Headache ***

Question 1

Sx of cluster

Answer 1

Severe unilateral orbital/ supraorbital or temporal pain lasting 15-180 mins
Associated w/ (usually unilateral + ipsilateral):
Conjunctival injection
Lacrimation
Nasal congestion
Rhinorrhea
Forehead swelling
Miosis
Ptosis
Eyelid edema
Agitation
Daily HAs over weeks/ months

Question 2

Red flags for HA

Answer 2

Fever, HTN
Confusion, altered MS, visual field defect, sz
Sudden onset
New onset in older pt

Question 3

Triggers of clusters

Answer 3

Alcohol
Nitrates in food
Nitroglycerin
Strong odors

Question 4

Rx for clusters - acute, bridging + maintenance

Answer 4

Acute: 100% O2 6-12L/min x15 mins + sumatriptan 6mg SC
Bridging: unilateral greater occipital nerve block 80mg methylprednisolone w/ 2ml 2% lido
Maintenance: verapamil 80mg TID (needs baseline ECG, repeat 10d after dose adjustments) , lithium, prednisone

Question 5

Sx of concussion (acute)

Answer 5

Loss or reduced consciousness
Amnesia of events before or after injury
Altered MS at time of injury
HA, vision changes

Question 6

Physical, emotional, cognitive + sleep sx of concussion

Answer 6

1) Physical:
HA
N/V
Visual disturbances
Photophobia
Phonophobia
Vertigo
Tinnitus
2) Emotional:
Irritability
Emotional lability
Anxiety
Fatigue
Inappropriate emotions
3) Cognitive:
Slowed reaction times
Difficulty concentrating
Poor memory
Confusion
4) Sleep:
Drowsiness
Sleeping more or less than usual

Question 7

Immediate management of potential concussion inc how to determine need for imaging

Answer 7

Immediate: ABC, c spine control, serial monitoring for few hours (neuro + mental status). SCAT5 as sideline assessment tool
Determine need for imaging via PECARN + CT head rules

Question 8

PECARN rules

Answer 8

GCS 14
Altered MS
Basal skull fracture
= CT

<2y/o: hematoma or hx of LOC >5s or severe mechanism or not acting normally = observation vs CT
>2y/o: LOC or vomiting or severe mechanism or severe HA = observation vs CT

Question 9

Canadian CT head rules

Answer 9

GCS <15 2hrs from injury
Suspected open or depressed skull fracture
Basal skull fracture sign
>2 episodes vomiting
>65 y/o
Amnesia before impact >30 mins
Dangerous mechanism

Question 10

DC instructions for concussion

Answer 10

No driving for 24hrs
Observed by responsible person for 24-48hrs
Return if deteriorates
Written + verbal advice re 1) sx of deterioration, 2) lifestyle advice + 3) typical post-concussive sx
Most recover within 3mo

Question 11

Return to work/ school/ play guidelines

Answer 11

48hrs: physical + cognitive rest
Gradual return to activity while not increasing sx
No high risk activities for 7-10d
If symptomatic, rest for 24hrs then go back to last safe level

Question 12

RF influencing recovery

Answer 12

Previous concussion
Skull fracture
Early onset HA
Anxiety
MVA
Delay returning to work
Lack of social supports

Question 13

Sx migraines

Answer 13

unilateral, throbbing, N/V, photophobia, aura (visual distortion, food craving, increased sensory perception)

Question 14

Triggers for migraines

Answer 14

temperature, noise, weather changes, odours, stress, poor sleep, menopause, menstruation, pregnancy, anxiety, OCP, citrus, caffeine, aspartame, cheese, chocolate, alcohol

Question 15

Management (lifestyle, prophylaxis + acute) migraines

Answer 15

Lifestyle: HA diary, identify triggers, stress reduction
Prophylaxis: amitryptiline, metoprolol 47.5-200mg/d, gabapentin
Acute management: zolmitriptan + NSAIDs, maxalt 100mg

Question 16

Tension sx

Answer 16

HA <15d/month
30mins - 7d
Pressure/ tightening
Mild-moderate
Bilateral
Not aggravated by exercise, photophobia and no N/V

Question 17

Tension management

Answer 17

Acute: Tylenol 1g, ASA 1g, NSAIDs
Prophylaxis: amitriptyline, venlafaxine
CBT

Question 18

Causes of HAs

Answer 18

Migraine
Cluster
Tension
Med induced
Tumor
Temporal arteritis
SAH
Increased ICP

Question 19

Sx temporal arteritis

Answer 19

Sudden, localised to temple
Scalp tenderness
Jaw claudication
Vision loss/ diplopia
Fever

Question 20

Ix for temporal arteritis

Answer 20

ESR/ CRP
Arterial biopsy
CBC
ALP (high)

Question 21

Rx for temporal arteritis

Answer 21

Prednisone 60mg/d

Question 22

Sx SAH

Answer 22

Thunderclap HA
Vomiting, neck stiffness
Orbital pain, diplopia, vision loss

Question 23

Ix SAH

Answer 23

CT, LP, ESR

Question 24

Rx SAH

Answer 24

mannitol/ lasix

Question 25

sx increased ICP

Answer 25

Worse over time
Worse in AM

Question 26

Ix increased ICP

Answer 26

CT or MRI

Question 27

Rx increased ICP

Answer 27

Surgery

Question 28

Types of migraine

Answer 28

Common Migraine (without aura)
Classic Migraine (with aura)
Complicated Migraine (sensorimotor symptoms)
- ophthalmoplegic
- basilar
- hemiplegic
- hemisensory
Cyclical Migraines (with menses)

Question 29

Inclusion criteria for CT head rules

Answer 29

GCS 13-15
Min 1 of:
LOC
Amnesia to the event
Witnessed disorientation

Question 30

Exclusion criteria for CT head rules

Answer 30

Age <16 years.
Blood thinners.
Seizure after injury.

Question 31

Rx for postural hypotension

Answer 31

avoid large meals, avoid alcohol, adjust meds, increase salt intake, bed tilt, elastic stockings, midodrine (alpha 1 agonist) or fludrocortisone, refer to OT

Question 32

What Ix for ?GCA

Answer 32

low risk = US, high risk = biopsy

Question 33

What nerve block can you do for acute migraine management?

Answer 33

Sphenopalatine ganglion block

Question 34

When can you use rimegepant + what class is it?

Answer 34

Migraine
Calcitonin gene-related peptide receptor antagonist

Question 35

Ottawa SAH tool components

Answer 35

age >40, neck pain/ stiffness, witnessed LOC, onset during exertion, thunderclap HA, limited neck flexion on exam

Question 36

When can you not use Ottawa SAH tool?

Answer 36

New neuro deficit, prior aneurysm, prior SAH, known brain tumor, chronic recurrent HA

Question 37

When to offer prophylactic rx for migraines?

Answer 37

If HA frequency >8 days/month

Question 38

What is cyclical vomiting syndrome associated w/?

Answer 38

Migraines

Question 39

Rx for cyclical vomiting syndrome

Answer 39

antiemetics, topiramate