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Neurology Clerkship > Headache > Flashcards

Headache Flashcards

1
Q

Estrogen and migraines

A

Estrogen increases the likelihood and frequency of migraine headaches

Mechanistically, this is thought to be due to its influence on nitric oxide levels

For this reason, it is most common in 20-40 year old females.

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2
Q

Migraine prodrome vs migraine aura

A
  • Prodrome:
    • Nonspecific phenomena that occur hours to days prior to headache onset
    • May be psychological (euphoria, depression, irritability) or constitutional (increased urination, increased defecation, anorexia)
  • Aura:
    • Transient frank neurologic dysfunction
    • Gradually develop over minutes and last 5-60 minutes
    • Classically occurs immediately before head pain, but may occur during headache or without headache in affected patients
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3
Q

Some classical migraine auras

A
  • Scintillating scotomas: zigzag luminous images, flashing lights with zigzag pattern, distortion of images
  • Smells
  • Tastes
  • Nausea
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4
Q

Features of the classical migraine headache

A
  • Unilatreal
  • Pulsating in quality
  • Lasts 4 hours - several days
  • Associated symptoms of nausea, photophobia, and phonophobia
  • Desire to seek rest in a quiet, dark place
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5
Q

Cortical spreading depression theory

A
  • Important in both migraine and seizure spreading
  • As disrupted cellular calcium homeostasis and chemical cascades propagate, trigeminal neurons signal dural vessels to release calcitonin gene-related peptide (CGRP), substance P, and neurokinin A
  • These mediators lead to inflammation and dilation of blood vessels, resulting in pain signals which are sent to the brain
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6
Q

If you think a patient’s headache is due to temporal arteritis, what do you do?

A
  • Give empiric corticosteroids
  • Send them to the ED
  • Here they will get a screening ESR and CRP
  • If elevated, they will get further workup including temporal artery biopsy
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7
Q

Features of a tension headache

A
  • Bilatreal
  • Band-like tightness/pressure quality
  • Sometimes precranial tenderness
  • Not associated with nausea, vomiting
  • May be associated with phonophobia or photophobia, but usually not both
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8
Q

Studies that one might order for suspected secondary headache

A
  • CT
  • LP
  • Biopsy
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9
Q

Headache red flags

A
  • Fever
  • Focal deficit
  • New-onset in age > 50
  • Thunderclap headache (instantaneous onset worst headache of life)
  • Progressive N/V that is worse in morning
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10
Q

Analgesic rebound headache criteria for diagnosis

A
  • Use of analgesics > 10 times per month
  • Headaches occur when in withdrawal period after analgesic use
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11
Q

Cluster headache

A
  • Pathology: vascular
  • Presentation: Asymptomatic for months, then experience a “cluster” of headaches 8-10 times per day
  • Features: Unilateral eye pain, Horner’s syndrome, rhinorrhea, lacrimation, conjunctival injection
  • Diagnosis: Clinical, but one-time brain MRI or CT is necessary to rule out other etiologies.
  • Treatment:
    • Abortive: Oxygen (nasal cannula). If this fails, triptans.
    • Maintenance: Verapamil
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12
Q

Migraine therapy

A
  • Abortive:
    • 1st line: NSAIDs
    • 2nd line: Triptans, ergots (but be careful in CAD), OR midrin
    • NOT butalbital – no longer recommended
  • Maintenance:
    • 1st line:
      • Beta blockers: Propranolol
      • Anticonvulsants: Topiramate, valproate, divalproex, gabapenti
    • 2nd line:
      • Combinations: Midrin
      • CCBs: Verapamil
      • Antidepressants: Amitryptiline, duloxetine, nortryptiline
    • 3rd line: Methysergide maleate, lithium carbonate, clonidine, captopril
    • 4th line: Botox injections q3 months
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13
Q

Idiopathic intracranial hypertension aka pseudotumor cerebri

A
  • Path: Increased ICP, for no discernable reason
  • Presentation: Female patient with increased ICP and papilledema, but THEN imaging is negative for any etiology
  • Often some form of visual disturbance is present, such as blurry vision when standing up quickly – untreated disease can lead to blindness
  • Causes: OCPs
  • Dx: Negative CT and/or MRI to rule out intracranial mass-occupying lesion. LP with opening pressure > 25 cm H2O with relief after LP
  • Tx:
    • 1st line: Acetazolomide and weight loss.
    • Refractory or bridging to acetazolomide: Repeated LPs
    • Truly chronic, refractory cases: VP shunt. Optic nerve fenestration (may help preserve vision)
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14
Q

If sinusitis does not respond to anticongestants, consider. . .

