RTS CNS Flashcards
Symptoms for migraine headaches
“POUND”
Pulsatile quality or severe throbbing pain
hOurs (duration of 4-72 hours)
Unilateral pain (70% of cases) sometimes bilateral
Nauseating or vomiting
Disabling intensity - sufferers often have to sit in a dark quiet room
“PUPIL”
P=Pain around sinus area, trigeminal nerve becomes inflamed which can radiate to teeth and jaw
U=Unilateral location
P=Physical activity worsens headache, Photophobia (light sensitivity), Phonophobia (sound sensitivity)
I=Inhibits daily activity when present
L=Location: temporal region of head
Red flag signs for headaches or secondary headaches which are very serious
“SNOOPY”
Systemic signs and disorders (fever, weight loss)
Neurologic symptoms (abnormal signs such as confusion, impaired alertness or consciousness)
Onset sudden, Older anyone >50 yo, Occipital (back of head) headache in children
Onset in thunderclap presentation
Previous headaches: new, worst, different Papilledema, pulsatile tinnitus, positional provocation, precipitated by exercise
Younger age, child under 12
Important questions to ask for a headache
AT&T WIRELESS Aura Timing Nausea/vomiting Tearing and any other eye symptoms Weakness/numbness Injury Runny nose during the attack Estrogen exposure (OCPs) Leg (joint pain) Energy less Stress Speech difficulties
What are cluster headaches?
“CLUSTER”
C – Conjunctival injection (bloodshot eyes). Conjunctival injection = A popular term for eyes that appear red due to dilation of the conjunctival vessels overlying the sclera Can occur every year usually similar time of the year (commonly spring & autumn)
L – Lacrimation, nasal congestion or rhinorrhea, forehead and facial sweating, miosis or ptosis Bouts can last 4-12 weeks at a time
U – Unilateral or ipsilateral - (the side affected can vary from time to time) pain is usually centered over one eye/ temple/ the forehead
S – Severe or very severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes if untreated
T – Triptan injection work. Oxygen and CCB work too.
E – Eyelid drooping (ptosis) or eyelid swelling.
R – Restlessness or agitation
Differential diagnosis for headache
Mnemonic: MM IT ACHES
Migraine
Meningitis, Medications
Increased intracranial pressure (tumours)
Tension headache, Temporal arteritis, Trigeminal Neuralgia
Arteriovenous malformations
Cluster headache
Hypertension, Hemorrhage
Eye disorders (Glaucoma), refractory error, exertional
Sinusitis, Sub-arachnoid hemorrhage, Systemic illnesses, Seizures, pSeudotumor cerebri
What medications are used to treat a migraine?
Treatment of migraine mnemonic: NSAiDs
N: NSAIDS like Naproxen, Aspirin, Ibuprofen, Diclofenac
S: Sumatriptan (And other Triptans such as rizatriptan, eletriptan, almotriptan, zolmitriptan, naratriptan, and frovatriptan).
AiDs: Antiemetic/dopamine receptor antagonists: Chlorpromazine, prochlorperazine maleate 3mg, and metoclopramide
Ds: Dihydroergotamine and ergot derivatives
Treatment Mnemonics Acute management = TEA
T = Triptan
E = Ergotamine
A = Aspirin & other NSAIDs, Acetaminophen
What can trigger a migraine?
CHOCOLaTE Ch – chocolate O – Oral contraceptive C – caffeine (or withdrawal) Ol – alcohol T – travel E – exercise
What is a migraine?
Migraine can be memorized by mnemonic: MIGRAINE
M = Males are less affected (Most patient are females), with aura warning signs before migraine begins (seeing flashing light/zig-zag lines)
I = Ion channel dysfunction causing a spreading front of cortical depolarisation (excitation) followed by hyperpolarisation (depression of activity) – pathogenesis
G = Genetic predisposition
R = Recurrent headache (Prophylactic treatment needed if > 3-4/month)
A = Aura (in 20% case), without aura migraine occurs without warning signs
I = Ilitriptan, sumatriptan, rizatriptan (Triptan) etc are the treatment of severe attack, not respond to paracetamol/NSAIDs
N = Nausea & vomiting
E = Ergotamine
What medications are used for migraine prophylaxis?
