DDx- headache

Question 1

What are the ‘Do Not Miss’ of HA aka Secondary Causes?

Answer 1

SAH, Meningitis (infection), Temporal Arteritis, Glaucoma, HTN, Cerebral ischemia/CVA/TIA, Arterial Dissection, and Brain Tumor, also space occupying lesion.

Question 2

What is SNOOP?

Answer 2

Systemic symptoms of dz, Neurological, Onset- sudden thunderclap, Onset- before age 5 or before age 50, Pattern change- progressively worse or waking up from sleep

Question 3

What are the Primary Headaches?

Answer 3

Tension-type headache
Migraine
Cluster
Associated with exercise

Question 4

Patterns for Primary Headaches

Answer 4

Positive family history
Stereotypic headache pattern over time
Menstrual association
Mutation (marker) on chromosome 19
Prodromes and/or auras
Resolution with sleep
Changing locations of headache
Otherwise healthy individual

Question 5

Most common type of primary headache? What class does it fall under? What is the etiology?

Answer 5

Tension headache. Extracranial. Muscle strain/stress.

Question 6

IHS Criteria for Tension HA?

Answer 6

*At least 10 previous headache episodes lasting from 30 minutes to 7 days characterized by at least 2 of the following pain characteristics:
-Pressing, tightening, nonpulsatile quality
-Mild or moderate intensity (may inhibit but does not prohibit activity)
-Bilateral location
-Not aggravated by routine physical activity
And one of the following:
No nausea or vomiting
Photophobia or phonophobia may be present, but not both

Question 7

IHS Criteria for Migraine Without Aura

Answer 7

Headache lasting 4-72 hours characterized by at least two of the following four characteristics:
Unilateral pain
Throbbing, pulsatile quality
Moderate to severe in intensity
Aggravation by routine activity
And at least one of the following:
Nausea and/or vomiting
Photophobia and/or phonophobia
Diagnosis should include at least 5 previous attacks and no evidence of underlying disease

Question 8

Etiology of Migraine Without Aura

Answer 8

No longer thought of as a vascular problem
Neurovascular Theory:
Hyperexcitable state of the cerebral cortex with subsequent vasuclar epiphenomenon of dilation and constriction: Cortical spreading depression

Question 9

IHS Criteria for Migraine With Aura

Answer 9

Headache follows attacks, with at least 3 of the following:
1 or more reversible visual symptoms (either positive or negative features) and/or sensory or speech problems
At least 1 aura symptom develops gradually over more than 4 minutes or 2 or more symptoms occur in succession
No aura symptom lasts more than 60 minutes
Headache follows aura with a free interval of less than 60 minutes (may also begin before or simultaneously with aura)

Question 10

What serious life-threatening event is more common with Migraine with Aura?

Answer 10

Stroke x4

Question 11

When are Triptans (for pain) contraindicated? (5-HT1B serotonin receptors)

Answer 11

Contraindicated in coronary vascular disease or uncontrolled HTN**

Question 12

Cluster HA etiology?

Answer 12

Not clearly understood- Trigeminal autonomic cephalgias

Question 13

ISH Criteria for Cluster HA- rarest

Answer 13

**Autonomic characteristics are telling
Individual episode of unilateral headache lasting 15 minutes to 1 hour, occurring up to several times a day for periods of 3 to 16 weeks
May resolve for months to years and then occur again
May have seasonal variations
Pain originates behind or around the eyes and may radiate into temple, jaw, nose, teeth or chin; drooping eyelid, tearing eye; facial flushing, nasal congestion
Usually no nausea or vomiting
Restlessness and agitation

Question 14

Cluster HA Risk Factors?

Answer 14

Alcohol use
Heavy smoking
Cold wind exposure
Heat blown into the face
Seasonal variation

Question 15

Tx for Cluster HA?

Answer 15

Acute:
High-flow oxygen – 10 L/min for 10 min
*Oral medications usually ineffective
Injectable triptan
DHE intranasal
Lidocaine intranasal
Non-Acute:
Ace inhibitors
Corticosteroids – high dose
Anti-seizure medication

Question 16

When is Neuroimaging Indicated?