A

. . . migraine as a mimic of sinusitis

It is actually VERY common. In fact, 80% of patients with “sinus headache” actually have migraines, NOT sinusitis.

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15
Q

If you have strong clinical suspicion for SAH despite a negative CT, you should. . .

A

. . . do an LP to look for xanthochromia

You WILL have to differentiate between migraine and SAH on the test.

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16
Q

Why is “new onset headache in a patient over age 50” a red flag sign for headaches?

A

Because this is the demographic of patients at risk for temporal arteritis

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17
Q

Lab data that support a diagnosis of temporal arteritis in someone with a case of TA vs migraine

A

Elevated ESR, CRP, and thrombocytosis

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18
Q

Platelets in temporal arteritis

A

Platelets may be elevated in temporal arteritis, AND this elevation correlates with the risk of vision loss

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19
Q

If there is strong clinical suspicion for temporal arteritis, . . .

A

. . . you should treat with corticosteroids immediately – prior to even confirming the diagnosis with a biopsy

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20
Q

“Headache that awakens the patient from sleep”

A

Concerning for brain tumor

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21
Q

How are triptans optimally used to abort migraines?

A

At the first sign that a migraine is coming on, such as during an aura in the case of migraine with aura

They can still help once the migraine has begun, but are less effective than if used ASAP

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22
Q

How much triptan can someone take for a prolonged migraine?

A

Can be used q4 hours PRN, but not more than three doses per 24 hours

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23
Q

Triptan side effects and contraindications

A
  • Side effects:
    • N/V
    • Tingling in fingers and toes
    • Hypertension/vasospasm
  • Contraindications:
    • History of CAD
    • History of HTN
    • Migraines involving hemiplegia or blindness as an aura
      *
24
Q

If you have to choose between a triptan and an ergotamine on the exam for the treatment of migraines, . . .

A

. . . triptan is almost always going to be the right answer

25
Q

First and most important step in migraine prophylaxis

A

Keeping a headache diary

To identify migraine triggers, and thus avoid them

26
Q

Midrin

A
  • Abortive AND maintenance therapy for migraines
  • Three components:
    • Acetominophen
    • Chloralphenazone (muscle relaxant)
    • Isometheptene mucate (vasoconstrictor)
  • If used for abortive therapy: Take 2 tablets at aura or headache onset, then one tablet hourly for three hours if headache persists (up to 5 doses total)
  • If used as maintenance therapy: Take 1 tablet BID, then a 3rd or 4th pill for breakthrough headaches
27
Q

When is pharmacologic migraine prophylaxis indicated?

A

When there are at least 3 attacks per month OR when acute therapy is not effective

28
Q

When using anticonvulsants for migraine ppx, . . .

A

. . . we use a much lower dose than antiepileptic dosing

Thus, serum level monitoring is not required and risk of induced seizures is very low

29
Q

With regards to migraine prophylaxis:

For whom are beta blockeres first line, and for whom are anticonvulsants first line?

A

In someone who is young and healthy, beta blockers may produce hypotension and dizziness, and generally be more difficult to tolerate. Thus, anticonvulsants like topiramate are usually first-line in these patients.

In someone who is older and has some HTN, beta blockers will be better tolerated and will have additional benefits for other aspects of the patient’s health. So, beta blockers will be first line.

30
Q

Chronic daily headache

A
  • Daily or near-daily headache lasting at least 4 hours per day and at least 15 days per month.
  • DDx changes substantially from standard headache ddx:
    • Transformed migraine
    • Medication overuse rebound headache
    • Chronic tension headaches
    • Heicrania continua
    • New daily persistent headache
31
Q

Transformed migraine

A
  • Form of chronic, daily headache that develops gradually over time in a patient with a history of episodic migraine
  • As frequency of episodic migraine increases, the associated photophobia, phonophobia, and N/V decreases, until the patient has near daily headches that resemble tension-type headaches, without any migraine-associated features
  • These patients will still experience concurrent attacks of non-transformed episodic migraine intermittently
  • The process of migraine transformation usually takes place over a 3-6 month period
32
Q

Chronic migraine

A

Heaache occuring more than 15 days per month for 3 or more months in a patient with history of migraine.

Headaches meet migraine criteria on at least 8 days per month

Transformed migraine may meet the criteria for chronic migraine.

