Exam 1: Headaches

Question 1

What are the red flags of a headache in and adult?

Answer 1

Sudden onset
Worst or first headache ever 
Thunder clap headache
Fever, neck stiffness (meningitis, encephalitis?)
Mental status changes
New headache in patient <5 or >50
Worsening pattern to a chronic headache
Focal neurological signs (other than aura)
Papilledema

Question 2

What are 3 types of headaches, typically seen in primary care, that have no specific cause?

Answer 2

Migraine
Tension-type
Cluster

Question 3

T/F: Primary headaches do not have a specific cause?

Answer 3

True

Question 4

T/F: Secondary headaches have an underlying structural or metabolic cause?

Answer 4

True

Question 5

T/F: Migraines, tension, and cluster headaches are secondary headaches?

Answer 5

False; they are all examples of primary headaches

Question 6

T/F: Mild HTN can cause a headache?

Answer 6

False; must have malignant HTN to cause a headache

Question 7

T/F: Eye strain is a common cause of headache?

Answer 7

False

Question 8

What patient history is important for headache?

Answer 8

Any aura or prodrome
Number/frequency per month
Family history (especially females of family)
Recent trauma
Time and mode of onset
Age of onset
Changes in vision
Quality, site, radiation of pain
Precipitating/relieving factors
Response to previous treatments
Changes in sleep, exercise, weight, or diet
Birth control method
Effects of menses
Change in work and lifestyle

Question 9

What is included in the physical exam for headache?

Answer 9

BP, heart rate
Listen for carotid bruit in neck
Palpate head, neck and shoulder areas (rule out sinus isues)
Check temporal/neck arteries
Examine spine and neck muscles for tightening

Question 10

What is included in the neuro exam for a headache?

Answer 10

Cranial nerves
Fundoscopic exam (papilledema, etc)
Tandem gait (walk straight line)
Romberg test
Symmetry of motor, sensory, and reflex skills

Question 11

What are symptoms of a migraine headache?

Answer 11

Pain: pulsatile, throbbing, unilateral
Nausea/vomiting
Photophobia/Phonophobia

Question 12

What are symptoms of a brain tumor?

Answer 12

Can have pain at any time, day or night; can awaken person from sleep

Question 13

What are symptoms of a tension-type headache?

Answer 13

Pain: band-like, dull, nagging, vice-like, steady, non-throbbing
Location: usually bilateral

*** No N/V or photo/phonophobia

Question 14

What are the indications for sending a patient for imaging for headache?

Answer 14

Worst headache ever
Unexplained abnormal neuro exam finding
Recent change in pattern, frequency, or severity
Progressive worsening despite appropriate treatment
Onset with exertion, cough, or sexual activity (could suggest lesion/mass)
Onset after age 40-50

Question 15

What imaging/procedure would you order for worst headache ever?

Answer 15

CT (quick check for bleed)

Lumbar puncture if concern for meningitis

Question 16

Name some common migraine triggers

Answer 16

Foods (chocolate, cheese, red wine, msg, nitrites, fried foods, oranges)
Menses
Change in weather
Stress
Alcohol
Hunger
Fatigue or lack of sleep
Loud noises
Flickering lights
Noxious stimuli (perfumes, etc)
Nitroglycerin
Minor head trauma
Exertion
Surgical menopause

Question 17

Which headache is most common: migraine, tension, or cluster?

Answer 17

Tension headache is most common but patients usually present for treatment of migraine as they can treat at home for tension headache

Question 18

T/F: All migraine sufferers get an aura 30-60 minutes prior to the headache?

Answer 18

False: Only about 20% of migraines have auras (mostly visual)

Question 19

What is scotoma?

Answer 19

Partial vision loss, loss of visual field, or blind spot in vision (aura)

Question 20

What is the criteria to diagnose migraines?

Answer 20

Attacks lasting 4-72 hours
Normal neuro exam
No other reasonable cause for headache

AND, at least 2 of the following:
Unilateral pain 60% of time
Throbbing/pulsating pain
Aggravation by movement or activity
Moderate to severe intensity

PLUS, at least 1 of the following:
Nausea and vomiting
Photophobia or phonophobia

Question 21

What are common abortive treatments for mild migraine symptoms?

