Flashcards in Cephalgia Deck (125):
What are the types of headaches?
Post traumatic headaches
unilateral headache location
temporal headache location
occipital location headache
headache location - eye
gradual headache onset indicates
sudden onset headache indicates...
may be more serious
What would be an important item to ask about headache onset?
pounding/pulsatile pain indicates...
sharp/stabbing headache indicates...
pressure/squeezing headache indicates...
Headache associated symptoms - anxiety indicates
associated symptom - aura
associated symptoms - vision change
associated symptoms - nausea/vomiting
associated symptoms - lacrimation/rhinorrhea
associated symptom - photophobia
What is important to document about headache timing?
Time of day/ interrupt sleep?
Duration of pain?
In relation to menstrual periods?
What are headache modifying factors?
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.
prevalence of migraines
25% US population
onset of migraine headaches
Usually disappear in 50s
migraine risk factors
caffeine >100 mg/day
Depressed activity areas lead to platelet and mast cell activation.
Fluctuations in chatecholamine levels cause alternating vasoconstriction/vasodilation.
Vasodilation = wall stretching = pain
Red wine/ other alcohol
Foods: Chocolate, cheeses, nitrates, soy, cold food, yeast extract
Medications - oral contraceptives, nittroglycerin, Zantac
What medications can cause migraines?
What foods can trigger migraines?
What are the migraine types?
Common - without aura
Classic - with aura
Menstrual - catemenial
Characteristics of a Common Migraine
Pulsatile, throbbing (50%)
Lasts hours - days
Associated with nausea/vomiting
How long does a common migraine last?
Hours to days
When does aura develop in classic migraine?
10-30 minutes prior to headache
Peripheral flashing lights - periphery
Pale spot that enlarges
What are the types of auras?
Where to the aura abnormalities develop?
Arise in the occipital cortex, not the eyes.
What is a prodrome?
Occurs before a classic migraine.
Increased excitability/irritability; fatigue, depression, appetite increase or cravings
Sensory Auras associated with classic migraine
numbness, paresthesias, dysphasia
What is a migraine equivalent?
Variant of classic migraine where aura occurs without the headache.
AKA- acephalic migraine
Migraine affects basilar artery, headache, vertigo, slurred speech, impaired coordination WITHOUT motor deficits. Occurs in younger patients.
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.
Headache with eye pain, vomiting, and ptosis which can persist for weeks.
Face, jaw, neck; tenderness and swelling over carotid artery; older patients; normal carotid ultrasound
No headache; vomiting, GI pain. Typically in young patients and typically develop common/classic migraines as they grow.
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"
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
First line acute treatment for migraine:
Excedrin migraine (ASA, acetaminophen, caffeine)
NSAIDs - Naproxen
What is excedrin a combination of?
Second line acute migraine treatment:
Sumatriptan - Imitrex
Rizatriptan - Maxalt MLT
Zolmitriptan - Zomig
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)
What is the benefit of adding naproxen to treximet?
migraine stays away for longer
How does Rizatriptan (Maxalt) come?
a dissolvable tablet
If one triptan does not work what should you do?
Try another one! One may work better than the other!
Which triptans are longer acting?Amerge
What antimetics are given for migraines?
Metoclopramide (Reglan) - PO/IM/IV
Prochlorperazine (Compazine) - PO/IM/IV
Promethazine (Phenergan) - PO/IM/Rectal
Other - Toradol, Dexamethasone
Why do rebound headaches occur from migraines?
Overuse of medications for migraines.
What is overuse of migraine medications?
>10 days out of the month
What drugs are likely to cause rebound headaches?
Acetaminophen - 45%
Narcotics - 31%
ASA - 24%
Ergot alkaloids - 6%
Triptans - 9%
When do you start migraine prophylaxis?
Greater than or equal to 2 headaches per week.
Prolonged duration - >2 days
What must the patient do if they are having rebound headaches?
Quit the offending medication "cold-turkey"
How much does prophylaxis decrease frequency of headaches?
How long does prophylaxis for migraines occur?
Continue medications for at least 2-3 months before tapering of discontinuing.
What medications are used for migraine prophylaxis?
Does migraine prophylaxis completely stop migraines?
No - decreases frequency by 50%
What beta blockers are used for prophylaxis?
Propranolol LA (Inderal LA)
Others: metaprolol, timolol
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
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
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"
Can you give Valproic acid (Depakote) or Topiramate (Topamax) to pregnant women?
What should you also give with Depakote?
Prenatal vitamins - Depakote depletes folic acid and causes hair to fall out.
What is the most common side effect of Depakote?
