Ch 7 Headache

Question 1

Primary headache and examples

Answer 1

not from other diseases but likely from complex interplay of genetics, developmental, and environmental

ex: migraine, tension type, cluster

Question 2

primary headache’s neuro exam is…

Answer 2

normal!
can see photophobia but otherwise normal neuro exam

Question 3

secondary headache and examples

Answer 3

associated with or caused by other conditions and will NOT resolve until specific cause is addressed

ex: intracranial bleeding, IICP, meningitis, accelerated HTN, giant cell arteritis, tumor, etc

Question 4

secondary headache’s neuro exam is…

Answer 4

have abnormalities that point to differential diagnosis’s

ie: viremic (influenza, COVID), acute sinusitis headache most common = usu self resolving, self limiting, normal neuro exam

Question 5

Red flags for secondary headaches

Answer 5

SNOOP

Systemic symptoms (fever, unintended weight loss, etc)
-meningitis, encephalitis, inflammation

Secondary h/a risk factors: HIV, malignancy, pregnancy, anticoag, >180/>120 BP, etc

Neuro signs/sx’s: new neuro findings: confusing, impaired alertness, nuchal rigidity, papilledema, cranial nerve dysfunction, abnormal motor function

Onset: sudden onset or split second “thunder clap” headache
Onset with exertion, sex, cough/sneeze from clearing throat and not sick= IICP

Onset: age of onset; > 50 yrs or < 5 yrs
-giant cell arteritis, mass lesion

P: prior headache history: change in quality, frequency (medication overuse, mass lesion, subdural hematoma)
Positional: change upright vs laying down, neck position
Papilla-edema: swelling of optic disk; vision problems

Question 6

Primary headache: Tension type headache: clinical presentation, last how long & diagnosis

Answer 6

lasts 30 mins - 1 week and 2 or more:
- pressing, non pulsatile pain
-mild to mod intensity
-usu bilateral
-NO nausea, photophobia, or phonophobia

Question 7

Primary headache: Migraine without aura clinical presentation & diagnosis

Answer 7

lasts 4-72 hrs with 2 or more of:
-unilateral but can be bilateral
-pulsating, mod - severe
- worsen with normal activity (walking, or causes avoidance of activities)
during headache, have 1 or more of:
- nausea and/or vomiting, photophobia, photophobia

females > male; strong family hx

Question 8

Primary headache: Migraine with aura clinical presentation & diagnosis

Answer 8

Repeated attacks of headache lasting 4-72 hours with normal exam

At least 2 of following:
-Unilateral pain 60% of time
-throbbing/pulsating pain
-Aggravating of movement or activity
-Moderate to severe intensity

Plus at least 1 of :
Nausea + vomiting
Photophobia or phonophobia

strong family hx

Question 9

Primary headache: cluster headache clinical presentation & diagnosis

Answer 9

occurs daily in groups or clusters
-lasts weeks-months, then disappears months to years
- usu at diff times of year, vernal and autumn with 1-8 episodes same time of day
-common 1 hr into sleep aka “alarm clock” headache
-located behind 1 eye, steady, intense “hot poker eye”, severe pain in crescendo pattern 15 min to 3 hrs (most 30-45 min)
- may have lacrimation, conjunctival injection, ptosis, nasal puffiness

Question 9

which type of headache is more seen in males and in 30’s yrs?

Answer 9

cluster

Question 10

primary headache treatment: analgesics as acute therapy and limits

Answer 10

NSAIDs, acetaminophen etc
BEST TO TAKE AT ONSET OF H/A

limit to 2 days per week (analgesic rebound headache)
-use with triptan, divan, gepant to enhance relief

Question 11

what acute therapy meds for migraine?