Answer 16

Nonacute headache and an unexplained abnormal finding on neurological examination
Red flag symptoms (SNOOP)
Onset after age 50 years
Headache that is progressively getting worse
Immunocompromised with headache and no fever - MRI
**Not indicated for Tension HA

Question 17

Neoplasm S/Sx & PE

Answer 17

Headaches – most commonly bilateral, frontal, and intermittent
Recent worsening of symptoms
N/V
PE:
Exacerbated by postural changes
Full ophthalmoscopic exam (increased ICP)

Question 18

Rebound HA S/Sx

Answer 18

Signs/Symptoms:
Typically occur in pts with underlying headaches that transforms to a chronic daily headache d/t excessive intake of headache relief medication (Imitrex)
Can also be caused by other foods, caffeine, etc

Question 19

Simple Partial Seizure

Answer 19

Unilateral sensory and motor symptoms. Gustatory and visual hallucinations, nausea.
Get MRI- rule out space occupying lesion/ Cancer Mets
EEG
**Imitrex may induce

Question 20

Treatment: Migraine with Aura?

Answer 20

Prophylaxis: 
-Amitriptyline 15 mg/d
-Naproxen 500 mg q 12hr
-Gapapentin 
Abortive:
-Imitrex

Question 21

What are Secondary HA and what are they?

Answer 21

Symptom of a disease that can active the pain sensitive nerves of the head. 
Brain tumor
Medicine rebound headache
Orthostatic hypotension 
Meningitis

Question 22

JR is a 46-year-old left handed male with a 5 month history of headache. He describes the headaches as bitemporal, throbbing and lasting from a few minutes to an hour in duration. The current frequency is 3 headaches a week for the past 5 months. The headaches are not associated with photophobia, phonophobia, or vomiting. They are not worsened with movement. After the symptoms resolve he does feel nausea occasionally. He does report episodes of visual and sensory disturbances prior to the headaches beginning. He notes it typically begins with a metallic taste in his mouth followed 20 minutes later by a visual disturbance of “looking through water”. He also has tingling of his left hand and left side of his tongue for 5-15 minutes followed by numbness in his left leg with no ambulatory difficulty. He has had headaches for 15 years that have been triggered by excessive coffee or alcohol (beer). The numbness and tingling have been new although he describes an episode, a year ago, where he had slurred speech and tingling in his left hand and tongue only lasting a few minutes. He reports no weakness associated with that episode. He takes Imitrex as needed for the headaches and rests until they resolve. DDX?

Answer 22

Brain tumor
Medication Rebound Headache
Migraine
Simple Partial Seizures

Question 23

Prophylactic medications for Migraine?

Answer 23

Beta blockers
Ca Channel blockers
Anti-epileptics
TCAs

Question 24

Most common secondary HA?

Answer 24

Fasting?

Question 25

HA Key Points

Answer 25

HEADACHE DISORDERS ARE AMONG THE MOST COMMON DISORDERS OF THE NERVOUS SYSTEM
.-IT HAS BEEN ESTIMATED THAT 47% OF THE ADULT POPULATION HAVE HEADACHE AT LEAST ONCE WITHIN LAST YEAR IN GENERAL.
-HEADACHE DISORDERS ARE ASSOCIATED WITH PERSONAL AND SOCIETAL BURDENS OF PAIN, DISABILITY, DAMAGED QUALITY OF LIFE AND FINANCIAL COST.
-A MINORITY OF PEOPLE WITH HEADACHE DISORDERS WORLDWIDE ARE DIAGNOSED APPROPRIATELY BY A HEALTH-CARE PROVIDER.-HEADACHE HAS BEEN UNDERESTIMATED, UNDER-RECOGNIZED AND UNDER-TREATED THROUGHOUT THE WORLD.

Question 26

Quiz

Answer 26

1. High Blood Pressure
2. Temporal Ateritis
3. Cluster Headache
4. MRI with Contrast
5. Onset after 50 –Red Flag
6. Ischemic Heart Disease – Don’t give Imitrex
7. Exertional Headache is a primary headache
8. At least five attacks lasting 4-10 hours in 72 hours= Migraine without Aura
9. Food craving prodome (esp sweet- like chocolate) with migraine in women.
10. 2% will have a serious cz who present to the ER