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Flashcards in Cephalgia Deck (125):
0

What are the types of headaches?

Migraine
Tension
Cluster
Post traumatic headaches

1

unilateral headache location

migraine
trigeminal neuralgia

2

temporal headache location

temporal arteritis

3

occipital location headache

tension headache

4

headache location - eye

acute glaucoma
temporal arteritis
sinusitis
migraine

5

gradual headache onset indicates

usually benign

6

sudden onset headache indicates...

may be more serious

7

What would be an important item to ask about headache onset?

head injury

8

pounding/pulsatile pain indicates...

migraine

9

sharp/stabbing headache indicates...

trigeminal neuralgia
cluster headaches

10

pressure/squeezing headache indicates...

tension headache

11

Headache associated symptoms - anxiety indicates

tension headaches

12

associated symptom - aura

migraine

13

associated symptoms - vision change

temporal arteritis
glaucoma

14

associated symptoms - nausea/vomiting

increased ICP
migraines

15

associated symptoms - lacrimation/rhinorrhea

cluster headaches

16

associated symptom - photophobia

meningitis
migraine

17

What is important to document about headache timing?

Time of day/ interrupt sleep?
Frequency?
Duration of pain?
In relation to menstrual periods?

18

What are headache modifying factors?

Environment?
Behavioral triggers?
Food triggers?
OTC analgesics

19

What is important to ask about the severity of a headache?

Worst headache? THE headache of a lifetime?
How does this compare with previous headaches?
Documentation important to monitor effectiveness of treatment.

20

prevalence of migraines

25% US population
18% women
6% men

21

onset of migraine headaches

age 10-40
Usually disappear in 50s

22

migraine risk factors

family history
obesity
sleep apnea
head injury
female
analgesic overuse
caffeine >100 mg/day

23

migraine pathophysiology

depolarization theory
serotonin release

24

Depressed activity areas lead to platelet and mast cell activation.

Depolarization Theory

25

Fluctuations in chatecholamine levels cause alternating vasoconstriction/vasodilation.

Seratonin release

Vasodilation = wall stretching = pain

26

Migraine Triggers

Sleep deprivation/interruption
Histamine
MSG
Caffeine
Red wine/ other alcohol
Foods: Chocolate, cheeses, nitrates, soy, cold food, yeast extract
Gluten
Weather-barometric changes
Fragrances
Medications - oral contraceptives, nittroglycerin, Zantac
Physical exertion

27

What medications can cause migraines?

Oral contraceptives
Nitroglycerin
Zantac

28

What foods can trigger migraines?

Chocolate
Cheeses
Nitrates
Soy
Cold food
Yeast extract

29

What are the migraine types?

Common - without aura
Classic - with aura
Basilar
Hemiplegic
Opthalmoplegic
Menstrual - catemenial
Migrainous carotidynia
Abdominal

30

Characteristics of a Common Migraine

Pulsatile, throbbing (50%)
Unilateral (50%)
Lasts hours - days
Associated with nausea/vomiting
Pathophobia/phonophobia
Often debilitating
Cutaneous allodynia

31

How long does a common migraine last?

Hours to days

32

When does aura develop in classic migraine?

10-30 minutes prior to headache

33

Peripheral flashing lights - periphery
Pale spot that enlarges

scintillating scotomas

34

zig-zagging lines
Teichopsia

Fortification spectrum

35

What are the types of auras?

scintillating scotomas
fortification spectrum

36

Where to the aura abnormalities develop?

Arise in the occipital cortex, not the eyes.

37

What is a prodrome?

Occurs before a classic migraine.
Increased excitability/irritability; fatigue, depression, appetite increase or cravings

38

Sensory Auras associated with classic migraine

numbness, paresthesias, dysphasia

39

What is a migraine equivalent?

Variant of classic migraine where aura occurs without the headache.

AKA- acephalic migraine

40

Migraine affects basilar artery, headache, vertigo, slurred speech, impaired coordination WITHOUT motor deficits. Occurs in younger patients.

basilar migraine

41

Familial migraines which occurs with paralysis on one side of the body. Can occur with or without a headache. Can persist for up to 24 hours.