When needed: If > 3-4 attacks/month
Mnemonic: ABCDE
A = Antidepressants (amitriptyline, venlafaxine) avoidance of triggers e.g. OCP, Stress, HRT containing estrogen
B = Beta blocker, metoprolol, timolol, propranolol (80-160 mg daily, in a sustained-release preparation),
C = Calcium channel blockers (less effective) verapamil (80-160mg daily), flunarizine, antiConvulsants (valproate, topiramate)
D = Depression medication, i.e. Tricyclic anti-depressant such as amitriptyline 10-50 mg at night, dosulepin
E = Epilepsy medication, Na valproate (300-600 mg/day), Topiramate (50-100 mg/day)
What are the commonly used medications for migraine in practice?
Practically commonly used drugs are BAT
Beta Blockers (Beta blockers and Calcium channel blockers)
Antidepressants (TCAs and SSRIs)
Topiramate
How do you diagnose migraine without aura?
"AUSTIN" Activity aggravates the headache Unilateral location Sensitivity to light and/or sound Throbbing Intensity moderate/severe Nausea/vomiting
What are some preventative drugs used in migraine?
BATS
Beta blockers
Anticonvulsants (GTV) gabapentin, topiramate, valproate
Tricyclic antidepressants
Serotonergic drugs (Sumatriptan 50mg (imigran recovery tablet) - Serotonin agonist (5-HT1D) that relieves migraine by causing blood vessels in the brain to narrow)
What are the features of a migraine?
"EAT FUN" E=Episodic A=Aura - zigzag lines T=Throbbing headache F=Family history/F(p)hoto-phobia U=Unilateral N=Nausea and vomiting
What is the classification of a headache?
“VITAMIN”
V=Vascular: migraine, cluster, toxic vascular, hypertensive
I=Inflammatory and traction: mass lesion (tumour, edema, hematoma, haemorrhage), arteritis, phlebitis, neuralgia, occlusive vascular disease, temperomandibular joint syndrome
A=Atypical variants
M=Muscle contraction headache: depressive equivalents and conversion reactions, cervical osteoarthritis, chronic myositis
I=Infectious (meningitis, encephalitis)
N=Non-cranial sources (eyes, ears, nose, throat, teeth)
What are the symptoms of migraine headaches?
"PUPIL" P=Pulsatile quality U=Unilateral location P=Physical activity worsens headache I=Inhibits daily activity when present L=Location: temporal region of head
What are the precipitating factors for a migraine headache?
C^6 Cino (wine) Cheese Chocolate Citrus fruits Coronary vasodilator (nitrates) Contraceptive pill
What are the side effects of tricyclic anti-depressants?
“A^4”
Anticholinergic side effects
Antihistaminic (sedation, weight gain)
Anti alpha-1 adrenergic (orthostatic hypotension)
Arrhythmogenic (quinidine-like ventricular cardiac effects)
What are the signs and symptoms of depression?
"ASSESS PAT" Appetite diminished +/- weight loss Sleep disturbance (especially diminished number of sleep hours) Sexual libido diminished Energy diminished Suicidality Self-worthlessness, guilt Psychomotor agitation Anhedonia Thought process impaired
What receptors do tricyclic antidepressants antagonise?
"SHAM" S=Serotonin H=Histamine A=Alpha M=Muscarinic
What are some anticholinergic side effects?
"can't see, can't pee, can't spit, can't shit" Can't see - blurred vision Can't pee - urinary retention Can't spit- dry mouth Can't shit - constipation
What are the symptoms of generalized anxiety disorder?
"STOMACH" S=Scanning and vigilance T=Two or more worries O=Organic causes should be ruled out M=Motor tension A=Anxiety unrelated C=Course of mood or psychotic should be ruled out H=Hyperactive autonomics
What drugs may cause depression?
"PROMS" P=Propanolol R=Reserpine O=Oral contraceptives M=Methyldopa S=Steroids
What are some medications used for migraine prophylaxis?
"Very Valuable Prophylactic Agents" V=Verapamil V=Valproate P=Propanolol A=Amitryptiline Hcl
What questions should you ask the patient for insomnia?
