Cephalgia

Question 1

types of headaches: primary

Answer 1

• tension-type
• migraine
• cluster

Question 2

types of headaches: secondary

Answer 2

• rebound (OTC overuse)

- manifestation of other diseases

Question 3

what should be asked in hx to help classify the HA?

Answer 3

• birth hx
• any OTC for pain?
• any new meds?
• change in social hx?
• hx of trauma
• surgical hx

Question 4

tension-type headache: how long does pain usually last?

Answer 4

30 min to 7 days

Question 5

tension-type headache: how is the pain described?

Answer 5

• fullness, tightness, pressure in head
• pain b/l
• band-like, dull, tight cap feeling around head
• tightness often found in suboccipital area

Question 6

tentions-type headache: how is the pain rated?

Answer 6

• mild to mod
• non-throbbing
• steady - not aggravated by normal daily activities

Question 7

tension-type headache: assoc sx

Answer 7

1. peripheral mm tenderness
   - neck and shoulders
   - constant or worsen with actual HA pain
   - correlated with frequency and intensity of HA pain
   - palpation illicit pain
2. sleep issues

Question 8

TTH pathogenesis

Answer 8

body’s response to stress

• stress and mental tension
• head and neck mvmts and postures
• anxiety and depression
• fatigue
• structural abnormalities
• viscerosomatics

Question 9

TTH pathophysio - peripheral pain mech

Answer 9

• tightness of pericranial myofascial tissues sends nociceptive inputs to the dorsal horn neurons
• become sensitized - causes what is normally innocuous stimuli to be interpreted as pain
• episodic TTH (<15 days)

Question 10

TTH pathophysio - central pain mech

Answer 10

• increased facilitation of cranial structures
• decreased inhibition of pain transmission at the level of spinal dorsal horn/trigeminal nucleus
• altered brainstem reflexes suggest abnormal limbic controlled pain systems
• mech for chronic TTH (>15days)

Question 11

TTH pathophysio - above tentorium membrane in pain referral pathways

Answer 11

• pain referred by CN V

- pain perceived in front, temporal, parietal regions

Question 12

TTH pathophysio - below tentorium membrane in pain referral pathways

Answer 12

• pain referred by CN IX, X, and upper cervical spinal nerve roots
• pain perceived in occipital region

Question 13

TTH tx

Answer 13

acute/abortive

• earlier the tx admin, the better
• start with max dose of chosen therapy
• NSAIDS and OMT
• effectiveness of med for acute relief decreases with increased use

Question 14

TTH prophylaxis

Answer 14

• behavior mod
• workspace adjustments
• tx
• exercises

Question 15

migraine HA presentation - prodrome

Answer 15

symptoms that occur 24-48 hours before migraine:

• euphoria
• depression
• irritability
• food cravings
• constipation
• neck stiffness

Question 16

migraine HA presentation: aura

Answer 16

• seen in classic migraine
• visual, auditory, or olfactory hallucinations (visual most common - scotomas and photopsia)
• vertigo
• paresthesias

Question 17

migraine HA presentation: headache

Answer 17

• u/l, throbbing, pulsaltile pain
• can radiate to opp side
• intensity increases
• relief from lying in dark, quiet room and sleeping it off

Question 18

migraine HA presentation: postdrome

Answer 18

• mvmt of head causes pain transiently
• exhausation
• mild elation or euphoria

Question 19

migraine HA pathogenesis

Answer 19

• initial episode occurs during puberty

- triggered by many things

Question 20

migraine HA pathophysio - genetics

Answer 20

• epigenetics
• more commonly passed on from mother
• defects in voltage gated Ca2+ channel or Na-K ATPase channel

Question 21

migraine HA pathophysio - psychiatric problems

Answer 21

• depression
• bipolar
• anxiety
• insomnia
• somatoform disorders
• boderline personality disorder
• narcissistic personality disorder

Question 22

migraine pathophysio - which CN causes it?

Answer 22

CN V nucleus

• 3 branches to the face - u/l pain
• meningeal vessels - vasoconstriction/dilation
• dura

Question 23

migraine pathophysio - which NT is thought to be involved?

Answer 23

serotonin

- use of triptans (sertonin agonists) effective in abortive therapy

Question 24

migraine HA tx

Answer 24

acute/abortive therapies

• mild-mod (w/o nausea or vomitting) - acetaminophen, NSAIDs, combo drugs with caffeine, OMT
• mod-severe - triptans, sumatriptan/naproxen, ergot alkaloids, opiates, OMT

Question 25

migraine HA prophylatics therapies

Answer 25

- surgery - adjusting one's environ to avoid triggers - OMT

Question 26

general cluster HA - which nerve involved?

Answer 26

trigeminal autonomic cephalgia (TAC) - short-lasting, u/l, severe attacks primarily within V1 distrib - parasymp hyperactive - symp impaire

Question 27

cluster HA dx criteria

Answer 27

- dx is clinical - severe u/l orbital, supraorbital, temporal pain - attack happens at around same time each day - pain lasts 15min-3hrs - ave of 8-10 wks/yr - hx of at least 5 attacks

Question 28

cluster HA - common symptoms

Answer 28

- severe orbital, supraorbital, temporal pain - strictly u/l - restlessness and agitation - rocking or rubbing their head for relief

Question 29

cluster HA - how often does HA occur?

Answer 29

up to 8x/day

Question 30

cluster HA - other symptoms driven by which autonomic?

Answer 30

PS - ptosis - miosis - lacrimation - rhinorrhea - conjunctival injection - nasal congestion

Question 31

cluster HA - what 2 forms can a patient have?

Answer 31

- episodic form - rhythmic attacks with periods of remission | - chronic form - no remission

Question 32

cluster HA pathophysio - theory 1

Answer 32

hypothalamic activation with secondary activation of trigeminal-autonomic reflex

Question 33

cluster HA pathophysio - theory 2

Answer 33

neurogenic inflamm of the wall of the cavernous sinus obliterates venous drainage --> injury of symp fibers traveling with internal carotid artery

Question 34

cluster HA tx

Answer 34

acute/abortive - 100% O2 - opiates - triptans, ergots, lidocaine - OMT

Question 35

cluster HA preventative

Answer 35

- glucocorticoids, lithium - surgery - occipital nerve procedures - deep brain stimulation - OMT

Question 36

rebound headache - presentation

Answer 36

- episode of HA - present upon awakening - transient relief with subsequent doses of analgesic - location, severity, and type of HA vary

Question 37

rebound headache - assoc symptoms

Answer 37

- nausea - asthenia - difficulty concentrating - memory problems - irritability

Question 38

rebound headache - dx criteria

Answer 38

- HA present >15days/month - reg use or overuse of pain meds for 3 mos - HA dev or worsened with cont use of meds

Question 39

rebound HA - higher risk with which meds?

Answer 39

- opioids - butalbital containing combo analgesics - aspirin/acetaminophen + caffeine combo

Question 40

rebound HA tx

Answer 40

- withdrawn offending meds | - bridge therapy - used to get through withdrawal period

Question 41

other considerations for secondary causes of HA

Answer 41

- flu - tumor/cancer - aneurysm - meningitis - sleep apnea

Question 42

CC of HA, what PE should be included?

Answer 42

- CN screening - pronator drift - rhomberg tests

Question 43

what OMT tech for acute HA?

Answer 43

- gentle OMT | - avoid HVLA and other direct tech to avoid symp stimulation