Hemiplegic

42

Headache with eye pain, vomiting, and ptosis which can persist for weeks.

opthalmoplegic migraine

43

Face, jaw, neck; tenderness and swelling over carotid artery; older patients; normal carotid ultrasound

migrainous carotidynia

44

No headache; vomiting, GI pain. Typically in young patients and typically develop common/classic migraines as they grow.

Abdominal migraine

45

Only occur at menses; menopause-dissapear or become sporadic; usually disappear or become sporadic; usually disappear in pregnancy; occurs day -2 through day +3; more common to have "menstrual-related migraines"

catemenial migraines

46

When would you image a migraine?

First or worse ever migraine
New onset >5o yo
Sudden onset HA - thunderclap HA
Abnormal neuro exam
HA awakens from sleep
Rapid onset with strenuous activity
Meningeal signs: vomiting, altered mental status, personality changes

47

First line acute treatment for migraine:

Excedrin migraine (ASA, acetaminophen, caffeine)
NSAIDs - Naproxen

48

What is excedrin a combination of?

ASA
Acetaminophen
Caffeine

49

Second line acute migraine treatment:

Triptans
Dihydroergotamine (DHE-45)
-SC/IM/IV
-Intranasal (Migranal)

50

Migraine Triptans

Sumatriptan - Imitrex
Rizatriptan - Maxalt MLT
Zolmitriptan - Zomig

51

Sumatripten Imitrex Dosing

SC 6 mg (max 12 mg/day)
NS 5, 10,20 mg (Max 40 mg/day)
Oral 100 mg (Max 300 mg/day)
Treximet (Sumatriptan 85 mg/naproproxen 500 mg)

52

What is the benefit of adding naproxen to treximet?

migraine stays away for longer

53

How does Rizatriptan (Maxalt) come?

a dissolvable tablet

54

If one triptan does not work what should you do?

Try another one! One may work better than the other!

55

Which triptans are longer acting?Amerge

Naratriptan (Amerge)
Frovatriptan (Frova)

56

What antimetics are given for migraines?

Metoclopramide (Reglan) - PO/IM/IV
Prochlorperazine (Compazine) - PO/IM/IV
Hydroxyzine (Atarax)
Promethazine (Phenergan) - PO/IM/Rectal
Other - Toradol, Dexamethasone

57

Why do rebound headaches occur from migraines?

Overuse of medications for migraines.

58

What is overuse of migraine medications?

>10 days out of the month

59

What drugs are likely to cause rebound headaches?

Acetaminophen - 45%
Narcotics - 31%
ASA - 24%
Ergot alkaloids - 6%
Triptans - 9%

60

When do you start migraine prophylaxis?

Greater than or equal to 2 headaches per week.
Severe
Prolonged duration - >2 days

61

What must the patient do if they are having rebound headaches?

Quit the offending medication "cold-turkey"

62

How much does prophylaxis decrease frequency of headaches?

50%

63

How long does prophylaxis for migraines occur?

Continue medications for at least 2-3 months before tapering of discontinuing.

64

What medications are used for migraine prophylaxis?

beta blockers
tricycling antidepressents
anti-seizure medications

65

Does migraine prophylaxis completely stop migraines?

No - decreases frequency by 50%

66

What beta blockers are used for prophylaxis?

Propranolol LA (Inderal LA)

Others: metaprolol, timolol

67

What is the prescription for propranalol for migraine prophylaxis?

80 mg daily to start
Increase over 3 weeks to 160 mg daily
Max: 240-320 mg

68

What types of tricyclic antidepressants are used for prophylaxis?

Amitriptyline (Elavil) 25 mg hs - normally 25-100
Nortriptyline (Pamelor) 10 mg hs - normally 30 mg

69

What antiseizure medications are used for migraine prophylaxis?