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
What are cluster headaches?
cluster headache prevalence
Men 20-40 yo
Risk factors for cluster headaches
What are cluster headaches often triggered by?
What is HIGHLY associated with cluster headaches?
Smoking!! Pt must quit smoking.
Cluster headache pathophysiology
trigeminal nerve stimulation
circadian rhythms - patients may awake from sleep with these headaches
characteristics of cluster headaches
Excruciating, stabbing pain - "suicide HA"
Unilateral - behind the eye, jaw, teeth
Duration: 15 min - 3 hours
-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
To diagnose a cluster headache you must have at LEAST one of the following:
Ipsilateral nasal DC
Conjunctival redness - maybe ipsilateral?
Horners syndrome - ipsilateral ptosis, ipsilateral miosis (pupillary constriction)
Acute treatment for cluster headaches
Triptans (sumatriptan, zolmitriptan)
***Oxygen - 100% NRB mask: 12-15 L x 20 min. Complete relief in 78% of patients
prophylaxis for cluster headaches
Verapamil - 80 mg TID ( may increase up to 160 mg TID)
+/- corticosteroids as a "bridging therapy" to BREAK THE CYCLE
Why to tension headaches occur?
symptoms of tension headaches
vice-like, gripping HA "band"
Forehead- occiput bilaterally
Radiates into posterior neck and trapezius
Duration: 30 min - 7 days
How do you differentiate a tension headache from a migraine?
NO n/v, photo/phonophobia, pulsatile; not worse with activity
Risk factors for tension headaches:
Lack of sleep
Malingering - people believe they have an issue but really don't.
Non-pharmacologic treatments of tension headaches:
Pharmacologic treatments for headaches:
Myofascial trigger point injections
TCAs or SSRI
What should you stay away from when treating migraine headaches?
Why would you use a TCA or SSRI for tension headache treatment?
To treat underlying stress/anxiety.
onset of post traumatic ha
Occurs within first seven days of injury
acute post traumatic headache
< 2 months after injury
chronic post traumatic headache
>2 months after injury.
At higher risk of becoming "daily" headache
characteristics of post traumatic headache
Frequently develop rebound headache.
treatment for post traumatic HA
risk factor for idiopathic intracranial htn
women 15-44 (3.5/100,000)
obese women 20-44 (19.3/100,000)
idiopathic intracranial htn
other names of IIH
benign intracranial htn (BIH)
Medications that cause IIH
Vit A derivatives (Accutane)
Symptoms of IIH
worse with eye movement
worse in morning
nausea and vomiting
monocular/binocular vision loss
pulsatile tinnitus - 60%
+/- neck pain
What are the PE findings for IIH?
Papilledema - slightly elevated
Diagnostic findings for IIH
LP - opening pressure >200 mmH20/>250 in obese (normal 70-180 mm H20)
MRI for IIH
negative for masses/hydrocephalus
Treatment for IIH
Low sodium diet
Avoid sulfa medications
Diuretics: acetazolamide (Diamox), Furosemide (Lasiz)
HA Mgmt: NSAIDs, TCAs
Large volume lumbar puncture (>20 mL spinal fluid removed)
Surgery: Optic nerve sheath decompression, CSF fluid shunt.
Prevalence of trigeminal neuralgia
Women > Men
Age >40 (peak 60-70)
Trigeminal Neuralgia AKA:
Risk factors for trigeminal neuralgia
Pathophysiology for trigeminal neuralgia
Demyelination of trigeminal nerve.
Light touch stimulates pain fibers.
Maxillary and mandibular branches most commonly affected.
Symptoms of trigeminal neuralgia:
Right side more commonly affected.
Associated with facial spasm.
Trigeminal neuralgia timing
Attacks last <2 minutes
Multiple times daily or monthly
Become more frequent over time
Trigeminal Neuralgia triggers:
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
Temporal Arteritis AKA
"Giant Cell Arteritis"
Risk factors for temporal arteritis
Average age 72
Associated with polymyalgia rheumatica (50%)
Symptoms of temporal arteritis:
+/- diplopia and/or visual field cuts
+/- systemic - fevers, malaise, weight loss
PE findings for temporal arteritis
Tenderness over temporal artery
How do you diagnosis temporal arteritis?
Temporal Artery Biopsy
Nonspecific labs: ESR, CRP (elevated)
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.
Treatment for temporal cell arteritis
What do you prescribe for temporal arteritis with no vision change?
Prednisone - 40-60 mg daily x 4 months
What do you prescribe for temporal arteritis with vision changes?
IV Solumedrol q 6h x 3-5 days then oral steroid