HA in PC (Jaynstein) (Midterm) Flashcards Preview

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Flashcards in HA in PC (Jaynstein) (Midterm) Deck (71)
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1
Q

Pt presents to UC with a complaint of “migraine”. States HA started yesterday and has continued for last 24 hours. What questions should you ask the Pt?

A
  • When did it start?
  • Where is the pain located?
  • Is the pain constant or intermittent?
  • Has the pain increased, decreased, or stayed the same?
  • Is this the worst HA of your life?
  • Is this HA like your normal migraines? (good to ask Pts who get frequent migraines)
  • Any head injuries in the last 2 weeks?
  • Any evidence of systemic symptoms?
  • Have you taken anything for the pain? Did it help? Does it normally help with previous HAs?
  • Does the pain change with position or exertion?
  • At it’s worse what level out of ten was the pain? What level is the pain currently? At its minimum what level was the pain?
  • Any family history of migraines?

Think OLDCAARTS

2
Q

A Pt states their HA is the worst HA of their life, what should you be concerned about?

A

Subarachnoid hemorrhage

3
Q

Pt presents to UC with a complaint of “migraine”. States HA started yesterday and has continued for last 24 hours. What PEs are important to do?

A
  • Neuro
  • HEENT
  • Remembera to do a full exam, don’t alter your exam just because it may be painful (like pupil exam in someone who has photophobia)
4
Q

A 46-year-old woman presents to primary care for evaluation of HA’s. She states that over the last 2 months she has had several headaches. What questions should you ask her?

A

Many of the same questions as the Pt presenting with a “migraine”. Additional questions may include:

  • How frequently are the HA’s occurring?
  • Is the pain always in the same place?
  • How long do they last? Do they resolve after sleep? After taking medication?
  • Have you found any patterns in the HA’s?
5
Q

Are men or women more likely to suffer from chronic HA?

A

Women

6
Q

What is a primary headache?

A

A HA that occurs independently, rather than as a sequelae from another medical condition

7
Q

What is a secondary headache?

A

HA that is a side effect of another process

8
Q

Which is more likely a primary or secondary HA?

A

Primary (80-90%)

9
Q

What are 3 common primary headaches?

A
  • Tension
  • Migraine
  • Cluster
10
Q

Which type of headache, tension, migraine, or cluster is most common?

A

Tension

11
Q

Which type of headache, tension, migraine, or cluster is the most common reason Pts present to primary care?

A

Migraine

12
Q

Name some examples of secondary causes of head aches

A
  • Infection
  • Trauma
  • Stroke
  • Rebound
13
Q

Cluster headaches are more common in men or women?

A

Men

14
Q

Best treatment for cluster HA?

A

Supplemental O2

15
Q

Possible causes of a secondary HA that has an infectious etiology?

A
  • Sinusitis
  • Meningitis
  • Encephalitis
16
Q

Possible causes of a secondary HA that has a vascular etiology?

A
  • CVA
  • TIA
  • SAH
  • Dissections
  • Temporal arteritis
17
Q

Possible causes of a secondary HA that has a CSF fluid etiology?

A
  • Spinal HA (only occurs after LP or epidural) occurs after removal of CSF
    • Occurs in about 30% of Pt’s who have LP
  • Pseudotumor cerebri (Too much CSF)
18
Q

What tests should be done to assess temporal arteritis?

A
  • The area over the temporal artery should be very tender to touch
  • Check for elevated ESR
  • Temporal artery biopsy is definitive test (rarely done)
19
Q

Classic findings of a spinal HA?

A
  • Recent LP
  • Positional
    • HA goes away when laying down but returns when sitting up
20
Q

Possible causes of a secondary HA that has “other” etiology?

A
  • Post-seizure
  • Preeclampsia
  • Intracranial mass
21
Q

What exam findings indicate possible secondary causes for HA and warrant a full work-up?

A
  • Evidence of underlying systemic disease
  • New or different pattern from previous HA
  • New HA in Pt’s >50 years old
  • Focal neurological symptoms or seizures
  • Symptoms provoked by standing, laying down, Valsalva, cough, or sex
  • History of neoplasia
  • HIV or Immunosuppression
  • Systemic signs and symptoms
  • Sudden onset of symptoms
  • Papilledema
22
Q

Can Pts who get migraines get meningitis or a SAH?