Valproic acid (Depakote) - 250 - 500 mg BID, prenatal vitamin/folate, weight gain

Topiramate - Topamax - 25 mg BID x 1 week, etc. Titrate to 100-200 mg daily. Weight loss/anorexia. Difficulty concentrating "Dopamax"

70

Can you give Valproic acid (Depakote) or Topiramate (Topamax) to pregnant women?

NO!!!!

71

What should you also give with Depakote?

Prenatal vitamins - Depakote depletes folic acid and causes hair to fall out.

72

What is the most common side effect of Depakote?

Weight Gain

73

What are "other" migraine prophylaxis medications?

Lisinopril - ACEI
Candesartan - ARB
Inadequate evidence - calcium channel blockers, SSRIs, carbamazepine (Tegretol)
Other - butterbur (petasites, Petadolex), Vit B12, magnesium oxide, coenzyme Q

Very refractory headaches: Lidocaine, Caffeine protocols, propofol infusion, Botox

74

What are cluster headaches?

Migraine variant

75

cluster headache prevalence

Men 4-1
Men 20-40 yo
Familial association

76

Risk factors for cluster headaches

family history
tobacco
head injury
shift work

77

What are cluster headaches often triggered by?

alcohol ingestion

78

What is HIGHLY associated with cluster headaches?

Smoking!! Pt must quit smoking.

79

Cluster headache pathophysiology

vascular dilation
trigeminal nerve stimulation
circadian rhythms - patients may awake from sleep with these headaches

80

characteristics of cluster headaches

Excruciating, stabbing pain - "suicide HA"
Unilateral - behind the eye, jaw, teeth
Duration: 15 min - 3 hours
Timing:
-multiple attaches may occur in the same day
-may occur daily at the same time
-May spontaneously regress and have months without symptoms
-May awaken from sleep

81

To diagnose a cluster headache you must have at LEAST one of the following:

Lacrimation
Ipsilateral flushing/sweating
Ipsilateral nasal DC
Conjunctival redness - maybe ipsilateral?
Horners syndrome - ipsilateral ptosis, ipsilateral miosis (pupillary constriction)

82

Acute treatment for cluster headaches

Triptans (sumatriptan, zolmitriptan)
***Oxygen - 100% NRB mask: 12-15 L x 20 min. Complete relief in 78% of patients

83

prophylaxis for cluster headaches

Verapamil - 80 mg TID ( may increase up to 160 mg TID)
+/- corticosteroids as a "bridging therapy" to BREAK THE CYCLE

84

Why to tension headaches occur?

myofascial origin

85

symptoms of tension headaches

vice-like, gripping HA "band"
Forehead- occiput bilaterally
Radiates into posterior neck and trapezius
Duration: 30 min - 7 days

86

How do you differentiate a tension headache from a migraine?

NO n/v, photo/phonophobia, pulsatile; not worse with activity

87

Risk factors for tension headaches:

Stress/anxiety
Depression
Overwork
Lack of sleep
Posture
Marital/family dysfunction
Conversion
Malingering - people believe they have an issue but really don't.

88

Non-pharmacologic treatments of tension headaches:

Exercise
Relaxation therapy/counseling
Yoga
PT
Accupuncture

89

Pharmacologic treatments for headaches:

NSAIDs
Tylenol
Myofascial trigger point injections
TCAs or SSRI

90

What should you stay away from when treating migraine headaches?

Narcotics

91

TCA

Tricyclinc antidepressants

92

Why would you use a TCA or SSRI for tension headache treatment?

To treat underlying stress/anxiety.

93

onset of post traumatic ha

Occurs within first seven days of injury

94

acute post traumatic headache

< 2 months after injury

95

chronic post traumatic headache

>2 months after injury.
At higher risk of becoming "daily" headache

96

characteristics of post traumatic headache

Mixed:
Migraine-tension
Frequently develop rebound headache.

97

treatment for post traumatic HA

VERY DIFFICULT!

