Ch8: Headaches

Question 1

what is a primary headache

Answer 1

not associated with other diseases

likely a complex interplay of genetic, developmental, and environmental risks

Question 2

(3) most common types of primary headaches

Answer 2

• migraine
• tension-type
• cluster (less common)

Question 3

what is a secondary headache

Answer 3

associated with or caused by other conditions, generally will not resolve until the specific cause is diagnosed and addressed

e.g., tumor, intracranial bleeding, increased intracranial pressure, use of select medications, meningitis, accelerated HTN, giant cell arteritis, acute sinusitits, viremia, etc.

Question 4

most common (2) secondary headache causes seen in primary care

Answer 4

• viremic (e.g., with the flu)
• acute sinusitis

both are usually self-limiting

Question 5

SNOOP mnemonic for red flags with headache

Answer 5

S - systemic symptoms (e.g., fever, unintended weight loss), secondary headache risk factors (e.g., >180/120, on anticoagulation)

N - neurologic signs (new-onset confusion, impaired alertness, nuchal rigidity, papilledema)

O - onset sudden or abrupt

O - onset age (>50yo)

P - prior headache history (change in quality or frequency), positional (worse with lying down), papilledema

Question 6

only (2) neuro signs that are NOT red flags in headache presentation

Answer 6

photophobia, phonophobia

Question 7

thunderclap headache, worry about…..

Answer 7

intracranial (subarachnoid) hemorrhage

Question 8

headache that is worse with lying down, and worst in morning when waking up. worry about…..

Answer 8

increased intracranial pressure

Question 9

how will papilledema usually present symptomatically

Answer 9

black spot in the middle of vision

Question 10

acute headache with new onset neuro changes, what is your role as generalist NP?

Answer 10

send to ER

you won’t be the one ordering imaging because you can’t manage that acute care in primary care setting

Question 11

giant cell arteritis, aka….

Answer 11

temporal arteritis

Question 12

etiology of giant cell arteritis, generally

Answer 12

auto-immune

Question 13

treatment for giant cell arteritis

Answer 13

co-managed with neurology

prednisone 60-80mg QD until inflammation is under control, and then systemic corticosteroids are continued for 6 months up to 18 months

while work-up and specialist consult is in the book, get them started on the high dose steroids

Question 14

priority complication of giant cell arteritis, if untreated

Answer 14

blindness

Question 15

at least ___% of people with giant cell arteritis will have a transient change in vision that will become permanent if not treated

Answer 15

50%

Question 16

NSAIDs and corticosteroids, risk for ____ ulcers

Answer 16

gastric ulcers

Question 17

most common med class to prevent NSAID and steroid-induced gastropathy

Answer 17

PPIs

Question 18

H. pylori causes ____ ulcers

Answer 18

duodenal

Question 19

long term use of systemic corticosteroids is prescribed for giant cell arteritis dx in older woman. what (2) medications should you consider to prevent sequela?

Answer 19

• daily PPI to prevent gastritis/gastric ulcer

- bisphosphonates to counter bone loss

Question 20

treatment for cluster headache

Answer 20

100% o2 inhaled

Question 21

headache associated with BP >180/>120. worry about….

Answer 21

intracranial hemorrhage

Question 22

headache unlikely to be caused by HTN unless the BP is above…..

Answer 22

> 180 / >120

Question 23

characteristics of TENSION headaches

Answer 23

• lasts 30min - 7 days (typically 1-24hrs)
• two or more of the following characteristics
  + pressing, non-pulsatile pain
  + mild to moderate intensity
  + usually bilateral
  + one or less of: nausea, photophobia, phonophobia

female:male ratio = 5:4

Question 24

characteristics of MIGRAINE headaches WITHOUT AURA

Answer 24

• lasts 4-72 hrs
• two or more of the following characteristics:
  + usually unilateral
  + pulsating quality
  + moderate to severe in intensity
  + aggravated by normal activities (e.g., walking)
• during the headache, there are one or more of: nausea, vomiting, photophobia, phonophobia
• positive family history in 70-90%

female:male ratio = 3:1

Question 25

characteristics of MIGRAINE headache WITH AURA

Answer 25

same symptoms as migraine without aura, except symptoms begin with or after aura onset aura is caused by focal dysfunction of cerebral cortex or brain stem that causes 1 or more aura symptom developing over 4 minutes or in succession symptoms include: - feeling dread or anxiety - unusual fatigue - unusual nervousness or excitement - GI upset - visual changes - olfactory alterations no aura symptoms should last >1 hr

Question 26

aura symptoms typically last _____, no longer than ______

Answer 26

typically 20 min | no longer than 1 hr

Question 27

characteristics of CLUSTER headache

Answer 27

- tends to occur daily in groups or clusters - clusters themselves last several weeks to months, then disappear for months to years - may occur at characteristic times of year such as vernal and autumnal equinox with 1-8 episodes/day, at the same time of day - most common time of day is 1 hr into sleep, described as "alarm clock headache" because the pain awakens person - headache is often located behind 1 eye with steady, intense pain ("hot poker in the eye") sensation, severe pain in a crescendo pattern - pain episodes last 15 minutes to 3 hours, most commonly 30-45 minutes - pain is severe - may have ipsilateral autonomic signs such as lacrimation, conjunctival injection, ptosis, or nasal stuffiness female:male ratio = 1:3 to 1:8 family history present in 20% of cases

Question 28

common triggers for primary headaches

Answer 28

- chocolate - alcohol - certain cheeses - monosodium glutamate (MSG) - artificial sweeteners (e.g., aspartame) - perfume - stress - too much or too little sleep - altered routine - hunger

