T3-HA Flashcards
Tension and migraine headaches are more common in ____ than ____
Females than males
Headaches are now thought to be more of a ______ dysfunction than a _____ dysfunction
Sensory processing
Vascular
5 phases of a migrane.
Prodromal - hours or days before aura
Aura
HA
Post drone
Interictal
Describe the prodromal stage of migraines? What is it mediated through?
Yawning, polyuria, neck pain, food cravings, mood changes, mental fogginess, light sensitivity
Mediated through the hypothalamus and connections to other structures such as locus coeruleus and TCC (trigeminocervical complex where TG and cranial structures converge with cervical afferent s from upper cervical spine) which impact sleep and neck pain respectively.
Describe the aura and what it is pathophysiologically
Aura is before or during the HA - visual or sensory motor language or brainstem dysfunction.
Related to Cortical spreading Depression (CSD) - spreading depolarization across cortex followed by a relative depression of electro graphic activity
What is Cortical Spreading Depression?
spreading depolarization across cortex followed by a relative depression of electro graphic activity. Responsible for the aura and associated migraine
what is the Trigeminal Cervical Complex (TCC)
Where Trigeminal afferent s from the trigeminal ganglion (TG) and cranial structures converge with cervical afferent s from upper cervical spine.
What part of the brain may be activated during the postdrome of migraine?
Locus coeruleus.
SNOOP4 acronym helps to identify warnings sings of _______ headaches.
Secondary
SNOOP4 acronym
S - systemic symptoms/secondary diseases
N - Neurological symptoms/signs
O - onset (thunderclap)
O - Older (age >50yrs)
P1 - positional
P2 - prior history
P3 - pregnancy/post partum
P4 - precipitated by Valsalva.
What are some concerning features of secondary headache that align with the S in SNOOP4 and what could be some DDX?
Systemic symptoms = Fever, night sweats, chills, weight loss, jaw claudication
Secondary disease = Cancer, immunosuppression, chronic infx (HIV, TB)
Metastasis, Giant Cell Arteritis, infection (CNS, systemic)
What are some concerning features of secondary headache that align with the N in SNOOP4 and what could be some DDX?
Neurological symptoms/signs = confusion, focal neuro symptoms, diplopia, transient visual obscurations, pulsitile tinnitus.
Mass lesion, structural lesion, stroke, hydrocephalus
What are some concerning features of secondary headache that align with the 1st O in SNOOP4 and what could be some DDX?
Onset - Thunderclap
Reversible cerebral vasoconstriction syndrome (RCVS), stroke, subarachnoid hemorrhage, cerebral venous sinus thrombosis, arterial dissection, pituitary apoplexy, idiopathic intracranial hypertension
What are some concerning features of secondary headache that align with the 2nd O in SNOOP4 and what could be some DDX?
Older (>50) - new onset, persistent/progressive HA
Mass lesion, giant cell arteritis
What are some concerning features of secondary headache that align with the 4Ps in SNOOP4 and what could be some DDX?
Positional - orthostatic, recumbent or worsens with change in position
Low ICP (CSF leak), mass lesion, cerebral venous sinus thrombosis, sinus pathology
Prior history - new onset or change to persistent/daily HA
Mass lesion, infection (CNS or systemic)
Pregnancy/Post partum - new onset during pregnancy
Cerebral venous sinus thrombosis, preeclampsia, RCVS, pituitary lesion, stroke
Precipitated by valsalva - cough, sneeze, bending, straining
Intracranial/posterior fossa mass, Chiari malformation
International Classification of HA disorders (ICHD -3) has 3 categories of HA:
Primary
Secondary
Cranial neuralgias/facial pain
Migraine, tension type and trigeminal autonomic cephalgias (cluster) are types of _______ headaches.
Primary.
_____ % of migraines are withOUT aura.
75
1st line Tx for migraines
Triptans - 5HT-1B and 1D receptor targets (serotonin)
What type of pharmacotherapy for migraines is newer and actually have a preventative action on migraines?
CGRP receptor agonists - Gepants.
How are Ditans different from Triptans if they both treat migraines and target serotonin receptors?
Ditans do not vasoconstrict however they may have AEs including dizziness, sedation and and 8hr driving restriction after use. Lasmiditan is a schedule V
What is the MOST important aspect to address in patient’s with chronic migraines?
Stress reduction. If you can’t get stress under control, then treatments are less likely to be effective.
What are some characteristics of a brain tumor headache?
30% of patients with brain tumors report HA.
Worse with position change, awakens them from sleep, non-descript (dull, achy). Associated with other neurological abnormalities.
What are some nutrition/herbal supplements to help support migraine health?
None approved by FDA, but
Mg, vit B2, feverfew have level B evidence in prevention
Coenzyme Q10 has level C evidence.
Melatonin.
Lifestyle factors to prevent migraines?
Quality sleep, good hydration, healthy diet meals, caffeine and alcohol in moderation, regular exercise and STRESS management.
When does Temporal Arteritis typically show up, what are symptoms and what is a serious complication if not treated?
Average age onset of 70
Dull aching HA in temporal location.
Blindness if not treated promptly with steroids.
How are Tolosa-Hunt syndrome and cluster type headaches similar and different
Similar: severe, unilateral periorbital headache
Different: THS - long term and ophthalmoplegia. Inflammation of cavernous sinus with relapsing remitting course and attacks every few months to years.
Cluster type: shorter (1-4hours) with no ophthalmoplegia. Non-inflammatory.
Your patient has nausea, vomiting, severe, throbbing headache, photophobia, neck stiffness and fever. What are you suspecting as diagnosis? Why?
Meningitis.
Fever. Migraine also has all of the above s/s but no fever.
IIH - Idiopathic Intracranial HTN - criteria for Dx?
S/s of increased ICP (HA, transient visual obscurations, pulse synchronous tinnitus, papilledema, visual loss)
No other neurological abnormalities or impaired LOC
Elevated ICP with normal CSF composition
Neuroimigaing study shows no etiology for ICH
No other cause of intracranial HTN apparent.
Other than HA, what other s/s accompany Cerebral venous sinus thrombosis?
Focal neurological deficits, AMS, seizure and papilledema.
RCVS is a result of ______
Reversible Cerebral Vasoconstriction Syndrome
Diffuse segmental vasoconstriction oof intracranial arteries. Severe and recurrent.
Glossopharangeal neuralgia, occipital neuralgia, trigeminal neuralgia are all examples of ______ neuralgias
Cranial
first line tx for trigeminal neuralgia?
Carbamazepine or oxcarbazepine.
What is the pathophysiology related to Trigeminal neuralgia
Demyelination of the primary sensory trigeminal afferent s in the root entry zone.
What are some examples of painful trigeminal neuropathies?
Herpes zoster, infection, post-herpetic neuralgia, post traumatic, MS plaque and neoplasm.
Trigeminal Autonomic Cephalgias 3 kinds:
Cluster HA
Paroxysmal Hemicrania
SUNHA - short lasting Unilateral Neuralgiform headache attack.
3 main systems prominent in pathophysiology of Trigeminal Autonomic Cephalgias
Pain - starts in V1 branch then projects to the trigeminocervical complex
Cranial Autonomic system - responsible for lacrimation, conjunctival injection and other autonomic features - sphenopalatine ganglion, VIP, target system for oxygen
Hypothalamus - includes circadian system and aggression areas which may explain regularity and restlessness (molecules melatonin, target for verapamil and lithium) .