Requires exclusion of secondary causes.

33
Q

Chronic tension-type headache

A
  • Occurs in patients with a history of episodic tension headaches that increase in frequency and meets criteria for chronic headache
  • Pain is bilateral in the temporal regions or hatband distribution, not associated with N/V, phonophobia, photophobia
  • Quality of pain is described as pressing or tightening, and is non-pulsatile
  • May also be associated pain and tenderness in the occipital area as well as the posterior strap muscles of the neck
  • May also have an occasional breakthrough migraine headache, but not at the same frequency as breakthrough headaches in transformed migraine
  • Treatment of choice is amitriptyline
34
Q

Hemicrania Continua

A
  • Truly constant unilateral headache at baseline with superimposed episodes of severe, sharp, stabbing pain occuring on the same side
  • Considered one of the trigeminal autonomic cephalalgias, along with tension headaches and SUNCT headaches
  • Superimposed episodes occur almost daily and last 30 minutes to 3 days, often accompanied by ipsilatreal autonomic symptoms (ptosis, conjunctival injection, lacrimation, nasal congestion, rhinorrhea) and foreign body sensation in the affected eye. Migraine features (N/V, photophobia, phonophobia) may also be present
  • Absolute response to indomethacin treatment is a DEFINING feature
35
Q

Hemicrania continua is frequently misdiagnosed as. . .

A

. . . migraine or cluster headache

Since the episodic exacerbations share migraine-like features and autonomic symptoms

The key differentiating features are:

  1. baseline headache, which is not present in migraine or trigeminal autonomic cephalalgias
  2. coexistence of migraine and TAC features during exacerbations
  3. Excellent responsiveness to indomethacin therapy
36
Q

What is the treatment for hemicrania continua?

A

Indomethacin

37
Q

New Daily Persistent Headache

A
  • Abrupt onset of a daily headache over a period of < 3 days
  • Patients have no prior history of a pre-existing headache syndrome
  • The patient recalling the date or circumstance during which the headache started is a pathognomonic feature
  • Headache is bilateral, may be aching or throbbing, and may be associated with tension-type features or migraine-type features. Thus, the abrupt onset rather than headache features should be used in making the diagnosis
  • Dx: Diagnosis of exclusion after ruling out more concerning causes of acute onset headache
38
Q

Occipital neuralgia

A
  • Headache in which the greater occipital nerves are irritated or inflamed
  • Causes pain in the distribution of the occipital nerve
  • May be unilateral or bilateral
  • Pain is neuropathic in nature (shooting, burning, electrical sensation) and is accompanied by overlying allodynia
  • Sometimes occurs secondary to a tension headache, as the surrounding muscle tension in the neck and scalp can irritate the nerve
  • Dx AND Tx: Occipital nerve block with steroid and local anesthetic. Can also be treated more conservatively with physical therapy and neuropathic analgesics (tricyclics, low-dose antiepileptics, gabapentinoids)
    • Tx for refractory cases: Pulse radiofrequency occipital nerve stimulation
39
Q

Therapy of medication overuse headache

A

Requires gradual weaning of the overused agent along with management of withdrawal symptoms AND the original headache syndrome

A minority of patients require admission to the hospital for weaning therapy

40
Q

Short-lasting unilateral neuralgiform headache attacks

A
  • Unilateral, moderate-severe headaches that occur in the trigeminal distribution
  • Often mistaken for trigeminal neuralgia
  • Pain is stabbing and lasts from 1 second to 10 minutes
  • Two forms differentiated by their associated autonomic symptoms, both of which may be episodic or chronic
    • Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). Autonomic Sx: both conjunctival injection and lacrimation
    • Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symtoms (SUNA). Autonomic Sx: at least one of facial sweating, facial flushing, ptosis, pupillary miosis, eyelid edema, nasal congestion, rhinorrhea, ear fullness, conjunctival injection, lacrimation (but NOT both conjunctival injection and lacrimation – since that is SUNCT)
  • Treatment:
    • Abortive: IV lidocaine
    • Maintenance: Topiramate, lamotrigine, or gabapentin. If refractory, occipital nerve block
41
Q

Flavors of hemicrania

A
  • Episodic paroxysmal hemicrania
    • Recurrent attacks separated by at least one pain-free month
    • 2-30 minute long attacks
  • Chronic paroxysmal hemicrania
    • Recurrent attacks without period of remission of 1 month or greater
    • 2-30 minute long attacks
  • Hemicrania continua
    • Intractable pain and autonomic symptoms consistent with hemicranias, lasting for > 3 months without cessation
42
Q

