HA in PC (Jaynstein) (Midterm) Flashcards
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
What HA red flags warrant further work-up but can be done, outpatient?
* 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
What HA red flags warrant transfer to the ER?
* 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
Describe a SAH HA
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
General headache PE should involve?
* 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
You suspect a Pt has a primary HA should you order labs?
Lab studies are not indicated (if thinking of ordering labs you should be working on a secondary HA ddx)
30
You suspect a primary HA but want to rule out some secondary causes. What imaging is the first-line test for evaluation?
CT-H without contrast
31
Which Pts who present with HA will benefit from a Non-contrast CT, and help rule in/out a secondary cause?
* 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
Which of the following is most beneficial to clinicians in diagnosing primary headaches?
* Labs
* Imaging
* HA diaries/logs
HA diaries/logs
33
Do you need a head CT to diagnose migraines?
No
34
Are men or women more prone to migraine HA?
Women about 18% of women have migraines while 6% of men do.
35
Name the classic characteristics of a migraine
* 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
What % of Pts with migraines experience an aura?
30% have an aura that occurs before or at the onset of the HA
37
How can migraine auras manifest?
May be sensory, linguistic, or motor
38
A certain subset of Pts who experience migraines are at an increased risk for stroke and heart attack, which group has the increased risk?
Pts who experience migraines with auras.
39
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.
Document them as having a HA, don't document/diagnose migraine until they meet the criteria.
40
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).
* 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
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. 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
If an aura last longer than 60 minutes what should you consider?
An underlying neurological problem such as a TIA
43
When should migraine treatment begin?
Ideally within the first two hours of the attack for best outcomes
44
Episodic HA syndromes can progress to chronic HA syndromes if?
They are undertreated, sadly this occurs often with migraines.
45
When initiating migraine treatment what expectations should you set with the Pt immediately?
* 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
What are the treatment goals for migraine mangement?
* 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
What classes of medications are used to prevent migraines?
* Antidepressants
* Anticonvulsants
* Beta-blockers
* CCBs
48
What classes of medications are used as migraine abortives?
* NSAIDS
* APAP
* ASA
* Triptans
* Sumatriptan (Imitrex)
* Combo meds
* Butalbital/APAP/Caffeine (Fioricet)
* DHE
* Narcotics (Last line)
49
Most Pts with mild-to-moderate migraine HA's will respond to which meds?
OTC analgesics such as NSAIDs, Aspirin, Acetaminophen, and combos of these that contain caffeine.
50
While combinations of meds containing caffeine have been shown to be more effective in treating migraines they have a higher risk of what?
Rebound HA
51
How is caffeine beneficial in the treatment of HA?
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
If tolerated why is aspirin a particularly good choice?
It has cardioprotective effects rather than increasing cardiovascular risks which most NSAIDs do.
53
Which Pts should you not recommend aspirin to for OTC treatment of their HA?
Any Pt you suspect may have a SAH
54
Which Pts should be started in migraine preventative treatment instead of just abortive treatment?
* Pts who have more than one day of HA per week
* Those who miss work due to HA
* Those with associated complex symptoms
55
How long does it take for migraine preventative therapy to become effective?
Often 8-12 weeks
56
Which OTC/supplements have been shown to prevent migraines?
* 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
Of the following antiepileptics used in migraine prevention rank them in order from most effective to least.
* Gabapentin
* Divalproex sodium (Depakote)
* Topiramate (Topamax)
* Divalproex sodium (Depakote)
* Gabapentin
* Topiramate (Topamax)
58
Of the following antidepressants used in migraine prevention rank them in order from most effective to least.
* Fluoxetine (Prozac)
* Amitriptyline
* Nortriptyline
1. Amitriptyline
2. Fluoxetine (Prozac)
3. Nortriptyline
59
Of the following Beta-blocker used in migraine prevention rank them in order from most effective to least.
* Timolol
* Atenolol
* Propranolol
1. Propranolol
2. Timolol
3. Atenolo
Both propranolol and timolol have high efficacy
60
Are CCB used first line?
They can be but they don't have as much evidence to support their use, better used as second or third-line therapy.
61
Which CCBs are used in migraine prevention?
* Diltiazem
* Verapamil
62
Pts who have migraines with auras are at increased risk for stroke and MI, what medications can further exacerbate this risk?
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
Define a rebound HA
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
What meds used to treat HA's can lead to rebound HA is over used?
Nearly all of them!
65
Name some common lifestyle triggers for migraines
* Emotional stress
* Depression
* Too little sleep
* Exercise or overactivity
* Skipping meals/fasting
66
Name some common food triggers for migraines
* Chocolate
* Nuts, peanut butter
* Cheese, yogurt, sour cream
* Red wine or other alcoholic drinks
* Processed meats
* Monosodium glutamate (MSG)
67
What is a common physical trigger for migraines?
Menstrual cycle or other hormonal changes
68
Name some common environmental triggers for migraines
* Weather or seasonal changes
* Travel through different time zones
* Odors or pollution
* Bright lights
69
What are some of the common pitfalls providers fall into when treating HA's?
* 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
When should you consider referring Pts with chronic HA's to neurology?
* 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
List an examples of a "headache cocktail"
* 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!!
