Trans 079: HEADACHE Flashcards
what are the headache red flag?
• Systemic symptoms • Neurologic symptoms and signs • Older age of onset >50 years old • Onset that is thunderclap (sudden/severe) • P5 o Pattern change o Progressive o Positional o Precipitation with Valsalva o Pregnancy
SNOOP5
is the most important part of the exam for
headache
Cranial nerve is the most important part of the exam for
headache
potential Giant Cell Arteritis or Temporal
Neuritis. The first step is to identify
ESR
Systemic inflammatory vasculitis (large and medium
arteries)
Temporal artery and posterior ciliary artery of the eye
Giant Cell Arteritis
giant cell arteritis common in male or female? age?
- Typically older (>50 y/o)
- Female>male
Some manifestation of Giant cell arteritis?
- Headache (90%) and scalp tenderness
- Jaw and tongue claudication (50%)
When they chew, there is progressive pain - Polymyalgia rheumatica (50%)
Generalized aching of proximal limb muscles - Fever and malaise
- Visual symptoms/loss (Posterior ciliary artery occlusion)
Blindness is usually permanent - Aortic dissection
If it goes untreated
Screening test Giant cell arteritis?
ESR, CRP, Temporal Artery Biopsy
Tx Giant cell arteritis?
Steroids
when to use imaging in headache?
if there is a concern for secondary cause, or red flag
preferred imaging for emergency?
CT
o MRI>CT head non-emergent/ if available
o MRA/CTA: for all thunderclap headache
- Severe head pain reaching maximum intensity <1 minute
- Lasting greater than or equal to 5 minutes
Thunderclap headache
most common brain tumor type is? and the most common cause of metastatic origin is ?
metastatic; lung
what type of edema is happening in stroke?
Cytotoxic edema
Normal opening pressure is
Normal opening pressure is between 10-25
presenting symptom of TB meningitis?
- Low grade fever, malaise, weight loss, gradual onset HA
- 50% increased ICP
- May have focal neurologic deficits (CN Palsy)
- Seizure common <18 y/o
More common presenting symptom - CSF findings
- Pleocytosis with lymphocytic predominance
- Decreased glucose (<50%)
- Increased protein
- AFB smear (MTB-PCR if available)
- Evaluate for HIV
if there is viral meningitis, what should be given immediately?
Acyclovir
Most common causes of viral meningitis?
Enteroviruses»Arbovirus>Herpesvirus>HIV
findings in bacterial meningitis?
- Strong Predictor
- Glucose <34mg/dl
- CSF to serum glucose ratio <0.23
- Protein >220 mg/dl
- Total pleocytosis >2000cells/microL
- PMN >1180 cells/microL
- LIFE THREATENING
- Occurring within 20 seconds, peaking in 1 minute
- Nonspecific features, may include vertigo, tinnitus, diplopia
- Rarely cranial nerve changes and cortical blindness
- 90% within 24 hours, rarely 5-14 days
whta type of headache?
Positional headache
post lumbar puncture headache? age? sex? RF?
• High risk: age 20-30s (16%), 50s (4%), >60 rare
- F > M, lower BMI, chronic headaches, technique/nee
• 24 F present with headache and episodes of “graying out” of her vision
- Holocephalic, occipital > frontal
- Pulsating, worse in morning
- Associated with nausea, neck stiffness, photophobia
- Coughing results in visual change
- Several months duration
intracranial hypertension
waht drug decreases CSF produciton?
Acetazolamide
• 18 F presents a 3yr history of severe HA (headache) once per month.
- Over 1 hour develops severe L>R pulsatile pain
the headache develops over 1 hour. Described as a severe pulsatile pain. It hurts on both sides of the head but more so on the left
- Nausea, sometimes vomiting
- Photophobia and phonophobia
Sensitivity to light and sound, also with smell at times
- Often will have some forehead pressure with nasal congestion during episode
- Worse with activity, prefers to be in a quiet, dark room
- Lasts 8-12 hours
- No menstrual association
- Exam: Normal
what case?
Migraine
which is more common in migraine, photophobia or phonophobia?
photophobia more common
Simple, accurate, fast screener for migraine – strongest predictors of migraine diagnosis
• Photophobia – Does light bother you when you have headache?
• Impairment (Disability) – Has a headache limited your activities for a day or more in the last 3 months?