Treatment for all hemicranias

A

Indomethacin is always the answer

Indomethacin trial is both diagnostic and therapeutic

43
Q

Main differentiating features between SUNCT/SUNA and hemicrania

A
  • Attacks in hemicrania are long on average (2-30 minutes in hemicrania vs 1 second - 10 minutes in SUNCT/SUNA)
  • Hemicrania is more likely in females, while SUNCT/SUNA is more likely in males
  • Hemicrania responds well to indomethacin trial
44
Q

Headache mimics

A
  • Sinusitis
  • Temporomandibular joint disorder
  • Cervicogenic headache (often w/ myofascial trigger points and reduced cervical ROM)
  • Trigeminal neuralgia (really a focal seizure, treat w/ carbamazepine)
45
Q

Trigeminal neuralgia

A
  • Shooting, shock-like pain occuring in one or all branches of the trigeminal nerve
  • Pain is paroxysmal and recurrent, and may be triggered by activities such as brushing hair or teeth, chewing. Lasts on the order of seconds to minutes. Facial spasms may also be present.
  • Can be idiopathic, secondary to mass or vascular lesion, or secondary to demyelination (as in MS)
    • Classic TN: Neurovascular compression of trigeminal root by an aneurysm (usually of the superior cerebellar artery)
    • Secondary TN: Caused by another process (demyelination, tumor at cerebellopontine angle, AV malformation)
    • Idiopathic TN: No causative lesions identified
  • Diagnosis: Clinical diagnosis. MRI w/ and w/o contrast is indicated to determine whether TN is primary or secondary (or CTA if MRI is contraindicated). Normal MRI suggests idiopathic TN.
  • Treat w/ carbamazepine. If refractory, other anticonvulsants or gabapentinoids may be tried. Microvascular decompression surgery may be indicated in refractory cases of classical TN (w/ aneurysm/arterial loop)
46
Q

Classical trigeminal neuralgia diagram

A

Classically caused by a “loop” of the SCA compressing CNV

47
Q

Can trigeminal neuralgia be caused by MS?

A

YES

48
Q

Hemiplegic migraine

A

An uncommon subtype of migraine with aura that is distinguished by motor weakness as the manifestation of the migraine aura in at least some migraine episodes.

May be sporadic or familial. Familial forms caused by a mutation in CACNA1A

49
Q

Migraine with brainstem aura

A
  • Episodes of migraine preceded at least some of the time by brainstem aura (but can also be preceded by typical aura)
  • Criteria:
    • ≥2 fully reversible brainstem symptoms (dysarthria, vertigo, tinnitus, diplopia, ataxia, hearing loss, impaired consciousness)
    • No motor or retinal symptoms
50
Q

Many patients with migraine report having ___ as children

A

Many patients with migraine report having motion sickness as children

51
Q

Post-dromal phase of migraine

A

Fairly common among patients with migraine

Symptoms of difficulty concentrating, specific food cravings, and fatigue following the end of a migraine headache

52
Q

Women with migraine are more likely to experience a migraine headache around the time of. . .

A

. . . their menses

Due to the effects of estrogen withdrawal

53
Q

Treatment of migraine in children

A
  • Abortive:
    • NSAIDs and acetominophen are first-line agents
    • Sumatriptan nasal spray is available for kids over age 12
  • Preventative:
    • Propranolol and amitriptyline are first-line agents
      • For propranolol, you should monitor blood pressure when starting the medication
      • For amitriptyline, you should monitor QTc. Prolonged QT at baseline is a contraindication.
    • Topiramate is an option for kids over age 12
    • For kids who cannot swallow pills, cyproheptadine oral solution can be perscribed (it is an antihistamine with anticholinergic and calcium channel blocking properties as well)
    • Riboflavin (B2) is considered effective for migraine prevention
54
Q

Coenzyme Q and riboflavin in migraine

A

Studies of the mechanism of migraine headaches suggest that migraineurs are in a state of mitochondrial energy depletion, and that suplementation with compounds that can be used by mitochondria to derive more energy, such as CoQ and riboflavin (B2), have mechanistic and clinical benefit.

55
Q

What percentage of migraine headaches are unilateral?

A

60%

So, 40% are bilateral! If something has all the features of a migraine, but is bilateral (or starts unilateral and then generalizes), do not be fooled into thinking it isn’t a migraine.

Neurology Clerkship (60 decks)

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