Question 29

OTC analgesics for the treatment of primary headaches

Answer 29

- NSAIDs and acetaminophen most commonly - best effects if taken at headache onset - limit use to 2 days/week to avoid rebound headache - use WITH triptans for optimal relief

Question 30

limit use of NSAIDs and acetaminophen to _______ to avoid rebound headache syndrome

Answer 30

max 2 days/week

Question 31

migraine abortive prescription therapies

Answer 31

- triptans (selective serotonin receptor agonists) - ergot derivatives (e.g., dihydroergotamine nasal spray or injection) - consider antiemetics PRN. consider opioids or systemic corticosteroids for severe symptoms refractory to first line therapies Notes: - best effect if taken at onset of headache - do not use in pregnancy, CVD disease, poorly controlled HTN d/t vasoconstrictive effects - can also be used in tension and cluster headaches non-responsive to first-line therapies

Question 32

migraine preventive prescription therapies (5) classes

Answer 32

- beta blockers (propanolol, metoprolol) - TCAs (amitriptyline, nortriptyline) - anticonvulsant drugs (divalproex sodium, valproate sodium [Depakote], topiramate [Topamax]) - calcitonin gene-related peptide (CGRP) antagonists (monoclonal antibodies ending in --mab) - supplemental butterbur, feverfew, coenzyme Q10, magnesium, riboflavin note: CCBs are old-school, used to be used, are NOT recommended and no longer considered effective

Question 33

nutritional supplements that can be used for migraine prevention (5)

Answer 33

- butterbur - feverfew - coenzyme Q10 - magnesium - riboflavin (B2)

Question 34

most common test performed in acute severe headache with new-onset abnormality on the neuroimaging, send to ER for this

Answer 34

CT without contrast

Question 35

CT without contrast is capable of revealing.....

Answer 35

- acute or chronic hemorrhage, regardless of etiology | - stroke

Question 36

CT with contrast is capable of revealing....

Answer 36

- tumor | - abscess

Question 37

MRI is capable of revealing.....

Answer 37

- tumor | - best for soft tissues

Question 38

(4) reasons for generalist NP to refer to a specialist (across body systems)

Answer 38

1. requires a service the NP cannot provide or is beyond scope (e.g., needs a cholecystectomy so refer to a surgeon) 2. a diagnosis that needs support or clarification by specialist (e.g., suspected autoimmune condition like RA or SLE) 3. has an already-diagnosed health condition which needs ongoing input from a specialist (e.g., CHF, angina pectoris) 4. fails to respond to standard first-line therapies (e.g., low back pain failed to respond to first line analgesics and PT)

Question 39

what is jaw claudication

Answer 39

pain in the jaw with chewing

Question 40

best FIRST test with suspected giant cell arteritis

Answer 40

ESR ESR >100 mm/hr before biopsy is warranted

Question 41

ESR result that would warrant temporal artery bx in suspected giant cell arteritis

Answer 41

>100 mm/hr

Question 42

definitive test for giant cell arteritis

Answer 42

arterial biopsy, done by a specialist

Question 43

management of suspected giant cell arteritis by the generalist NP

Answer 43

- draw labs including ESR (>100, suspicious) - refer to neuro for arterial bx to confirm - in the interim, start on HIGH DOSE systemic corticosteroids (1-2mg/kg/day prednisone) until stabilized - anticipatory guidance that they will likely remain on lower-dose systemic steroids for 6 months - 2 years to prevent remission - consider starting aspirin to reduce stroke risk - consider GI protection with long-term steroid use such as a PPI - consider bone-protection such as bisphosphonates with long-term steroid use

Question 44

what is giant cell arteritis

Answer 44

- autoimmune - vasculitis that affects the medium- and large-sized vessels including the temporal artery - inflammation and swelling of the arteries leads to decreased blood flow and associated symptoms - most commonly occurs in women 50-85yo - often seen comorbid to polymyalgia rheumatica

Question 45

giant cell arteritis (temporal arteritis) is commonly comorbid with.....

Answer 45

polymyalgia rheumatic (PMR)

Question 46

clinical presentation of giant cell arteritis

Answer 46

- tender or nodular vessel, usually the temporal artery - pulseless vessel (d/t constriction) - accompanied by severe, unilateral headache - 50% will experience visual impairment including transient visual blurring, diplopia, eye pain, or sudden loss of vision

Question 47

how is giant cell arteritis diagnosed

Answer 47

- ESR and CRP usually markedly elevated (ESR >100) - refer for arterial biopsy - color duplex US can be used to complement bx or as alternative

Question 48

common dietary triggers for migraines

Answer 48

...... refer to a nutritionist! - sour cream - ripened cheeses (e.g., cheddar, stilton, brie, camembert) - sausage, bologna, salami, pepperoni, summer sausage, hot dogs - pizza - chicken liver and pate - herring (pickled or dried) - any pickled, fermented, or marinated food - MSG commonly found in soy sauce, meat tenderizers, and seasoned salt - freshly-baked yeast products including sourdough bread - chocolate - nuts and nut butters like peanut butter - broad beans, lima beans, fava beans, snow peas - onions - figs, raisins, papaya, avocado, red plums - citrus fruits - bananas - caffeine (tea, coffee, cola, energy drinks) - alcohol - aspartame, phenylalanine-containing products

Question 49

possible lifestyle triggers for migraines

Answer 49

.... in general, people with chronic primary headaches have less issues when maintaining a regular schedule of sleep, nutrition, hydration, and exercise - menses, ovulation, or pregnancy - illness of any kind - intense or strenuous exercise - altered sleep patterns - altered eating patterns including fasting or missing meals - bright lights/flickering lights - excessive or repetitive noises - odors, fragrances, tobacco smoke - weather, seasonal changes - high altitudes - medications including SSRIs, SNRIs, analgesic overuse, hormonal contraception, MHT - stress