Tension Headaches and TCAs Flashcards
1
Q
______ is vital to dx
A
headache history
2
Q
what is the most common type of headache
A
tension type
3
Q
over ______ of adults experience TTHA periodically
A
80%
4
Q
TTHA also common in:
A
children and adolescents
5
Q
what are the two forms of TTHAs
A
- episodic
- chronic
6
Q
what is the chronic TTHA
A
- frequency 15 days or more a month for 6 months
7
Q
most patients who suffer from TTHA _______
A
do not seek specific medical tx and use OTC medication to combat symptoms
8
Q
what is the ICHD diagnostic critera for infrequent episodic TTH
A
- at least 10 episodes of headache occuring on less than 1 day a month and less than 12 days a year
- lasting 30 mins to 7 days
- 2 or more of the following 4 characteristics: bilateral location, pressing or tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity
- both of the following: nausea or vomiting, no more than one of photophobia or phonophobia
9
Q
symptoms begin before the age of 20 in ____ of patients
A
40%
10
Q
what areas are usually involved
A
- no predilection - may involve frontal, temporal, parietal or occipital areas alone or in combination
11
Q
TTH associated with:
A
pericranial/cervical muscle tenderness
12
Q
studies have shown that patients with chronic TTH have a higher incidence of:
A
active TrPs in the upper trapexius, SCM, temporalis, and suboccipitals and other posterior cervical muscles
13
Q
TTH occurs in relation to:
A
emotional conflict
14
Q
most patients with TTH experience occassional:
A
very painful headaches often accompanies by migrainous symptoms
15
Q
epidemiological characteristics of TTH patients _______ from migraine pts
A
not significantly different
16
Q
migraine and TTH share common triggers such as:
A
stress, mental tension, fatigue, lack of sleep, menstruation
17
Q
TTH and migraines are at two ends of a _____ and many people will experience _______-
A
continuum, both types over a lifetime
18
Q
what is the non pharmacological management
A
- decrease intake of caffeine and alcohol as well as any medications that have been chronically used by the patient for the headache
- strategies to cope with stress and muscular pain
19
Q
non pharmalogical therapy may result in:
A
increased frequency and intensity of headaches
- after 1-2 weeks the withdrawal should subside
20
Q
how should you taper off caffeine
A
decrease by 25% each week so headache is avoided
21
Q
what are the strategies for coping with stress and muscular pain
A
- relaxation therapy with EMG biofeedback
- hypnotherapy
- massage therapy and physical therapy
- increase physical activity especially outdors
- deep breathing exercises
- 1 minute headspace mini breathing meditation
- calm app teaches mindfulness and medication in daily 10 minute presentations
- psychotherapy for cognitive therapy and mindfulness exercises
22
Q
what are the pharmacological managements for TTHs
A
- analgesics: aspirin, acetominophen
- NSAIDs: indomethacin, ibuprofen, naproxen, ketoprofen
- combination: aspirin and/or acetominophen with caffeine (excedrine migraine)
- muscle relaxants: diazepam, methocarbamol (robaxin), cyclobenzaprine (flexeril), carisoprodol, baclofen
23
Q
describe the use of analgesics for TTHs
A
- no more than 2 days per week
- low dosages of TCAs can be helpful in managing the headache
24
Q
when are TCAs best taken and why
A
before bedtime because of sedative effects
25
what are the TCAs
- amitriptyline (Elavil), nortriptyline (pamelor), doxepin, despiramine
26
all Trigeminal autonomic cephalgias are:
unilateral headaches accompanies by autonomic features
27
for trigeminal autonomic cephalgias rule out:
secondary cause
28
what are the types of trigeminal autonomic cephalgias
- cluster headache
- paroxysmal hemicrania
- short lasting unilateral neuralgiform headache attacks
- hemicrania continua
- probable trigeminal autonomic cephalgia
29
what is a cluster headache
- at least 5 attacks fulfilling criteria B-D
- severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes when untreated
- either or both of the following: one or more of the following ipsilateral symptoms or signs: conjunctival infection and or/lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead and facial sweating, forehead and facial flushing, sensation of fullness in the ear, miosis and/or ptosis, a sense of restlessness or agitation
- frequency from 1-2x/d to 8x/d for less than half the time when active
30
what is an episodic cluster headache
-attacks fulfilling criter for cluster headache and occuring in bouts (cluster periods)
- 2 or more cluster periods lasting 7 days to 1 year ( when untreated) and separated by pain free remission periods of 1 month or more
31
what is a chronic cluster headache
- attacks fulfilling criteria for cluster headache and critertion below
- occurring without a remission period or with remissions lasting less than 1 months for 1 year or more
32
cluster headache attacks are:
- provoked by alcohol
-frequently occurs during sleep or napping times
- during an attack patients with characteristically pace, cry, scream or pound their fists
33
who do cluster headaches affect
- primarily men (4:1)
- age of onset 20-40
34
_____ of patients have chronic symptoms with cluster headahces
10%
