19 - Headaches Flashcards Preview

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Flashcards in 19 - Headaches Deck (47):

What are the types of primary headaches?

1. Migraine
2. Tension-type headache
3. Trigeminal autonomic cephalalgias
4. Other primary headache disorders

Likely heightened response to pain or part of the brain that suppresses pain in head not working


What are some other primary types of headaches?

- Probable primary cough headache
- Primary exercise headache
- Probable primary exercise headache
- Primary headache associated with sexual activity
- Probable primary headache associated with sexual activity
- Primary thunderclap headache
- Cold-stimulus headache
- Headache attributed to external application of a cold stimulus
- Headache attributed to ingestion or inhalation of a cold stimulus
- Probable cold-stimulus headache
- Headache probably attributed to external application of a cold stimulus
- Headache probably attributed to ingestion or inhalation of a cold stimulus
- External-pressure headache
- External-compression headache
- External-traction headache
- Probable external-pressure headache
- Probable external-compression headache
- Probable external-traction headache
- Primary stabbing headache
- Probable primary stabbing headache
- Nummular headache
- Probable nummular headache
- Hypnic headache
- Probable hypnic headache
- New daily persistent headache (NDPH)
- Probable new daily persistent headache


What are the types of secondary headaches?

- Headache attributed to trauma or injury to the head and/or neck
- Headache attributed to cranial or cervical vascular disorder
- Headache attributed to non-vascular intracranial disorder
- Headache attributed to a substance or its withdrawal
- Headache attributed to infection
- Headache attributed to disorder of homoeostasis
- Headache or facial pain attributed to disorder of the cranium, neck,
eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure
- Headache attributed to psychiatric disorder
Painful cranial neuropathies, other facial pains and other headaches
- Painful cranial neuropathies and other facial pains
- Other headache disorders


What are the three types of primary headaches?

- Tension
- Migraine
- Cluster


What are they types of secondary headaches?

Secondary (sinus, hypertension, etc…)


How common are head aches?


Almost everyone in America has them at some time

The concerning aspect is when they are different ***


When are head aches concerning?


The concerning aspect is when they are different ***


Describe age extremes in head aches

We always worry when elderly or kids have HA
20% of elderly c/o frequent HA
75% of kids have HA by time 15; 28% of those migraine.


Describe a tesnion headache


Aka “stress”
90% in US; more common in women (in kids equal boys/girls)
Usually has a trigger
Usually constant, bilateral, not associated with nausea or photophobia


When do tension headaches occur?

Change in sleep
Skipped meal
Hormone fluctuation
Certain foods (MSG)


What's at the bottom of tension headaches?

No more muscle tension
Chemical changes (likely serotonin)


How do you treat a tension headache?


- Avoiding triggers
- Ibuprofen (any OTC NSAIDS)
- Tylenol
- Caffeine as adjunct
- Biofeedback/relaxing


Describe migranes

12% population
Female more than male
Can “outgrow” them
Kids can get too


Describe the pathology of migraine

Theory on pathology of migraine not clearly figured out. Believe it is vasodilatation of temporal artery, leads to inflammation, more dilation. This process also stimulates sympathetic nervous system (dilated pupils, nausea)
Newer belief that neurotransmission leading to vascular changes

Some theories on DA being involved, but again likely serotonin is issue


What are patterns of migraines

Usually start in young adulthood

Genetic component

Most “outgrow”


What are the signs and symptoms of migraine

- Throbbing
- Movement makes worse
- Moderate to severe
- Photophobia
- Sound sensitive
- Fatigue
- Nausea/vomiting
- Visual issues
- Unilateral (2/3) and often switches side
- Triggers (hormone is biggie)


Describe some patterns we see in a migraine

20% have an aura…visual changes prior to the HA; can also have paresthesias

Visual migraines have the changes and often no HA

Can also have short term paralysis


How do you treat a migraine?

Rest/light avoidance

NSAIDS/caffeine – NSAIDs can be as effective as triptans – especially when anti-nausea meds and/or caffeine added. (Many are FDA approved)


Describe triptans


- Zomig, Imitrex , Relpax, Maxalt
- Spendy ($20/pill – Imitrex cheap now)
- 80% effective
- Increase risk of CV event
- Don’t use in people uncontrolled HTN, h/o CV disease
- SE – dizzy, flushing, “feel strange”


How do triptans work?

- Serotonin receptor agonist
- Possibly leads to vasoconstriction
- 80% migraine sufferers could get benefit but only 18%.
- Why? CV risk (1/ 1/mil compared to 1/200 NSAIDs), cost, pt doesn’t tell doctor about HA
- New combos of NSAID + triptan more effective than either alone
- Triptans are FDA approved


Describe treatment of migraines with intranasal lidocaine

Effective in about 50% of migraines (and clusters) within 5 minutes


What does she use to treat migraines in the ER?