• Nausea – Are you nauseated or sick to your stomach when you have a headache?
o 2 out of 3 symptoms : 93 positive predictive value
o 3 out of 3 symptoms : 98 positive predictive value
These are very predictive of migraine
Migraine prevalence peak at what age, gender?
o Prevalence peaks at 25-55 years of age
o “Our most productive years
o Female > male 3:1
a secondary symptom, occurring simultaneously with a disease or condition not directly related to it.
epiphenomenon
an inherited neurological disorder characterized by neurological, sensory, autonomic, vestibular, cognitive, and gastrointestinal symptoms.
migraine
o Bilateral location
o Pressing/ tightening (non-pulsatile) quality
o Mild to moderate
not usually very bad
o Not aggravated by activity
• No nausea/ vomiting
• Either photophobia or phonophobia – “not both, not usually significant
Again, mild to moderate and not associated with nausea – that is tension headache
• Good history is key
what case?
Tension headache
is the most common headache disorder in the world
Rarely treated by a physician
tension headache
• A headache present on > or = 15 days / month with a prior headache disorder.
• Regular overuse for >3 month of one or more acute medications
o 10 days/month for most meds, 15 days/month for simple analgesics
• Headache has developed or markedly worsen during medication overuse
Medication Overuse Headache (MOH)
Don’t take triptans more than ______ times a week
3
is an old barbiturate and has been gradually been used less and less because of this issue.
butalbital
Migraine Preventive Therapy: Goals
- Reduce attack frequency, severity, and duration
- Reduce acute medication use and potential for MOH
- Improve responsiveness to treatment of acute attacks
- Improve function and reduce disability
lifestyle modifications for migraine?
SEEDS:
o Sleep hygiene
o Exercise daily
Exercising daily is helpful. Exercise during an attack is not helpful, it can make the pain worse. You want them to have a routine where most days of the week they are doing regular exercise if possible
o Eat regular meals
Avoiding fasting is important for people with migraine
o Diary of headaches
You can get a sense if the lifestyle recommendation that you’ve given them are helping
o Stress reduction
or addressing depression and anxiety are also important in preventing migraine
Supplements that can be taken for migraine?
o Magnesium 400mg BID (Level B) o Riboflavin (Vit B2) 200mg BID (Level B) o Avoid Butterbur (Petasites) – concerns for hepatotoxicity has shown to be helpful for migraine in some studies but unfortunately, if you don’t process this particular supplement right, it causes a hepatotoxic metabolite so we stopped recommending this particular supplement but I know its still out there and its worth knowing that it has its potential complication
In terms of medication approaches, we usually think about medicine anytime when the headache is getting more than weekly (greater than___a month) or more than____ days a month
4;
8
anti seizure meds for headache that can cause weight loss?
Topiramate
when do you say that it is a chronic migraine already?
oftentimes called Chronic Daily Headache
Headache for >15 days/ month, for at least 3 months
• For > 8 days/month, for at least 3 months, headache fulfills criteria for migraine without aura
The most common aura is
The most common aura is visual
People see bright flashing light, things like arc or a dark spot, that then gradually encompasses their vision. It could be off to just one side of the visual field or sometimes spread to the other side. But the key is it should only last less than an hour, on average, it’s about 20minutes and it has to be at least 5 mins. So it’s not something that’s very brief. Its long enough to get your attention.
aura should last for how long?
> 5 mins but <60 mins
are neuropeptides implicated in migraine. This is actually what’s triggering the pain.
Serotonin receptors 1B/1D and CGRP
Vasoconstrictive agents for acute tx of migainre
▪ Triptans (5HT 1B/1D receptor agonists)
▪ Ergotamines
non vasoconstrictive agents for acute tx of migainre
Ditans (5HT 1F receptor agonists)
Gepants (“CGRP antagonists)
contraindications of triptans?
o Prinzmetal’s angina
o High risk for cardiovascular disease (“they had MI, stent)
o Uncontrolled hypertension
o Cerebrovascular disease (“they had stroke)
o Basilar / hemorrhagic migraine
classic triad of serotonin syndrome?
dysfunction, dysautonomia, and mental status changes
• At least 5 attacks
• Severe or very severe unilateral, orbital, supraorbital, and/or temporal pain lasting 15-180mins
Shorter than a migraine. It lasts about 30mins to 2 hours. And then it will completely go away, and then it will occur in the same day, often in the same time
what case?
Cluster headache
ipsilateral cranial autonomic feature in cluster headache?
o Conjunctival injection and/or lacrimation o Nasal congestion and/or rhinorrhea o Eyelid edema o Forehead and facial sweating o Forehead and facial flushing o Miosis and/or ptosis o A sensation of fullness in the ear
aka suicide headache?>
cluster headache
a Ca channel blocker, is a common cluster headache preventative
verapamil