Answer 11

triptans (sumatriptan, almotriptan, rizatriptan)
ergot derivatives (migranal as nasal spray or inj)
diltans
gepants (ubrelvy)

BEST TO TAKE AT ONSET OF H/A

Question 12

triptans, ergots, detains cautions/precautions

Answer 12

NO in pregnancy, CVD, poorly controlled HTN (d/t vascular effect)

Question 13

prophylactic/prevention primary h/a treatment meds

Answer 13

Migraine prophylaxis takes 4-6 weeks to have effect
-BB (metoprolol, propranolol)
-TCA (amitriptyline)
-antiepiletic drugs (AED): divalproex sodium, sodium valproate, topiramate
-supplements (butterbur, feverfew, coenzyme Q10, mg, riboflavin
- lithium (only for cluster h/a)
-calcitonin gene rated peptide (CGRP) antagonists (Amovig, Ajovy, Ubrelvy, etc) but $$$

Question 14

rescue therapy for primary headaches

Answer 14

only when other tx ineffective or severe or specific sx’s…
antiemetics, short course systemic corticosteroids,
NO opioids

Question 15

triptans are good for

Answer 15

migraines with photophobia and photophobia (not really for pain. give with NSAID for pain)

Question 16

when is neuroimaging usually warranted?

Answer 16

in most secondary headaches not primary

Question 17

if have acute, severe headache with new onset abnormality on neurological exam…

Answer 17

order CT without contrast
-can show acute/chronic hemorrhage blood, stroke

Question 18

CT with contrast of head shows

Answer 18

tumor, abscess

Question 19

MRI of head shows

Answer 19

tumor

Question 20

older adult using long term systemic corticosteroid has a risk of..

Answer 20

gastric ulcer while on a systemic corticosteroid than a younger person!

Question 21

what is giant cell arteritis? common in what age groups?

Answer 21

autoimmune vasculitis that affects medium and large sized vessels (temporal artery) = inflamed/swelling = decreased blood flow = sx’s

50-85 years, females
often seen with polymyalgia rheumatica

Question 22

which meds are used to treat headache symptoms, and best taken at headache ONSET?

Answer 22

NSAID
acetaminophen
triptans
ergot derivatives
oral CGRP antagonist (gepants, ubrogepant (Ubrelvy)
5-HT1F receptor agonist (ditans, lasmiditan Revow)

Question 23

Which meds are used to minimize risk of developing headaches and need WEEKS of prior use to have clinical effect?

Answer 23

Beta blocker
TCA
topiramate
injectible/oral CGRP antagonist (erenumab (Aimovig), ubrogepant Ubrelvy), vitamin, minerals, herbal

Question 24

giant cell arteritis clinical presentation

Answer 24

-tender or nodular pulseless temporal artery WITH severe unilateral headache
50% have visual impairment (blurring, diplopia, eye pain, sudden loss of vision)

CRP/ESR very elevated
Dx with temporal artery biopsy or duplex US

Question 25

giant arteritis intervention

Answer 25

goal: reduce pain and minimize risk of blindness

-give high dose systemic corticosteroids (1-2 mg/kg/day prednisone until stabilized) then reduce dose and continue for 6 mo- 2 yrs
-aspirin (reduce stroke risk)
-PPI or misoprostol (GI protection from steroids)
-bisphosphonate (bone protection)

Question 26

diet triggers for migraines/primary headaches

Answer 26

avoid:
sour cream
ripe cheese (cheddar, brie, camembert)
preserved meat (sausage, salami, pepperoni, hot dogs)
pizza
chicken liver, pate
herring
pickled, fermented, marinated foods
MSG
yeast sour dough bread
chocolate
nuts, peanut butter
beans
onions
figs, papayas, avoacods
citrus fruits
bananas
caffeinated (tea, energy drinks, coffee)
alcohol
aspartame, phenylalanine foods/bev

Question 27

when do you consider using preventative meds for headaches?

Answer 27

Freq long lasting h/a a/s with significant disability
Contraindication to abortive tx
Frequent use of abortive tx
Uncommon migraine (hemiplegic, basilar, migraine with prolonged aura, migrainous infarction)