35
what is etiology of cluster headahce
unknown possible dysfunction of hypothalamus
36
where is pain in cluster headaches
centered behind or around the orbit or in the temporal area but radiation to the teeth and jaws is common- some patients seek dental tx for pain
37
what is the abortive tx for cluster headaches
- 100% oxygen at 7-10 L/min for 15 mins using face mask is effective within 10-15 minutes in 60-70% of cases
- sumatriptan (6mg Sc or nasal spray)
- DHE-45 (1mg IM or IV or migranol)
- intranasal administration of 1ml of 4% topical lidocaine
- indomethacin (oral or rectal)- cluster headache may respons
38
what is the prophylactic treatment for episodic cluster headache
- calcium channel blockers - verapamil
- ergotamine
- lithium carbonate
- methysergide
- valproate
- prednisone
39
what is the prophylactic treatment for chronic cluster headaches
- verapamil
- lithium carbonate
- methysergide
- gabapentin
40
describe hemicrania continua
- common in women
- temporal or frontal pain is most common
- throbbing, aching, sharp, stabbing
- age 10-77 years old with mean age 35-49 years
- a daily continuous strictly unilateral primary headahce
- the intensity of the pain may fluctuate but the headache never remits
41
what is the tx for hemicrania continua
indomethacin
42
what is the ICHD diagnostic criteria for hemicrania continua
- unilateral headache fulfilling the following
- present more than 3 months with exacerbations of moderate or greater intensity
- either or both of the following: 1 or more of the following ipsilateral autonomic symptoms: conjunctival infection and or/lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead and facial sweating, forehead and facial flushing, sensation of fullness in the ear, miosis and/or ptosis, a sense of restlessness or agitation or aggravation of pain by movement
- responds absolutely to indomethacin
43
what are the chronic paroxysmal hemicrania characteristics
- many consider CPH a variant of cluster headahce
- occurs primarily in women 2:1
- age range is 37-42 ( mean age = 34 years)
- attacks may be precipitated by flexion and occasionally by rotation of the neck
- pain is chronic, unilateral and localized to the temple, forehead, ear, eye or occipital regions
- throbbing, stabbing or boring pain
- severe to very severe pain in 88-93%
- restlessness common during attacks
44
what is the ICHD diagnostic criteria for paroxysmal hemicrania
- at least 20 attacks fullilling the following
- severe unilateral orbital, supraorbital and/or temporal pain lasting 2-30 min
- 1 or more of the following ipsilateral symptoms or signs: conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead and facial swelling, forehead and facial flushing, sensation of fullness in the ear, miosis and/or ptosis
- frequency more than 5 days for less than half the time
- prevented absolutely by therapeutic dose of indomethacin
45
what is episodic paroxysmal hemicrania
- attacks fulfilling criteria for 3.2 paroxysmal hemicrania and occuring in bouts
- 2 or more bouts lasting 7 days to 1 year ( when untreaed) and separated by pain free remission periods of 1 month or more
46
what is chronic paroxysmal hemicrania and how frequent
- 66-88%
- attacks fulfilling criteria 3.2 for paroxysmal hemicrania
- occurring without a remission period or with remission periods lasting less than 1 month for 1 year or more
47
what is the treatment for paroxysmal hemicrania
- absolute responsiveness of CPH to indomethacin is part of diagnostic criteria: 25mg 3x a day up to 500mg 3x a day
- long lasting remissions have been observed
48
what is the diagnostic criter for short lasting unilateral neuralgiform headache attacks
- at least 20 attacks fulfilling criteria B-D
- moderate or severe unilateral head pain with orbital, supraorbital, temporal and/or other trigeminal distribution, lasting 1-600 sec and occurring as single stabs, series or stabs or in a saw tooth pattern
- 1 or more of the following ipsilateral cranial autonomic symptoms or signs: conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead and facial swelling, forehead and facial flushing, sensation of fullness in the ear, miosis and/or ptosis
- frequency 1 or more days for more than half the time when active
49
what are the differences between SUNCT and TN
- TN is more common in females, SUNCT in males
- autonomic features: conjunctival injection/tearing must be present in SUNCT, less common in TN
- pain location: typically ocular area in SUNCT, V1 TN is very rare
- TN has a refractory period
50
what is the diagnostic criteria for SUNCT
- attacks fulfilling criteria 3.3 short lasting unilateral neuralgiform headache attacks
- both of conjunctial injection and lacrimation (tearing)
51
what is SUNCT treatment
- lamotrigine
- gabapentin
- topiramate
- IV lidocaine
52
what are the primary referrals for dx and headache management
- family doctor or neurologist
- orofacial pain specialist or pain management medical team
53
what are the secondary referrals once a dx is made
- psychotherapise
- acupunturist
54
you should refer your patient with facial pain and headache within _______ of your initial treatment if the pain is not being managed and to get a proper dx and tx
2 weeks