98

risk factor for idiopathic intracranial htn

women 15-44 (3.5/100,000)
obese women 20-44 (19.3/100,000)

99

IIH

idiopathic intracranial htn

100

other names of IIH

Pseudotumor cerebri
benign intracranial htn (BIH)

101

Medications that cause IIH

Vit A derivatives (Accutane)
Tetracyclines
Oral contraceptives

102

Symptoms of IIH

retro-orbital pain
worse with eye movement
throbbing
worse in morning
nausea and vomiting
monocular/binocular vision loss
pulsatile tinnitus - 60%
+/- neck pain

103

What are the PE findings for IIH?

Papilledema - slightly elevated

104

Diagnostic findings for IIH

LP - opening pressure >200 mmH20/>250 in obese (normal 70-180 mm H20)

105

MRI for IIH

negative for masses/hydrocephalus

106

Treatment for IIH

Weight loss
Low sodium diet
Avoid sulfa medications
Diuretics: acetazolamide (Diamox), Furosemide (Lasiz)
+/- steroids
HA Mgmt: NSAIDs, TCAs
Large volume lumbar puncture (>20 mL spinal fluid removed)
Surgery: Optic nerve sheath decompression, CSF fluid shunt.

107

Prevalence of trigeminal neuralgia

Women > Men
Age >40 (peak 60-70)

108

Trigeminal Neuralgia AKA:

"Tic Deouloreux"

109

Risk factors for trigeminal neuralgia

Multiple sclerosis

110

Pathophysiology for trigeminal neuralgia

Demyelination of trigeminal nerve.
Light touch stimulates pain fibers.
Maxillary and mandibular branches most commonly affected.

111

Symptoms of trigeminal neuralgia:

Right side more commonly affected.
Stabbing/lancinating/electric shock.
Associated with facial spasm.

112

Trigeminal neuralgia timing

Attacks last <2 minutes
Multiple times daily or monthly
Become more frequent over time

113

Trigeminal Neuralgia triggers:

Trigger zones
Washing face
Brushing teeth
Chewing
Cold air

114

Treatment of Trigeminal Neuralgia

Carbamazepine (Tegretol) - 200-800 mg in divided doses BID or TID
+/- other anti-seizure meds
+/- baclofen, capsaicin, gamma knife, microvascular decompression

115

Temporal Arteritis AKA

"Giant Cell Arteritis"

116

Risk factors for temporal arteritis

Average age 72
Associated with polymyalgia rheumatica (50%)

117

Symptoms of temporal arteritis:

Temporal HA
+/- diplopia and/or visual field cuts
+/- systemic - fevers, malaise, weight loss
Jaw claudication

118

PE findings for temporal arteritis

Tenderness over temporal artery
Diminished pulses

119

How do you diagnosis temporal arteritis?

Temporal Artery Biopsy
Nonspecific labs: ESR, CRP (elevated)

120

What should you always do if you suspect temporal cell arteritis?

START TREATMENT!!! Biopsy will be positive for 2 days starting treatment.

DO NOT WAIT FOR BIOPSY RESULTS, START STEROID IMMEDIATELY AND GET BIOPSY WITHIN 2 DAYS, if not treated CAN LEAD TO PERMANENT BLINDNESS.

121

Treatment for temporal cell arteritis

Corticosteroids

122

What do you prescribe for temporal arteritis with no vision change?

Prednisone - 40-60 mg daily x 4 months

123

What do you prescribe for temporal arteritis with vision changes?

IV Solumedrol q 6h x 3-5 days then oral steroid

124

Headache DDX

Temporal arteritis
Post traumatic HA
Tumor
Subarachnoid hemorrhage
Venous thrombosis
Meningitis
Spinal HA
Post seizure/post -ictal HA
Acute angle - closure glaucoma
Carbon manoxide poisoning
Pseudomotor celebri
Sinusitis
TMJ dysfunction
Cervicalgia
Preeclampsia (pregnancy)
Chiari malformation
Drug/caffeine withdrawal
Trigeminal neuralgia
Obstructive sleep apnea
Tension HA
Cluster HA
Migraines