A

Obviously yes, it’s important to not just dismiss someone who has a history of migraines who is presenting to the office for HA as just having another migraine (especially if they say their current HA feels different than their typical migraine)

23
Q

A Pt presents with HA after sex what should you do?

A

Do a full workup for a SAH. Could potentially be post-coital HA but that typically presents with a repetative pattern of HA following sex. SAH is a don’t miss diagnosis.

24
Q

A Pt presents with a HA and you give them pain meds which resolve the HA, does this rule out possible serious causes for the HA?

A

No! If you suspect an underlying cause for the HA work it up regardless of whether the pain is relieved with medication or not. Response to pain meds is not a diagnostic indicator.

25
Q

What HA red flags warrant further work-up but can be done, outpatient?

A
  • HA in Pts aged < 5 or > 50 with no prior HA history
    • Think mass lesion (example brain tumor)
  • Increase in frequency or severity of HA in Pts with prior history of migraines
    • Think:
      • Medication misuse
      • Subdural hematoma
      • Mass lesion
  • HA that awakens Pt from sleep
  • Change in HA pattern
  • Systemic symptoms
    • Fever
    • Neck stiffness (may warrant transfer to ER depending on clinical appearance)
  • Temporal artery tenderness
26
Q

What HA red flags warrant transfer to the ER?

A
  • Worst HA of life
    • SAH
    • CNS infection
  • Sudden onset reaching severe maximal intensity within minutes (thunderclap HA)
    • ICH
    • Meningitis
  • Rapid onset with strenuous exercise
    • SAH
    • Carotid artery dissection
  • Neuro deficits
    • LOC
    • AMS
27
Q

Describe a SAH HA

A

Comes on suddenly with 10/10 pain, may only last a few minutes, slowly resolves but does not fully go away. Pt may show up days after the initial HA occured.

SAH is an often missed diagnosis

28
Q

General headache PE should involve?

A
  • BP check
  • Fundoscopy
  • Auscultation for bruits
  • Temporal artery inspection and palpation
  • Meningismus
    • Brudzinski
      • Passive forward flexion of the neck causes the patient to involuntarily raise their knees or hips in flexion.
    • Kernig
      • Have the supine patient, with hips and knees flexed, extend the leg passively. The test is positive if the leg extension causes pain.
  • Extensive Neuro exam
    • Motor
    • Sensory
    • Coordination
    • Gait
29
Q

You suspect a Pt has a primary HA should you order labs?

A

Lab studies are not indicated (if thinking of ordering labs you should be working on a secondary HA ddx)

30
Q

You suspect a primary HA but want to rule out some secondary causes. What imaging is the first-line test for evaluation?

A

CT-H without contrast

31
Q

Which Pts who present with HA will benefit from a Non-contrast CT, and help rule in/out a secondary cause?

A
  • CT will be helpful
    • Focal neurological signs
    • Onset of HA with exertion or sex
    • Worst HA of life
    • CHI (closed head injury) with LOC
  • CT might be helpful
    • CHI without LOC
    • Recent significant change in HA pattern
    • Progressive worsening of HA despite appropriate therapy
    • Onset after age 50
32
Q

Which of the following is most beneficial to clinicians in diagnosing primary headaches?

  • Labs
  • Imaging
  • HA diaries/logs
A

HA diaries/logs

33
Q

Do you need a head CT to diagnose migraines?

A

No

34
Q

Are men or women more prone to migraine HA?

A

Women about 18% of women have migraines while 6% of men do.

35
Q

Name the classic characteristics of a migraine

A
  • HA that lasts 4-72 hours
  • Unilateral pain
  • Throbbing pain
  • HA worsens with exercise/activity
  • Moderate to severe pain
  • Associated with N/V, light, and sound sensitivity
36
Q

What % of Pts with migraines experience an aura?

A

30% have an aura that occurs before or at the onset of the HA

37
Q

How can migraine auras manifest?

A

May be sensory, linguistic, or motor

38
Q

A certain subset of Pts who experience migraines are at an increased risk for stroke and heart attack, which group has the increased risk?

