pt is vomiting)
-side effects- nausea and vomiting
-contraindications- pregnancy, pts with hemiplegic or basilar migraines, hx of stroke or TIA, uncontrolled hypertension, pts with coronary or peripheral vascular disease and prinzmetal angina
-pts with controlled hypertension -> triptans commonly used safely although caution is advised

54
Q

other medicinal treatments

A

-ubrogepant (ubrelvy)- Calcitonin gene–related peptide antagonists
-lasmiditan (reyvow)- lacks vasoconstrictive properties that other triptans have -> good for pts with cardiovascular risks
-rimegepant (nurtec OTD)- Calcitonin gene–related peptide antagonists
-prochlorperazine- sedative, rectally, IV, IM
-metoclopramide- antiemetic, IV
-chlorpromazine- sedative, antiemetic

55
Q

prophylactic management

A

-if migraine headache occur more frequently than 2 or 3 times a month or significantly disability is associated with attacks
-avoidance of triggers and maintenance of homeostasis with regular sleep, meals, and hydration
-headache diary

56
Q

antidepressants

A

-amitriptyline: more effective, weight gain, dizziness, constipation, improves insomnia
-can be addictive
-SSRIs

57
Q

antihypertensive

A

-beta blockers (propranolol)
-ACE and ARBs (lisinopril, candesartan)

58
Q

antiseizure meds

A

-topiramate
-valproate
-gabapentin
-cheaper options

59
Q

choice of treatment

A

-individualized choice of medication will depend on comorbidities, cost, patient preference (route, frequency)
-trial and error of medications
-length of use
-tapering and withdrawing medication
-in chronic migraines -> acupuncture, botulinum toxin type A - reduces frequency
-neurostimulation techniques- single- pulse transcranial magnetic stimulation, vagus nerve stimulators, and implantable occipital nerve stimulation

60
Q

treatment barriers

A

-medication overuse
-underuse
-incorrect medication use- unadvised switches, mixing with OTC meds, delayed use of therapy

61
Q

goal of treatment for headache recap

A

-frequency and severity of attacks, presence and degree of temporary disability, profile of associated symptoms such as nausea and vomiting determine Rx
-pt hx, response to, tolerance for specific medication must be considered
-coexisting conditions (heart disease, pregnancy, uncontrolled hypertension) may limit treatment choices
-formal plan of care empowers patients to manage their condition with potential to reduce the number of office and emergency visits

62
Q

management recap

A

-early intervention
-stratified treatment
-dose and route- oral, injection, nasal, suppository
-medication overuse
-rescue treatment- connotes an ineffective outcome from abortive treatment and a need for effective symptom relief with goal of averting an unscheduled visit to a physician office or hospital emergency dept

63
Q

cluster headache

A

-clinical dx
-pathophysiology- hypothalamic cell activation/triggering the trigeminal autonomic vascular system
-typically, men > women
-usually beings at age 20-40
-alcohol may trigger attack- stress, glare, or ingestion
-frequency- episodic:
-between 1 every other day to 8/day
-for 1-3 months; followed by remission for months to years
-some patients have cluster headache without remission

64
Q

IHS criteria: cluster headache

A

-duration 15-180 minutes (3 hours untreated)
-severe UNILATERAL orbital, supraorbital/periorbital or temporal pain
-associated symptoms: (at least one; ipsilateral to pain)
-conjunctival injection (swelling of blood vessels in eye), lacrimation
-nasal congestion, rhinorrhea
-forehead and facial swelling
-miosis (pupil constriction) and ptosis (drooping)
-eyelid edema

65
Q

cluster headache management

A

-acute treatment:
-Sc or intranasal triptans (sumatriptan- imitrex)*
-100% O2*
-ergotamine or a combination
-intranasal lidocaine? - can numb the area of the trigeminal nerve
-NSAIDS
-prevention: verapamil, methysergide, lithium, valproate, combination

66
Q

primary cough headache

A

-A. at least 2 headache episode fulfilling criteria B-D
-B. brought on by an occurring only in association with cough, straining and/or other valsalva maneuvre (pressure, ex. going to bathroom)
-C. sudden onset (immediate)
-D. lasting between 1s and 2h
-E. not better accounted for by another ICHD-3 dx

-peaks immediately
-usually from short lasting efforts

67
Q

primary exercise headache

A

-A. at least 2 headache episodes fulfilling criteria B and C
-B. brought on by and occurring only during or after strenuous physical exercise
-C. lasting <48 hours
-D. not better accounted for by another ICHD- dx

-usually from sustained physical exercise
-hot weather, high altitude
-usually pulsating
-indomethacin usually effective

68
Q

primary headache associated with sexual activity

A

-A. at least 2 episodes of pain in the head and/or neck fulfilling criteria B-D
-B. brought on by and occurring only during sexual activity
-C. either or both of the following:
-increasing in intensity with increasing sexual excitement
-abrupt explosive intensity just before or with orgasm
-D. lasting from 1 min to 24h with severe intensity and/or up to 72 h with mild intensity
-E. not better accounted for by another ICHD-3 dx

-first onset -> mandatory to exclude subarachnoid hemorrhage, intra- and extracranial arterial dissection and reversible cerebral vasoconstriction syndrome (RCVS)
-multiple explosive headaches during sexual activity -> RCVS until proven otherwise by angiographic study

69
Q

primary thunderclap headaches

A

-A. severe head pain fulfilling criteria B and C
-B. abrupt onset, reaching max intensity in < 1 min
-C. lasting greater than or equal to 5 mins
-D. not better accounted for by another ICHD-3 dx

-mandatory to exclude subarachnoid hemorrhage etc.
-this is a dx of last resort -> all organic causes have been ruled out
-CT first to check for increased ICP (also eye exam to check for papillae edema)-> lumbar puncture
-if you do a lumbar puncture with increase ICP it can cause herniation of the brain
-thunderclap is not primary -> prof stated on 9/13/23

70
Q

idiopathic intracranial hypertension (IITCH)

A

-IIH
-pseudotumor cerebri
-disorder associated with obesity, female gender, occasionally pregnancy
-generalized headache
-generally present on awakening, worse with recumbency (migraine gets better when you lie down)
-improves as the day goes on
-often associated with papilledema but can also occur without visual problems
-MRI< including an MR venogram
-lumbar punction- if safe to do so
-treatment:
-acetazolamide-> 1st choice -> then topiramate - decreases fluid
-CSF removal
-shunting- chronic

71
Q

scotoma

A

-visual disturbances; field defects

72
Q

photopsia

A

unformed light flashes

73
Q

scintillating scotomas

A

some combination of field defects and luminous hallucinations

HEENT (18 decks)

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