- Toradol/Vistaril
- 10 mg Compazine IV
- 25 mg – 50 mg Benadryl IV
- Droperidol/Benadryl
- Imitrex (SQ)

Can treat about 100% HA without narcotics


What are treatments that are "out of style" and NOT FDA approved?

Ergots (can still get – nasal, oral, IM IV)

Narcotics (do NOT do this***)
- Vicodin #1 med in US
- Doesn’t address problem
- Rebound
- Addiction

Barbiturates (Fioricet)


What does compazine do? She uses it for nausea

What does Compazine do? DA inhibition…treats nausea???

Makes them sleepy, can easily prescribe in PO, okay in pregnancy

Benadryl – prevents tardive dyskinesias; helps with nausea


What is compazine highly effective in?

Peds migraines (Ann Emerg Med Feb 2004)
- Compazine 85% effective
- Toradol 55% effective

She sees a much higher "bang for her buck" with toradol, especially when given IV


Describe migraine treament based on pain

Pain scale (1 – 10) after Compazine or Toradol in adults (Acad Emerg Med June 98)
- 0.5 Compazine
- 3.9 Toradol


Describe the use of droperiod and benadryl

Other combo is droperidol/Benadryl…an old anti nausea medicine. Has bad wrap for QT prolongation. In 30 years of use, 9 cases of torsades de points

Droperidol also Dopamine (DA) blocker, with alpha adrenergic blockage as well

My observation is about 95% after 1.25 mg twice

Neurology Jan 2003 found 82% compared to 57% placebo


Describe prophylaxis against migraines


meds to prevent – consider when HA interfere with life, > 2/wk, > 2/month that don’t respond, or cant take rescue meds
Beta blockers
Antiseizure (Neurontin)


Describe botox

31 injections in 7 spots about q 12 weeks
8 to 9 fewer HA/mo. vs 6 to 7 fewer with placebo
Doesn’t work on tension HA
Unsure MOA
Only for those >15 migraines/mo.


Describe prophylaxis

Prophylaxis considered successful if decrease number by 50% (and that happens about 50% of the time)


Describe cluster head ache


Clusters (weeks or months) of HA that can last from 3 min to hours. Pain so intense person can consider suicide. Much more common in males
Eye/nose on one side often affected (red/runny eye, runny nose)

Believe cause trigeminal nerve issue

0.4% population


How do you treat a cluster head ache?




Narcotics (this is the one she will give it for)

Occipital nerve stimulation


What are the secondary causes of secondary head ache?

- Bleed
- Metabolic issues (thyroid, DM)
- Caffeine or med withdrawal
- Tumor
- Brain Infection
- Stroke
- Vision
- Illness/fever
- Acute sinusitis
- Sleep apnea


Describe encephalitis

- HA
- Fever
- +/- rash (scary rash - look at slide 38)
- Very stiff neck (touch chin, bounce on toes)


Describe the use of caffeine

Withdrawal of even 100 mg/day symptoms of HA, irritability, difficult concentrate

Starts 12- 24 hours after stopping, peaks 2-3 days


Describe sleep apnea

Only about 1/3 of those with HA and sleep apnea improved c CPAP


When should you worry about secondary causes that could be life threatening

- Age extremes..over 50 without clear history or cause
- Neuro changes
- Different HA
- Worst of life
- Trauma
- Seizures (new)
- Neck/fever/exposure
- PMH of cancer or HIV


Describe what you get in the ER if you come in with a head ache

- CT (with or without contrast)
- LP
- Can’t get MRI in ER usually


Describe the use of CT in headaches

Studies found that 95% SAH are found on noncontrast CT; therefore many believe that one needs to get LP if CT is negative to see if blood in the CSF


Describe hypertension and head ache

Some people never have s/s of HTN, others very sensitive


Describe a sinus head ache

90% of “self diagnosed” sinus HA actually migraines…61% given ABX by physician (Allergy Asthma Proc Mar 2004)


Describe sinusitis

- Almost no sinusitis is bacterial (.5-5%)
- 70% of healthcare visits get ABX for chronic, 83% for acute
- What works instead– nasal saline, nasal steroids, decongestants, prednisone, antihistamines
If no better 10 days, fever (not “felt warm”), ill then consider ABX
- Fall allergies will get better after the first hard freeze


Why do antibiotics make people with headaches feel better?

Due to the anti-inflammatory properties

Can use:
- Quinolones
- Bactrim
- Clarithromycin
- Cephalexin


What is chiari?

Chronic headaches that occur by narrowing of the skull (squeezing the brain)

Need brain surgery


What is temporal arteritis?


- Inflammation of temporal artery
- > 50 yrs. old
- Women > men
- 15-30/100,000


How do you diagnose temporal arteritis?


- > 50 y/o
- New onset
- ESR > 50 (high sed rate)
- Pain at site or decreased pulse
- Bx of temporal artery (biopsy?)

TX Prednisone prior to BX (to prevent permanent visual loss)


What are some newer treatment options for headaches?

Antipsychotics (U of I uses Haldol/Benadryl in ER)