A

Pts who experience migraines with auras.

39
Q

If you have a Pt who presents with a HA that you suspect is a migraine but they don’t quite meet the diagnostic criteria for migraine what should you document.

A

Document them as having a HA, don’t document/diagnose migraine until they meet the criteria.

40
Q

What are the diagnostic criteria for migraine HA without aura? (There is a buttload of them, not sure if she expects us to memorize them or not).

A
  • Migraine without aura
    • A. At least 5 attacks fulfilling criteria B-D
    • B. HA attacks lasting 4-72 hours (untreated or unsuccessfully treated)
    • C. HA has at least 2 of the following:
      • Unilateral location
      • Pulsating quality
      • Moderate or severe intensity (inhibits or prohibits daily activity)
      • Aggravation by walking stairs or similar routine physical activity
    • D. During HA, at least 1 of the following:
      • Nausea and/or vomiting
      • Photophobia and phonophobia
    • E. History, physical, and neurological examination do not suggest underlying organic disorder
41
Q

What are the diagnostic criteria for migraine HA with aura? (There is a buttload of them, not sure if she expects us to memorize them or not).

A
  • A. At least 2 attacks fulfilling criteria B below
  • B. At least 3 of the following 4 characteristics:
    • One or more fully reversible aura symptoms indicating focal, cerebral, cortical, and/or brain stem dysfunction
    • At least 1 aura symptom develops gradually over 4 min; or, 2 or more symptoms occur in succession
    • No aura symptom lasts more than 60 min. If more than 1 aura symptom is present, the accepted duration is proportionally increased.
    • HA follows aura with a free interval of less than 60 min. (It may also begin before or simultaneously with the aura).
  • C. History, physical, and neurological examination do not suggest any underlying organic disorder.
42
Q

If an aura last longer than 60 minutes what should you consider?

A

An underlying neurological problem such as a TIA

43
Q

When should migraine treatment begin?

A

Ideally within the first two hours of the attack for best outcomes

44
Q

Episodic HA syndromes can progress to chronic HA syndromes if?

A

They are undertreated, sadly this occurs often with migraines.

45
Q

When initiating migraine treatment what expectations should you set with the Pt immediately?

A
  • To decrease the number of days Pt has HA rather than set an expectation of no HA’s ever
  • Set limit to the number of HA related visits for pain control (2/month)
46
Q

What are the treatment goals for migraine mangement?

A
  • Treat HA’s promptly
  • Limit HA’s to 2 hours or less
  • Optimize out Pt treatment
  • Reduce healthcare costs
    • Decrease ER visits
  • Minimize adverse SE of meds
  • Minimize use of narcotics
47
Q

What classes of medications are used to prevent migraines?

A
  • Antidepressants
  • Anticonvulsants
  • Beta-blockers
  • CCBs
48
Q

What classes of medications are used as migraine abortives?

A
  • NSAIDS
  • APAP
  • ASA
  • Triptans
    • Sumatriptan (Imitrex)
  • Combo meds
    • Butalbital/APAP/Caffeine (Fioricet)
  • DHE
  • Narcotics (Last line)
49
Q

Most Pts with mild-to-moderate migraine HA’s will respond to which meds?

A

OTC analgesics such as NSAIDs, Aspirin, Acetaminophen, and combos of these that contain caffeine.

50
Q

While combinations of meds containing caffeine have been shown to be more effective in treating migraines they have a higher risk of what?

A

Rebound HA

51
Q

How is caffeine beneficial in the treatment of HA?

A

Often HA’s are caused by intracranial vasodilation which puts pressure on the brain. Since the skull is a closed system any change in pressure (especially increased pressure) can cause severe HA. Caffeine works by causing vasoconstriction which reduces the pressure and thus relieves the HA.

52
Q

If tolerated why is aspirin a particularly good choice?

A

It has cardioprotective effects rather than increasing cardiovascular risks which most NSAIDs do.

53
Q

Which Pts should you not recommend aspirin to for OTC treatment of their HA?

A

Any Pt you suspect may have a SAH

54
Q

Which Pts should be started in migraine preventative treatment instead of just abortive treatment?

