TEST #3 Hon Headache Flashcards
International Headache Society (IHS) Classification of Headaches
• PRIMARY HA’s (Benign HA disorders):
- Migraine (with or without aura)
- Chronic Migraine
- Tension type
- Cluster HA
- Post-traumatic HA – Drug rebound HA
- Other
• SECONDARY HA (Headaches that are a sign of organic disease)
Headache History Part 1
• Need good general health history
• HEADACHE HISTORY: – How many types of HA? – Frequency a) Previous b) Current c) Mode of increase: gradual or sudden
• PAIN: – Intensity – Location – Duration – Impact of exertion
• PRODROME: – Changes in energy levels, mood, appetite – Fatigue – Muscle aches – Aura
• ASSOCIATED SYMPTOMS: – Nausea – Vomiting – Anorexia – Photophobia – Phonophobia – Diarrhea – Stuffy/Runny Nose – Watery eyes – Ptosis/Miosis – Dizziness – Behavior a) Retreats to dark room b) Paces c) Rocks
Headache History Part 2
• TRIGGERS: – Hormones (menstrual cycle, OC’s, HRT) – Diet – Stress – Environmental changes – Sensory stimuli
• CURRENT AND PREVIOUS MEDICATIONS TRIED:
– For both prophylactic and abortive therapy
– Dosages
– Effectiveness
– Side effects
• GOOD MEDICATION/ SURGICAL HISTORY: – Co-morbidities a) Sleep disturbance, Mood disturbance – Other medications – Head Trauma – Previous LOC – Seizure D/O – Allergies
• FAMILY/ SOCIAL HISTORY: – Family illnesses a) IncludingHA’s – Habits – Occupation
Headache Exam
• GOOD GENERAL EXAMINATION: – Vital signs (particularly BP/Pulse) – Cardiac Status – Extracranial structures – ROM & presence of pain in C-spine
• NEUROLOGICAL EXAM: – Neck flexion – Presence of bruits over the head and neck – Optic fundi, pupils, visual fields – Thorough cranial nerve exam – Motor power in limbs – Muscle reflexes – Plantar responses – Sensory exam – Coordination – Gait
Worrisome Signs
• SIGNS WHICH MAY INDICATE HA OF PATHOLOGICAL ORIGIN (SecondaryHA):
– “Worst HA”
– Onset of HA after age 50
– Atypical HA for patient
– HA with fever
– Abrupt onset (max. intensity in sec. to min.)
– Subacute HA with progressive worsening over time
– Drowsiness, confusion, memory impairment
– Weakness, ataxia, loss of coordination
– Paresthesias / Sensory loss / Paralysis
– Abnormal medical or neurological exam
When a Brain is insulted, it does 3 things:
1) Swell
2) Bleed
3) Seize
Diagnostic Evaluation
• Lab testing (appropriate for variant or atypical forms) • Neurodiagnostic tests • Other WSR, TSH, CBC, glucose -CT, MRI/MRA, EEG, L.P., arteriogram -Dental, ENT, allergy evaluation
To Image or Not to Image
- As a general rule, many physicians (including neurologists) believe that any person with HA should have a ONE-TIME, thorough neuroimaging study (CT head with and w/o contrast or MRI of the head).
- Clearly, any patient with a “WORRISOME HISTORY” or abnormal examination needs an urgent imaging study and perhaps even an L.P. and possibly arteriogram. (Remember: CT CAN MISS 5-10% OF SUBARACHNOID HEMORRHAGES and an L.P. MAY BE NEEDED if the CT is NORMAL!)
Primary HA Disorders
1) COMMON Migraine
– (migraine without aura)
2)CLASSIC Migraine
– (migraine with aura)
(Consider CHRONIC migraine)
3) TENSION-Type HA
4) CLUSTER HA
Common Migraine
- Intensity: MODERATE TO SEVERE
- Disability: Inhibits or prohibits daily activities; pain aggravated by activity
- Age of onset: late teens to early 20’s; prevalence PEAKS between 35-40 YEARS!!!!
- Gender ratio F:M = 3:1!!!!!!!
- Frequency: 1-4 attacks per mo. (occ infreq.) – but 14 days or fewer per month
- Duration: 4 to 72 hr, usually 12-24 hr.
- Location: UNILATERAL OR BILATERAL
- Description: THROBBING/ SHARP/ PRESSURE
- Prodrome: Mood changes, myalgias, food cravings, sluggishness, excessive yawning
- Postdrome: Fatigue, irritability, “fog”
- Behavior: RETREAT TO DARK, QUIET ROOM
• Aura: NONE!!!!!
– Note: 80-90% of migraine sufferers DO NOT experience an aura!!!
Associated Symptoms of a Common Migraine
• MOST COMMON: – Nausea (90%) – Vomiting (33%) – Photophobia – Photophobia
• LEAST COMMON: – Diarrhea – Conjunctival injection – Stuffy nose – Lacrimation – Miosis – Ptosis
Classic Migraine
• AURA:
– Usually lasts 15-30 MIN., but sometimes longer.
– Commonly VISUAL SYMPTOMS (e.g. scintillations, scotoma – often hemianopic), BUT CAN BE ANYTHING NEUROLOGICAL
Chronic Migraine
- Many patients with EPISODIC MIGRAINE will ultimately develop CHRONIC MIGRAINE.
- H/o headaches consistent with migraine, now with headache 15 OR MORE DAYS PER MONTH , headache lasting 4 HOURS OR LONGER, for a period of at least 3 MONTHS, not attributed to another disorder.
What Causes Migraines?
- The most widely discussed theory is that migraine is caused by “NEUROGENIC INFLAMMATION.”
- The trigeminal nerve becomes activated, releasing neuropeptides, causing painful neurogenic inflammation within the meninges, with subsequent effect on the dural vasculature (vasodilation, plasma protein extravasation, and mast cell degranulation).
Tension- Type Headache
- Intensity: MILD TO MODERATE
- Disability: May inhibit, but DOES NOT PROHIBIT DAILY ACTIVITIES
- Age of onset: Variable; generally peak incidence 20-40 yr.
- Gender ratio F:M = 3:2
• Frequency:
– EPISODIC Type: 15 days/month
a) ??? Analgesic Rebound HA’s
• Duration:
– EPISODIC Type: SEVERAL Hours
– CHRONIC Type: ALL DAY, waxing and waning
- Location: BIFRONTAL, BIOCCIPITAL, neck, shoulders, band-like
- Description: DULL, ACHING, SQUEEZING, PRESSURE
- NO PRODROME OR AURA
- Behavior generally not affected
