HA

Question 1

primary causes of migraine

Answer 1

i. HA & associated features are the disorder
ii. Tension 69%
iii. Migraine 16%
iv. Cluster 0.1%

Question 2

secondary causes of migraine in order

Answer 2

i. HA caused by other disorder
ii. Infection 63%
iii. Trauma 4%
iv. Vascular Disorder 1%
v. SAH <1%
vi. Tumor 0.1%

Question 3

what types of infections cause headaches

Answer 3

sinus infection- pressure on sinuses, tops of the teeth

meningitis- nuchal rigidity, fever, rash, body aches

dental abscess

Question 4

headaches in the population M:F

Answer 4

b. 5:9 M:F

cluster more common in males
migraines more common in females

Question 5

TTH presentation

time
and location

Answer 5

pain is constant an daily an worse late in the day

bilateral
vise-like band

vi. Emanates from neck and shoulders

Question 6

“Featureless” HA

Answer 6

TTH

NO associated sx like n/v

Question 7

ix. S.C.A.L.P (PE)

Answer 7

1. skin
2. Connective Tissue
3. Aponeurosis í connected to the skin
4. Loose connective tissue
5. Pericranium íoutside of the bony cranium
6. Occipital nerves are superficial and attached to the capitis muscles

Question 8

triggers for TTH

Answer 8

1. Stress
2. Depression/Anxiety
3. Posture
4. Jaw clenching when sleeping
5. Female - get more tension HA’s than males do
6. Middle age

Question 9

how to differentiate TTH in a person with anxiety or depression

Answer 9

pts with mental health issues wake up with HA and they get worse throughout the day

Question 10

chronic TTH

Answer 10

at least 10 episodes month
at least 30 minutes
location bilateral pressing or tigehtning 
no n/v
no photophobia

Question 11

best way to treat a HA

Answer 11

at the onset
on’t treat your HA like an earthquake
OTC analgesic snd drink a ton of water

less likely to progress and reoccur
caffeine can be helpful

Question 12

caffeine helps HA becasue

Answer 12

is a vasoconstrictor

Question 13

what to avoid with TTH

Answer 13

Opiates

Question 14

amitriptyline (TCA)

Answer 14

works really good as a low dose for TTH

usually want to take it at night because it can cause drowsiness

Question 15

EMG

Answer 15

biofeedback therapy that can be used to treat TTH

Question 16

ALT to medication for TTH

Answer 16

acupuncture

maybe massage

Question 17

TENS tx

Answer 17

Transcutaneous Electrical Nerve Stimulation

causes nerve stimulation of mm and can reset nerves and help mm to stay more relaxed in
TTH of in pts with chronic back pain

Question 18

onset of migraines

Answer 18

6-8 in boys

after menses in women

Question 19

Fhx in what % of pts with migraines

Answer 19

70%

Question 20

Pathophysiology of migraines

Answer 20

vasonstriction followed by vasodilation theory kind of debunked

looks like more of a nuero vascular issue with spreading that leads to trigeminal vascular system triggering and cortical spreading depression that depolarizes the cortex –> leads to blood vessel dilation

triggers inflammatory mediators to be released

Question 21

triggers for migraine

Answer 21

1. FH - predisposing factor 70%
2. Stress 80%
3. Lack/excess of sleep>50%
4. Missed meals 57%
5. Foods (chocolate, EtOH) 27-38%
6. Hydration status definitely a trigger for migraine HA
7. Light 38%
8. Noise, glare
9. Menstruation (catamennial migraines) 65%
   a. Raises a whole new tx option for hormones
   b. Progesterone - related to HA
   i. Estrogen was added to the progesterone only BC b/c HA was a huge SE