A
  • Pts who have more than one day of HA per week
  • Those who miss work due to HA
  • Those with associated complex symptoms
55
Q

How long does it take for migraine preventative therapy to become effective?

A

Often 8-12 weeks

56
Q

Which OTC/supplements have been shown to prevent migraines?

A
  • Butterbur (think Butter Beer form Harry Potter)
    • Works in adults and children
    • Must be purified of potentially toxic alkaloids
      • She recommends the brand Petadolex
  • Magnesium supplements
    • Especially beneficial for Pts with aura
    • Can help with sleep and sleep quality if given at bedtime
  • Coenzyme Q10
    • Shown to be effective in chronic migraine treatment
    • Expensive
    • Added bonus of slightly reducing BP
57
Q

Of the following antiepileptics used in migraine prevention rank them in order from most effective to least.

  • Gabapentin
  • Divalproex sodium (Depakote)
  • Topiramate (Topamax)
A
  • Divalproex sodium (Depakote)
  • Gabapentin
  • Topiramate (Topamax)
58
Q

Of the following antidepressants used in migraine prevention rank them in order from most effective to least.

  • Fluoxetine (Prozac)
  • Amitriptyline
  • Nortriptyline
A
  1. Amitriptyline
  2. Fluoxetine (Prozac)
  3. Nortriptyline
59
Q

Of the following Beta-blocker used in migraine prevention rank them in order from most effective to least.

  • Timolol
  • Atenolol
  • Propranolol
A
  1. Propranolol
  2. Timolol
  3. Atenolo

Both propranolol and timolol have high efficacy

60
Q

Are CCB used first line?

A

They can be but they don’t have as much evidence to support their use, better used as second or third-line therapy.

61
Q

Which CCBs are used in migraine prevention?

A
  • Diltiazem
  • Verapamil
62
Q

Pts who have migraines with auras are at increased risk for stroke and MI, what medications can further exacerbate this risk?

A

Use of estrogen hormone therapy, particularly at doses found in oral contraceptives. This, however, is not an absolute contraindication for their use. Make sure to have a risk/benefit discussion with these Pts.

63
Q

Define a rebound HA

A

Recurring HA that is induced by repetitive and chronic use of acute medications

Rebound is a self-sustaining clinical phenomenon, which makes acute medication use ineffective until medications have been withdrawn and washout or medication withdrawal occurs. Medication-induced or medication misuse headache has been referred to as drug-induced headache, analgesic rebound headache, and ergotamine rebound headache.

64
Q

What meds used to treat HA’s can lead to rebound HA is over used?

A

Nearly all of them!

65
Q

Name some common lifestyle triggers for migraines

A
  • Emotional stress
  • Depression
  • Too little sleep
  • Exercise or overactivity
  • Skipping meals/fasting
66
Q

Name some common food triggers for migraines

A
  • Chocolate
  • Nuts, peanut butter
  • Cheese, yogurt, sour cream
  • Red wine or other alcoholic drinks
  • Processed meats
  • Monosodium glutamate (MSG)
67
Q

What is a common physical trigger for migraines?

A

Menstrual cycle or other hormonal changes

68
Q

Name some common environmental triggers for migraines

A
  • Weather or seasonal changes
  • Travel through different time zones
  • Odors or pollution
  • Bright lights
69
Q

What are some of the common pitfalls providers fall into when treating HA’s?

A
  • Misdiagnosing migraines
  • Over treating HA with medications linked to rebound HA
  • Under-treating migraine, limit of abortive treatments in lieu of analgesics
  • Blaming HA solely on stress
70
Q

When should you consider referring Pts with chronic HA’s to neurology?

A
  • After getting CT-H
    • <5 or >50 years old
    • Progressive HA’s despite aggressive optimal treatment
    • History of cancer
    • Uncertain Dx

However, most Pts with primary HA’s even chronic ones can be managed in primary care.

71
Q

List an examples of a “headache cocktail”

A
  • Benadryl 25-50mg IM/IV
  • Compazine 10mg IM/IV
    • Or Reglan 10mg IM/IV
    • Or Phenergan 25mg IM/IV
  • +/- Toradol 30 mg IM/IV
    • Use caution is an NSAID, can cause bleeding events

Use narcotics only as a last-line treatment!!