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Neurology 2 > Clin Med - Headache > Flashcards

Clin Med - Headache Flashcards

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1
Q

What 7 factors must you determine for each type of HA

A
  1. frequency
  2. duration
  3. intensity
  4. type of pain (throbbing, sharp, etc.)
  5. Presence of GI sx
  6. Visual sx (aura)
  7. other neuro sx
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2
Q

what is one of the most important diagnostic tools for HA

A

History

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3
Q

Other neuro sx common associated with HA

A
  • tinnitus
  • hearing loss
  • dysarthria *
  • dysphagia *
  • weakness *
  • sensory loss *
  • LOC *
  • aphasia/dysphasia *

*could be signs of emergent condition (stroke, aneurysm)

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4
Q

Headache intensity classification

A
  • disabling: can’t get out of bed
  • severe: limits activity 50-90%
  • moderate: limits activity 25-50%
  • mild: does not limit activity at all
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5
Q

6 types of HA

A
  • migraine
  • tension
  • cluster
  • HA with head trauma
  • HA with vascular disorders
  • HA with nonvascular intracranial issue
  • HA with substance abuse/withdrawal
  • HA with infection (meningitis)
  • metabolic HA
  • HA from cranial structure
  • cranial neuralgia
  • other facial pain
  • psychogenic HA
  • HA: not otherwise classified
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6
Q

Two types of HA classified by cause

A
  1. primary - idiopathic

2. secondary - organic, related to other disease state

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7
Q

Two types of secondary/organic HA

A
  • intracranial

- extracranial

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8
Q

Three types of primary HA

A
  • migraine
  • cluster
  • tension
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9
Q

Common causes of secondary HA

A
  • toxic (CO poisoning)
  • metabolic
  • vascular
  • infectious
  • tumor/mass lesion
  • trauma
  • heredo-degenerative
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10
Q

What is very important in diagnosis toxic exposure HA

A

HISTORY

  • exposure
  • profession (exposure)
  • etc.
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11
Q

Examples of toxic causes for HA

A
  • organic compounds: solvents, drugs
  • inorganic compounds: lead, arsenic, cadmium, etc.
  • gases and fumes: H2S, CH4, CO, H2O, formaldehyde
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12
Q

Drugs that cause HA

A
  • oral contraceptives
  • nitro
  • fluoxetine
  • opioid pain meds
    MANY others
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13
Q

Causes of metabolic HA

A
  • renal failure
  • hepatic failure
  • acidosis
  • alkalosis
  • CO2 retention
  • anemia
  • hypo- and hyperthyroid
  • cushing
  • hyperparathyroid
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14
Q

Vitamin deficiency cause of HA

A
  • Niacin - pellagra
  • Thiamin - beri beri
  • vitamin C - scurvy
  • B12 - combined system disease
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15
Q

One common cause of infectious HA

A

meningitis

- history and PE important to look for other sx of meningitis

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16
Q

Parenchymal infectious causes of HA

A
  • bacterial
  • brain abscess
  • spirochete: syphilis
  • viral
  • HIV
  • fungal
    etc etc
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17
Q

Extracranial mass lesions that can cause HA

A
  • sinus carcinoma
  • mastoid tumor - cholesteatoma
  • head and neck carcinoma
  • carotid body tumor
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18
Q

Migraine epidemiology

A
  • F>M
  • onset generally 2nd or 3rd decade of life
  • fam history common
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19
Q

Migraine pathophys

A
  • exact mechanism unknown
  • maybe dt genetic abnormality that makes neuromuscular system hyperexcitable
  • a trigger is usually involved
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20
Q

What happens when a trigger activates a migraine?

A
  • cortical spreading depression which may or may not lead to aura
  • release of neuropeptides (serotonin, cytokines, etc.) which bind to intracranial blood receptors = vasodilation
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21
Q

Common migraine triggers

A
  • red wine
  • skipping meals
  • excessive afferent stimuli (flights, odors)
  • weather changes
  • sleep deprivation
  • stress
  • hormonal factors
  • certain foods
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22
Q

Two types of migraine

A
  • migraine with aura (25%)

- migraine without aura

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23
Q

When does aura occur during migraine phase?

