(enochs + some) Lecture 2: Headaches Flashcards
What are the 3 primary headache syndromes?
- Migraine
- Tension
- Cluster
90% of all headaches
What are the secondary classes of headaches?
- Meningitis
- Intracranial mass
What are the danger signs of a HA?
- Systemic symptoms, illness, or condition
- Neurologic symptoms or abnormal signs
- Onset is new or sudden (> 40 or thunderclap)
- Other associated conditions & features
- Previous HA history with progression
SNOOP
Other:
Head trauma
Illicit drug use
Awakens from sleep
Worse with Valsalva
Precipitated by cough, exertion, or sex
What are the danger neurologic signs?
- Confusion
- ALOC
- Papilledema
- Meningismus (nuchal rigidity, light reaction)
- Focal neurologic deficits
- Seizures
CAPS MF!!
What are the other features that suggest a secondary source for headache?
5
- Impaired vision, Halos around lights (glaucoma)
- Visual field defect
- Sudden, severe, unilateral vision loss
- Blurring of vision on forward bending or HA upon awakening
- N/V, worsening of HA with body position change
What PE systems should we do for every headache patient?
- HEENT
- Neurological
- Vital signs
What features would suggest that we order imaging for headaches?
6 things
- Age of onset > 40
- Focal neurologic S/S
- Onset of headache with exertion, cough, or sexual activity
- Change in pattern (frequency/severity)
- Cancer, lyme disease, or HIV
- Progressive worsening despite adequate therapy
When is a LP recommended for headache?
- Meningismus
- Subarachnoid hemorrhage
Measure opening pressure for SAH
Opening pressure MUST BE MEASURED LATERALLY
What is the preferred imaging study for HA?
MRI
Hard to do in kiddos
What are specifically NOT common causes of recurrent headaches?
- Acute/chronic sinusitis
- Poor vision/eye strain
- HTN (unless in crisis)
When is admittance suggested for headache?
- Need for repeated parenteral pain meds
- Facilitate/expedite imaging/consults
- Monitoring when ER workup is inconclusive
- Pain severe enough to impair activities
What is the most common type of migraine?
Without an aura
MC in women also
What are the 4 classic phases of a migraine?
- Prodrome (common)
- Aura (uncommon)
- Headache
- Postdrome
What S/S are common in a prodrome for migraines?
- Euphoria
- Depression
- Irritability
- Food cravings
- Constipation
- Neck stiffness
- Yawning
60% of people w migraines have this. 24-28 hrs prior to HA
what symtpoms occur in the aura phase? what causes these symptoms?
- MC is visual s/s but can be sensory, verbal and motor.
- attributed to cortical spreading depression
occurs in 25% of people w migraine. lasts <1 hr
How does a classic headache associated with migraine typically present?
- Unilateral
- Throbbing/pulsatile
- Associated anorexia, N/V, cutaneous allodynia, vision blurring, hyperalgesia, photophobia, cog impair.
- Aggravated with routine physical activity
Can be bilateral in 40% of cases. lasts 4-72 hrs.
What is the diagnostic criteria for a migraine without aura?
If you have an aura, only 2 attacks instead of 5!
seems importante
What are the mainstays of migraine treatment?
- Preventative: meds, avoiding triggers
- Abortive/symptomatic: NSAIDs, triptans, ergotamines, antiemetics
- Resting in a quiet, darkened room with cold washcloth to head.
If a patient is unable to tolerate one NSAID for their migraines, what should we recommend next?
Trying a different one :)
What is the first-line prescribed medication for migraines?
Triptans
MOA and use of triptans?
- MOA: 5-HT 1b/1d agonists
- Use ASAP at start of headache
works on trigeminal nerve receptors in cranial blood vessels.
What are the 3 most successful Triptans and what other medication shows good efficacy together with them?
- Rizatriptan
- Eletriptan
- Almotriptan
- NAPROXEN!!!!!!
ARE Naproxen
What is the only injectable triptan?
Sumatriptan
Suma SubQ
What is the general protocol regarding triptan use?
- If you fail one, try it at least 3 times before switching to a different one
- Use < 10 times a month to prevent overuse
What are the contraindications to triptan use?
7 of them
- CAD, peripheral vascular disease
- Familial hemiplegic migraine and basilar migraine
- Ischemic stroke or risk factors for stroke
- IHD
- Prinzmetal’s angina
- Patients taking ergot compound meds
- Avoid in patients > 65
Refer to neuro if using triptan in child.
Ischemic conditons + ergots + weird migraines
What should we be cautionary of when prescribing a triptan?
- Patient on HR-lowering meds
- Patients on SSRI’s or SNRI’s
- Patients using CYP3A4 inhibitors with eletriptan in 72 hrs
- Avoid breastfeeding 12 hrs after use. Preg C.
What patient education should be provided regarding triptans?
7 things
- DNU if MAOi used in past 2 weeks
- DNU within 24 hrs of migraine med
- Wait 2 hours in between dosages
- Only use sumatriptan once the headache begins
- Do not breastfeed within 12 hours of use
- Only for patients 18-65
- May impair decision-making/driving.
What are ergotamines derived from?
Fungi
Shrooms are the cure
What are the BBW of ergots?
Who are ergotamines contraindicated in?
- Peripheral vascular disease
- CAD
- HTN
- Renal impairment
- Hepatic impairment
- Sepsis
- Pregnancy
- Breastfeedings
For a mild-mod migraine, what are the recommended med classes?
- Simple analgesics
- NSAIDs
- Combo drugs (Excedrin migraine)
- Antiemetic for N/V
How does a cluster headache typically present?
- Severe unilateral temporal HAs in grouped attacks/episodes
- Occurs over weeks to months
- Occurs at night and wakes patient
- Ipsilateral autonomic S/S
- Alcohol is the common trigger
What are the primary treatments for cluster HAs?
- 100% O2 at 7-12L/min over 15 min via NRB
- Contralateral admin of nasal sumatriptan
- DHE (ergot derivative)
- Preventative stuff
