Stroke Wrap up/ Headache - Rothrock Flashcards
what are the two subtypes of hemorrhagic stroke/
SAH
ICH
what are the two types of ischemic stroke?
embolic
thrombotic
A (thrombotic/emoblic) stroke may be characterized by the size of vessel it originates in
thrombotic
HA can be secondary to…
SAH Meningitis Abnl ICP Intracranial hematoma Ischemic stroke Tumor Abscess other
what is the hallmark of a low ICP HA?
okay lying flat, bad HA when standing up
what are some of the causes of thunderclap HA?
Aneurysmal rupture
Cerebral sinus thrombosis
Acute intracranial hypotension/CSF oligemia
Carotid artery dissection
Pituitary apoplexy
Unruptured aneurysm (?expansion,thrombosis)
Sexual headache (“explosive” type)/exertional
Crash migraine
Benign (idiopathic) thunderclap headache
what are the cuases of primary thunderclap headache?
sexual HA
exertional HA
what is the most common cause of thunderclap HA?
crash migraine
can you Dx headache over the phone or via proxy?
no
What things should you do on physical exam for HA?
check eyes: fundi, pupils, visual fields
BP
gait
(side-locked/global) HA is concerning
side-locked
what is the most common Dx for pts present with a CC of HA?
migraine
if a pt. meets the ICHD criteria for migraine and there are no red flags and the neuro exam is normal, what will imaging show?
a normal brain
what are the causes of primary headache?
tension-type headache migraine cluster paroxysmal hemicrania hemicrania continua hypnic (“alarm clock”) headache others
what are the things to look for when trying to figure out if someone has a secondary headache?
acute onset or thunderclap
>55
occipto-nuchal location
abnormal exam
what is the ICHD criteria for migraine?
5 or more attacks: unprovoked, 4-72hr duration, prohibit/significantly inhibit routine activities, nausea and/or photo/sonophobia
what causes migraine?
genetically induced neuronal hypersensitivity
the (blank) nucleus receives afferent messages and acts as a sensory relay center
trigeminal nucleus caudalis
pain receptors on the (blank) vessels activate primary afferent neurons of the trigeminal nerve
dural blood vessels
PANs coming from the dural blood vessels first pass through the (blank) before synapsing in the TNC
pons
After synapsing in the TNC, pain signals then synapse where?
posterior third of the thalamus
After synapsing in the thalamus, pain signals go where?
post central gyrus, cingulate gyrus, and hypothalamus
Is the pain pathway in migraine wired in series or in parallel?
series
what part of the cortex is sensitized in migraine?
occipital cortex
What are the kinds of things that can cause the neurons to depolarize in migraine?
sleep deprivation
stress
change in barometric pressure
menstrual cycle
After neurons depolarize, what happens in migraine?
they hyperpolarize and go electrically silent
First you get a aura like a flash, then as it moves across your vision you get a blind spot in its wake. Positive phenomena from depolarizing and black spot from hyperpolarized
what is it called when you get a black spot following a aura like flash/
cortical spreading depression
Cortical spreading depression causes pain in (anterograde/retrograde)
retrograde
cortical spreading depression releases (blank) at the dural vessel receptors
neuropeptides
release of neuropeptides at the dural vessel receptors causes the vessels to release (blank and blank)
bradykinin and histamine
the release of histamine and bradykinin causes (anterograde/retrograde) pain transmission back up the brain
anterograde
what are the two determining factors in the development of migraine?
the combo genetics and epigenetics (aka childhood abuse)
when are migraines the worst in females?
menarche
pregnancy
just before menopause
if the sensitization process of migraine is allowed to advanced unchecked, (blank) will be increasingly difficult to attain
stabilization
Where would you want to have a drug target in the CNS to act on migraine?
trigeminal nucleus caudalis
what types of receptors are in the TNC?
5-HT
what stops cortical spreading depression?
GABA
(blank) is an AED that can be used for migraine prophylaxis
topiramate
what are the pharmacologic characteristics you need to consider when using a drug to treat migraine?
inherent efficacy of drug stage of attack when drug is administered drug’s T max drug’s C max drug’s ability to reach receptors drug’s affinity for those receptors
What drugs are best used for acute Tx of migraine?
[NSAIDS, triptans, ergotamines/dihydroergotamine, opiates/opioids]
What are the drugs you should consider for preventative migraine Tx?
beta blockers, specifically propanolol TCAs AEDs Botox gabapentin
What is the only FDA approved drug for chronic migraine Tx?
botox