Question 22

Unilateral
Throbbing
Episodic with early onset

Answer 22

migraine

Question 23

red flag for migraine onset

Answer 23

almost always start in childhood or teen years but always by the 20s

Question 24

four stages of a migraine

Answer 24

prodrome
aura
migraine
postdrome

Question 25

migraine presentation

Answer 25

1. Unilateral 2. Throbbing 3. Episodic with early onset - teens & young adults 4. Anorexia 5. N/V 6. Photophobia/phonophobia/osmophobia a. Osmophobia - sensitivity to smells 7. Cognitive impairment a. Word finding b. Executive fxn can become a problem 8. Blurred vision 9. Migraine HA build gradually, last hours to days 10. Focal neurological deficits, or sensations may preceed onset

Question 26

what % of pts have aura with migraine

Answer 26

25%

Question 27

mc presentation of MS

Answer 27

optic neuritis in 40 year old woman if you have a new onset migraine you really need to think about this

Question 28

how to determine if a migraine is chronic and need prophylaxis

Answer 28

insurance is ver stingy with migraine medications like triptans need to revaluate if they are using them a lot missing school or work decrease risk of neurological damage menstral migraine

Question 29

mngmt of acute migraine

Answer 29

NSAID triptan sumatriptain+naproxen antiemetic

Question 30

triptan injection SE

Answer 30

feel like shit for 20 minutes and then you're better triptan injections hurt they cause muscle spasm

Question 31

preventative management for migraines

Answer 31

lifestyle mods BB/Anti htn meds (meto, timo, propra) TCA antidepressants :amitriptyline in small doses at bedtime anticonvulsants topiramte, valproate CCB

Question 32

why would you want to avoid a BB for prophylactic mngmt

Answer 32

not in marathon runners (HR already low) make you tired so be careful heart blocks, really anything where the hr is too low

Question 33

suppresses appetite can treat migraines

Answer 33

anticonvulsants topiramate (topamax) and valproate

Question 34

cluster ha pathophys

Answer 34

trigemino vascualr stimulation like migraine but in a different part of the brain (hypothalamus?)

Question 35

typical trigger with cluster

Answer 35

alcohol stress glare specific foods

Question 36

CM of cluster HA

Answer 36

``` deep unilateral peri-orbital trigeminal area agitation ```

Question 37

timing/duration of cluster HA

Answer 37

3. Pain is "explosive" in nature | 4. Episodic, episodes last weeks

Question 38

associated features of cluster HA

Answer 38

(ipsilateral parasympathetic activation): a. Nasal congestion, rhinorrhea b. Lacrimation and redness of eye c. Horner syndrome (sympathetic deficit associated with parasympathetic activation with injury to ascending fibers surrounding dilated carotid artery)

Question 39

tx for cluster ha

Answer 39

oxygen tx --> shuts down inflammatory process triptans

Question 40

preventative mgmt

Answer 40

<2 mo prednisone high dose >2mo verpamil

Question 41

less common causes of HA

Answer 41

``` analgesia rebound substance use or withdrawl' trauma mass GCT arteritis subarachnoid hemorrhage sunken brain ```

Question 42

what is sunken brain

Answer 42

post lumbar puncture

Question 43

WORST HA OF MY LIFEEE

Answer 43

subarachnoid hemorrhage

Question 44

e. Abnormal neurological examination with HA

Answer 44

is reason for worry red flag TIA or stroke

Question 45

Systemic signs

Answer 45

rash fever these should make you think of infx

Question 46

vomiting proceeding the HA

Answer 46

worried about ICH | or intracranial pressure increase

Question 47

pain with pressure change

Answer 47

worried about ICH | or intracranial pressure increase

Question 48

if a HA wakes you from sleep

Answer 48

and it's not cluster think intra cranial pathology

Question 49

Onset >55

Answer 49

j. Onset >55 - late onset is a bad sign | intra cranial thing

Question 50

classic migraine does or does not have an aura?

Answer 50

has an aura

Question 51

timing needed to dx cluster

Answer 51

5 episodes from 1 every other day to 8 days without other causes

Question 52

imitrex

Answer 52

vasodilator used for migraine accompanied with SE like N/v

Question 53

1st line for migraine

Answer 53

tylenol

Question 54

d. Subacute worsening over days suggests what origin of a HA

Answer 54

bleeding

Question 55

g. Vomiting preceding HA

Answer 55

ICP