Headaches Flashcards
What are the red flags of secondary headaches?
- Sudden and very strong
i. Like thunder: think aneurism or SAH - Abnormal neurological examination
i. Assymetry in reflexes, Babinski, etc. - Neurological complaints
- Acute
- Fever and nuchal rigidity
i. Meningitis, encephalitis - Progressive disease
- Signs of high ICP
- SOL - Confusion
- Awaking from sleep
What is the differential diagnosis for increased ICP?
Lupus
Temporal arteritis (older men with jaw claudication, amaurosis fugax-resorptive blindness, very high ESR~100, goes with polymyalgia aromatica)
hypertensive encephalopathy
pseudotumor cerebri (usually young obese female, subacute, see TVO’s-transient visual obstructions, high pressure of CSF, more CSF production than absorption, see papilledema-edema of the optic disc, small ventricle so normal CT, dangerous-can compress optic nerve and cause blindness, diagnose with LP)
metabolic
How are facial pain and trigeminal neuralgia differentiated?
Trigeminal neuralgia: in distribution of CNV, one or 2 (max) branches, usually one sided (vs. facial pain on both sides)
Trigger: when shaving, touch, wind, eating, etc.
Like a shock, very short lasting, strong and severe with tactile triggers
Usualkly >50 y/o
Treated prophylactically with Carbomezapine/tegratol (not good for other neuropathies)
What are the diagnostic criteria for migraine with and without aura compared to tensino headaches?
Migraine without aura (80% of migraines):
A. At least 5 attacks fulfilling criteria B–D
B. Headache attacks lasting 4–72 hours (untreated
or unsuccessfully treated)
C. Headache has at least two of the following
characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
D. During headache at least one of the following
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not attributed to another disorder
With aura (20% of migraines):
A. At least 2 attacks (because so specific) fulfilling criteria B–D
B. Aura consisting of at least one of the following:
1. fully reversible visual symptoms
2. fully reversible sensory symptoms
3. fully reversible dysphasic speech disturbance
C. At least two of the following:
1. homonymous visual symptoms and/or unilateral sensory symptoms
2. At least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
3. each symptom lasts ≥5 and<60 minutes
D. Headache fulfilling criteria B–D for 1.1 Migraine
without aura begins during the aura or follows
aura within 60 minutes
E. Not attributed to another disorder
Tension headache:
Need 10 episodes to diagnose (nonspecific)
Pain at level of 4-6 (vs migraine 7-10)
Bilateral (migraines unilateral)
What is the treatment for medication overuse headache?
- Withdrawal
- Preventive treatment
- Asses psychological co morbidity
- Consider abortive treatment
Preventative:
• Amitriptyline - 10-25-50(3w)
Drowsiness, anti cholinergic effect, weight gain. Not good for elderly.
• Beta blockers
Impotence, asthma, depression, P.V.D
• Valproic acid
Tremor, weight gain, terratogenicity, alopecia , PCO (polycystic ovary)
• Topiramate
Paresthesias, kidney stones, confusion, weight loss
• Ca channel blockers
Bradycardia, edema, dizziness
Nonmedical prevention
• Bio feedback
• Relaxation and stress reduction interventions
• Acupuncture (?) Not considered by doctors
Hypnosis
How is cluster headache distiinguished from others?
Does not respond to endomethacin nor other NSAIDs (unlike Paroxysmal hemicrania) but 80% respond to oxygen
Repeats every year for a month, remission in between, for 30-1h at a time, once a day, usually around the same time of day-evening
(Paroxismal hemicrania shorter and frequent-up to 40/day, SUNCT much shorter but very frequent-up to 200/day)
7:1 male to female (paroxismal hemicrania twice as common in women)
Treatedf with Imitrex, steroids or dilitiazam (Ca channel blocker) Preventatively