A
  • can proceed migraine

- during migraine

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24
Q

characteristics of a aura headache

  • development
  • how long last
A
  • gradual development

- last less than one hour

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25
Positive migraine aura symptoms
- visual (bright lines, shapes, objects) MC - auditory (tinnitus, noises, music) - somatosensory (burning, pain, paresthesia) - motor (jerking, repetitive rhythmic movements)
26
Negative migraine aura symptoms
- absences or loss of function | - loss of vision, hearing, feeling, ability to move part of body
27
Most common sx of migraine
- pain - photophobia - phonophobia - nausea
28
Visual sx of migraine
- scintillating scotoma (MC) - blurred vision - visual loss - diplopia * * and many less common features
29
Mood/behavior changes due to migraine
- mood changes - irritability - depression - euphoria *before, during, after migraine
30
Things to consider when dx-ing migraine
- TIA - CVA - intracranial hemorrhage - hypoglycemia MANY MORE
31
Diagnostic criteria for migraine without aura
5 attacks of the following: - untreated HA lasts 4-72 hours Plus two of the following: - Unilateral - pulsating - moderate/severe pain - exacerbated by physical activity Plus at least one during HA: - n/v - photo- or phonophobia
32
Diagnostic criteria for migraine with aura
Two attacks of the following: - One or more reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, retinal) - Two of the following characteristics: - one aura sx >5 minutes or 2 or more sx in succession - at least one aura sx is unilateral - ea aura sx lasts 5-60 min - aura is accompanied by or followed by HA within 60 min
33
Is imaging necessary to dx migraine?
Nope!
34
When is imaging necessary necessary when pt presents with non-acute HA
- unexplained abnormal finding on neuro exam | - atypical HA features
35
What HA sx warrant imaging?
- sudden and severe - "first or worst" - recent significant change in pattern, frequency, severity - new or unexplained neuro sx or signs - HA always on same side - HA not responding to tx - new onset HA after age 50 - new onset w/ HIV or cancer - sx: fever, stiff neck, papilledema, cog impairment, personality change
36
What imaging to order for HA?
- CT w/o contrast (1st to ro bleeding) - MRI - MRA (vascular issues)
37
First line tx for mild/moderate attacks
- simple analgesics (NSAIDs or acetaminophen) | - antiemetic for n/v
38
First line tx for moderate to severe attacks without n/v
- oral migraine specific meds (triptans)
39
First line tx for mod to severe attacks with n/v
non-oral migraine specific meds - sub q sumatriptan - nasal sumatriptan non-oral antiemetics - topical or rectal phenergan - parental dihydroergotamine (DHE)
40
Meds to consider when treating migraine in the ER
(usually severe by time reach ER) - sumatriptan subq - dihydroergotamine (DHE) - antiemetics (metoclopramide, prochlorperazine, chlorpromazine) - ketorolac
41
what type of meds should be avoided in migraine tx
- opioids | - barbituates
42
Rebound headache/medication overuse HA (MOH) - which meds possible - which meds most likely? - which meds lowest risk
- all acute symptomatic meds have potential - risk highest in opioids, butalbital containing analgesics, aspirin/acetaminophen/caffeine combos - triptans moderate risk - NSAIDS lowest risk
43
how to prevent MOH
- acute meds limited to < 10 days per month or <15 days for NSAIDs
44
simple analgesics
- NSAIDs - aspirin - ibuprofen - naproxen - diclofenac - ketorolac - acetaminophen
45
HA dt temporal arteritis
- severe HA | - recurrent/persistent over weeks to months
46
Temporal arteritis - dx - tx
- elevated ESR and CRP and temporal artery biopsy | - high dose steroids and NSAIDs
47
Presentation of cluster HA
- brief, severe, constant - non throbbing - 10 min to < 2 hours - unilateral, return to same side - begins as burning behind eye
48
What HEENOT sx do cluster HA present with?
- conjunctival injection - tearing - nasal stuffiness - ipsilateral Horner's syndrome
49
what can precipitate cluster HA
- alcohol | - vasodilation drugs
50
Dx of cluster HA
- hx and PE to r/o other causes of HA
51
Cluster HA tx
- 100% O2 via nonrebreather - sumatriptan IM or nasal spray - dihydroergotamine
52
Tension HA - how common? - pathophys - men vs. women
- most common benign HA disorder - no pathophysiologic mechanism - W > M
53
Tension HA location | - often associated with what?
- neck, back of neck, top of head | - often assoc. with neck pathology (degenerative disk dz, etc.)
54
What is very important in dx of tension HA?
- history of PE | - necessary to r/o more ominous dx and/or to determine underlying condition causing HA
55
What is common cause of tension HA that can be found in history?
- often secondary to analgesic overuse | - thoroughly address efforts at medical management!
56
Tension HA presentation
- steady, nonthrobbing - bilateral - global head pain - not associated with prodrome, neuro signs/sx or n/v
57
What are CT findings fro tension HA?
usually normal CT :)
58
Tension HA tx
- similar tx to other HA (triptans, anti-inflammatories) with possible addition of a muscle relaxer
59
Non pharm tx for tension HA
- psychotherapy - PT - muscle relaxants - relaxation techniques
60
GCS
memorize if you wish
61
Concussion | - overview
- head injury due to contact and/or acceleration or deceleration forces - cortical contusion - can be coup contrecoup
62
Hallmark sx of concussion
- confusion - amnesia - +/- LOC ** assess duration to assess severity of injury (and risk of complications)
63
Early sx of concussion
(minutes to hours) - HA - dizziness - lack of awareness of surroundings - n/v
64
late sx of concussion
(hours to days) - mood or cognitive disturbances - sensitivity to light and noise - sleep disturbances
65
Other sx of concussion
- vacant stare - delayed verbal expression - inability to focus - disorientation - slurred/incoherent speech - gross incoordination - emotions out of control - memory deficits - LOC *can show up 2-3 days after injury, educate family!
66
Concussion Dx
- Head CT w/o contrast
67
Concussion: when to order a CT
- GCS < 15 two hours after injury - suspected open/depressed skull fx - signs of basilar skull fx - >2 vomit - >65 yo - amnesia before impact > 30 min - neuro deficit - seizure - use of anticoagulants
68
Concussion tx
- monitored at home X 24 hours
69
When to return to ER after concussion
- inability to awaken pt - severe/worsening HA - confusion/somnolence - restlessness/unsteadiness - seizure - vision change - vomiting, fever, stiff neck - urinary or bowel incontinence - numbness/weakness
70
Post concussion syndrome sx
- seizures (MC) - HA - dizziness - neuropsychiatric sx - cognitive impairment - depression - anxiety - PTSD *does not require LOC
71
Post concussion syndrome Dx
- neuropyschological testing | - neuroimaging (CT, MRI, EEG)
72
Post concussion syndrome CT
- 10% show abnormal bleed, mild subarachnoid hemorrhage, subdural hemorrhage, contusion
73
Post concussion syndrome MRI
- more sensitive than CT | - shows abnl in 30% pts with normal CT
74
Post concussion syndrome Tx
- migraine meds - analgesics - psych counseling - psychotropic meds
75
Post concussion syndrome recovery
- most recover quickly within several weeks | - minority have prolonged disability

Neurology 2 (21 decks)

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