"INSOMNIA STRIKES HIM" I=Interruption of sleep during night N=Naps during the day S=Snoring during the night O=On the clock (What time do you go to bed? Total sleep time?) M=Morning awakening N=Narcolepsy (sudden fall asleep) I=Illness/stress recently A=Activity before going to sleep? (Watching TV) S=Sadness T=Tremor I=Irritability K=K-caffeine E=Exercise (in the morning or afternoon) S=Sweating/skin or hair changes, neck pain HI=Heat/cold intolerance M=Menstrual irregularities
Key questions for migraine
"”WWHAM”
Who is it for?
Have they had it before – if not already diagnosed=refer
What are the Symptoms?
Severity of pain, visual disturbances, rash, stiff neck, vomiting
How long have they had it?
Frequent attacks, more than 2 attacks in a month = refer
Action taken?
OTC treatment failure, more than 3 days of codeine already taken = refer
Medication?
Hormonal therapy, analgesia overuse, vasoconstrictors
Sumatriptan
ABCD of Sumatriptan
A - Acute migraine treatment / Asthenia as a side effect
B - Basoconstriction (“v”) of cerebral vessels
C - Coronary vasospasm
D - 5 HT1 type D receptor
Prophylaxis and treatment of different headache types
Prophylaxis and treatment of different headache types mnemonic: “1st letters in name – prophylaxis last letters in name – treatment” Tension headache T-Tricyclic antidepressants (prophylaxis) N-Nsaids (treatment) Cluster C-Calcium channel blockers, corticosteroids L-Lithium with calcium channel blockers are prophylaxis Ter-Triptans - Treatment
Clinical uses for gabapentin
Gabapentin
Gaba-gaba analogue
P-peripheral neuropathy, migraine, bipolar disorder, it is a calcium channel blocker
What are the 54321 rule for migraine from the international headache society?
“54321”
5-5 or more attacks
4-repeated episodes lasting 4-72 hours untreated
2-Any two of the following unilateral, throbbing, worsened by movement and moderate to severe
1 Any 1 of the following nausea/vomiting, photophobia and phonophobia
“SNOOP”
"SNOOP" S-Systemic signs or symptoms N-Neurologic symptoms O-Onset>50 y/o O-Onset was sudden P-Papilledema, positional provocation, precipitated by valsalva, progressive headache or precipitated by change
SIde effects of triptans
“Flashing tinkling neck ties”
Flashing-flushing
tinkling-tingling
neck ties-neck tightness
Symptoms of horner’s syndrome found in cluster headaches
"HORNs of the PAMpas deer" HORN-Horner's syndrome P-Ptosis A-Anhidrosis M-Miosis
Critera for cluster headaches
Atleast 5 attacks fulfilling the critera
Severe or very severe unilateral, supraorbital and/or temporal lasting 15 to 180 minutes if untreated.
Headache is accompanied by greater than or equal to 1 of the following:
Ipsilateral conjunctival injection and/or lacrimation
Ipsilateral nasal congestion and/or rhinorrhoea
Ipsilateral eyelid edema
Ipsilateral forehead and facial sweating
Ipsilateral miosis and/or ptosis
A sense of restlessness or agitation
Attacks have a frequency from 1 or 2/day to 8/day
Criteria for trigeminal neuralgia
Paraoxysmal attacks of pain lasting from a fraction of 1 seconds to 2 minutes, affecting one or more divisions of the trigeminal nerve.
Pain has greater than or equal to one of the following characteristics:
Intense, sharp, surficial or stabbing
Precipitated from trigger areas or by trigger factors
Attacks are stereotyped in the individual patient
There is no clinically evident neurological deficit
Not attributed to another disorder
Side effects of sodium valproate
"VALPROATE" V-Vomiting A-Alopecia L-Liver toxciity P-Pancreatitis and pancytopenia R-Retention of fat (weight gain) O-Oedema (peripheral oedema) A-Appetite increase T-Tremor E-Enzyme inducer (liver)
What are the trigeminal autonomic cephalalgias?
SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing)
SUNA (short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms)
Paroxysmal hemicrania
Cluster headache
Hemicrania continua