Answer 21

OTC: NSAIDS, APAP, ASA, Excedrin, caffeine
If one NSAID doesn’t work, try another one
Prescription: Triptans, Fioricet

• • Early treatment is most effective
• • Large, single dose works best
• • Over use of Fioricet can cause rebound headaches

Question 22

What are common abortive treatments for moderate to severe migraine symptoms?

Answer 22

• Moderate inhibits daily activity but not incapacitating
  OTC: NSAIDS, Aleve, antiemetics for N/V
  Triptans especially in combination with Aleve
  Benzos can be used to get the patient to sleep (possibly breaking the migraine)
• Severe incapacitating should go to ED for IV treatment

Question 23

What is the first-line preventative (prophylactic) treatment for migraines?

Answer 23

Beta blockers (propranolol) - most effective treatment studied
CCB (verapamil) - not as effective as a BB but may relieve aura
Tricyclic antidepressants (amitriptyline)
Anticonvulsants (valproate/Depakote, topiramate/Topamax) [BLACK BOX WARNING: risk for suicide for those with major depression]

** If first-line doesn’t work, refer to neuro

Question 24

Define episodic tension headache

Answer 24

At least 2 of the following:
Pressing/tightening, non-pulsating, squeezing, vice-like
Mild to moderate intensity (inhibits but does not prohibit activity)
Bilateral
No aggravation from routine physical activity

Both of the following:
No nausea or vomiting
Photophobia or phonophobia absent, or only one present

Question 25

What are the treatments for tension headaches?

Answer 25

OTC: APAP, ASA, NSAIDs (start with ibuprofen), Aleve Triptans NOT helpful If OTC does not work may add caffeine but can cause rebound headaches Prophylaxis usually unnecessary but if prescribed - Amitriptyline

Question 26

What are the characteristics of a cluster headache?

Answer 26

Severe "ice pick" piercing pain behind one eye and temple Tearing Rhinorrhea Ptosis Miosis (extreme constriction of pupil) on one side (Horner's syndrome) Typically affects middle aged males

Question 27

What is the treatment for a cluster headache?

Answer 27

Oxygen at least 12L with mask for 15 minutes Sumatriptan (Imitrex) by injection or intranasal Prophylaxis: verapamil daily

Question 28

What are the red flags in pediatric headaches?

Answer 28

``` Patient < 5 New onset Focal neurological signs Nocturnal awakening with headache Difficulty waking child in the morning Vomiting Significant change in headache pattern Papilledema Head trauma with LOC > 10 minutes Inability to control headache with appropriate treatment ```

Question 29

T/F: Pediatric migraines are bilateral and often shorter in duration than an adult's.

Answer 29

True: pediatric migraines are often bilateral

Question 30

What are the abortive treatments for pediatric migraines?

Answer 30

OTC: NSAIDs most effective, APAP (NSAIDs most effective per studies) Antiemetics (suppositories, PO) Sedatives (Benadryl, then benzos) Triptans (not FDA approved for younger than age 18 but are used safely and effectively) Sumatriptans > age 12

Question 31

What are the most common headaches in kids?

Answer 31

Migraine | Tension

Question 32

Secondary headaches in pediatric patients are usually due to _______.

Answer 32

Viral infections, possibly with: ``` Fever Sinusitis Pharyngitis Acute otitis media Mono Mild head trauma ```

Question 33

T/F: Most headaches in kids/teens are not due to serious underlying disorders.

Answer 33

True

Question 34

What is the risk of mixing triptans and SSRIs?

Answer 34

Serotonin syndrome (often begins within about 6 hours of taking the medication or increasing the dose) Mild cases include high blood pressure and a fast heart rate; usually without a fever. Symptoms in moderate cases include high body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils...

Question 35

T/F: Parents are the best source for patient history when seen for headaches?

Answer 35

False: Interview patient alone as well as with the parents. Children often describe history more accurately than their parents.

Question 36

A patient complains of headache that occurs regularly and may worsen with changes in atmospheric pressure or when stooping. Which type of headache could this be?

Answer 36

Sinus headache

Question 37

An older patient comes in with complaints of a headache to his right temple. He admits to tenderness to his scalp and the right temple. You examine his temple area and it is reddened and warm to the touch. What is your diagnosis?

Answer 37

Temporal arteritis; this is a medical urgency to prevent blindness