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CMT-uno > Headache > Flashcards

Headache Flashcards

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1
Q

HA

Primary vs Secondary

A

Primary: Migraine (with or without aura), Tension, Cluster
-No known underlying cause
-90% of headaches are benign primary type

Secondary Headache: Brain tumors, aneurysms
-Symptoms of underlying disorder

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2
Q
A
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3
Q
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4
Q

Migraine

general

A

Common disorder
Women > Men

Boys < Girls (< 12yo more often seen in boys) -Increased with age, Abdominal migraines

Age 30-39
Though possible from child to elderly
Very old and very young uncommon

Familial/genetic component
Major cause of disability worldwide

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5
Q

Migraine

patho

A

Still developing theory
Genetic component – hyperexcited neurovascular system
Cortical spreading depression
Trigeminal nerve activation
Intracerebral vasodilation component

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6
Q

Migraine

S/Sx

A

Episodic disorder
Lasting minutes to days
Unilateral, usually
Retro-orbital
Pulsating
Photophobia / Phonophobia
Associated with nausea and vomiting
May be associated with aura
No persistent, hard neurological findings

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7
Q

Migraines classifications

Classic vs common

A

Migraine with aura (classic migraine)
Less common

Migraine without aura (common migraine)
More common by 5:1

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8
Q

migraine

prodome

A

Yawning, euphoria, fatigue/depression, irritably, food cravings

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9
Q

Migraine

Aura

A

Aura is defined as a focal visual, sensory, or motor neurologic disturbance with a developing headache

Can include bright lines, shapes, tinnitus, noises, paresthesia, loss of vision, hearing, feeling or ability to move a part of the body

Increases in intensity over one to several hours, often unilateral, throbbing or pulsatile in quality

Common to report photophobia, phonophobia and cutaneous allodynia (perception of pain caused by normal activities i.e., wearing glasses)

Associated with ~25% of migraines (classic migraine)

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10
Q

Migarine

headache

A

Usually Unilateral throbbing, nausea, vomiting, photophobia, phonophobia

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11
Q

migraine

Scintillating scotoma

A

Scintillating scotoma – Aura spots that flicker between light and dark

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12
Q

HA

PE to do’s

A

Obtain blood pressure and pulse
Listen for bruits for clinical signs of arteriovenous malformation
Palpate the head, neck, and shoulder regions
Check temporal and neck arteries
Examine the spine and neck muscles

The neurologic examination should cover mental status testing, cranial nerve examination, funduscopy and otoscopy, and symmetry on motor, reflex, cerebellar (coordination), and sensory tests.

Gait examination should include getting up from a seated position without any support and walking on tiptoes and heels, tandem gait, and Romberg test.

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13
Q

Migraines

Dx

A

clinical

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14
Q

Migraine

criteria (w/o aura)

A

●(A) At least five attacks fulfilling criteria B through D
●(B) Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
●(C) Headache has at least two of the following characteristics:
*Unilateral location
*Pulsating quality
*Moderate or severe pain intensity
*Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
●(D) During headache, at least one of the following:
*Nausea, vomiting, or both
*Photophobia and phonophobia
●(E) Not better accounted for by another ICHD-3 diagnosis

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15
Q

criteria for migraine with aura

A

● At least two attacks fulfilling criterion B and C
● One or more of the following fully reversible aura symptoms:
*Visual
*Sensory
*Speech and/or language
*Motor
*Brainstem
*Retinal
●(C) At least three of the following six characteristics:
*At least one aura symptom spreads gradually over ≥5 minutes
*Two or more symptoms occur in succession
*Each individual aura symptom lasts 5 to 60 minutes
*At least one aura symptom is unilateral
*At least one aura symptom is positive
*The aura is accompanied, or followed within 60 minutes, by headache
●(D) Not better accounted for by another ICHD-3 diagnosis

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16
Q

migraine

abortive Tx

A
  • Nonpharmacologic/avoidance of triggers
  • NSAID & APAP
    Ketorolac
  • Triptans
    Sumatriptan (Imitrex)
    Rizatriptan (Maxalt)
  • Ergotamine
  • Dopamine antagonist & Diphenhydramine
    Metoclopramide (Reglan)
    Prochlorperazine
    Chlorpromazine (Thorazine)
  • Steroids
  • Fluids
  • Opioids
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17
Q

migraine

preventative medications

A

Topiramate (Topamax)
Valproate (Depakote)
Propranolol (Inderal)
Non-pharmacological/avoidance of triggers

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18
Q

Migraine

Special population Tx

A

Pregnant
Avoid ergotamine & NSAIDs
Antiepileptics NOT approved for migraine use
ACOG recommends Reglan (B) and Acetaminophen

< 12 yo – pediatric population considerations
Avoid Triptans
NSAIDs & APAP
Promethazine (Phenergan)
Propranolol for preventative

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19
Q

Tension headache

general

A

Most common type of headache
Bilateral, band or vice like
Pericranial muscle involvement
Nuchal rigidity?

No hard neurological findings

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20
Q

Tension HA

Classifications based on frequency

A

Infrequent episodic
< 1 per month

Frequent episodic
1-14 per month

Chronic
> 14 per month

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21
Q

Tension HA

EPI

A
  • Most common type of primary headache
  • Universal, 86% of 12-41yo
    W > M, slightly
  • 2-3 times more common in kids as opposed to migraines
    Increases with age and is also higher in female kids
    Presentation similar to adults
  • Most people can identify a cause:
    Stress, fatigue, eye strain, myalgias, mild viral infections
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22
Q

Tension HA

features

A

Mild to moderate pain
Non-throbbing
Dull, pressure, band, tight hat
Pericranial muscle tenderness

No other associated features

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23
Q

tension

Dx

A

clinical

At least two of following:
Bilateral
Pressing or tight quality
Mild to moderate intensity
Not aggravated by routine physical activity

And, both of following:
No nausea or vomiting
No more than one of photophobia or phonophobia

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24
Q

Tension HA

acute Tx

Study These Flashcards
A

NSAIDs & Acetaminophen
Ibuprofen, ketorolac, naproxen
Most common options for pediatric patients

Combination meds
Butalbital, APAP, Caffeine (Fioricet)

Migraine medications

Muscle relaxants (mixed data)

Opioids

Nonpharmacologic/avoidance of triggers

25
# Tension HA Chronic Tx
NSAID Amitriptyline Nortriptyline Fluoxetine -SSRI Muscle relaxant Nonpharmacologic: Physical therapy Acupuncture Avoidance of triggers
26
# Cluster HA S/Sx
Unilateral Non-pulsatile EXTREME though brief episodes of pain in clusters of hours to days Conjunctival injection Rhinorrhea Lacrimation Facial swelling Horner’s syndrome
27
# Cluster headache Epidemiology
Rare < 1% of population Male > Female, 4:1 Typically, 20-40 age range Genetic link Smoking
28
Horner’s Syndrome
**Miosis – constricted pupil Ptosis – drooping of upper eye lid Anhidrosis– absence of sweating on the face** Enophthalmos – sinking of eye into bony cavity
29
# Cluster HA Dx
A sense of restlessness or agitation Attacks have a frequency between one every other day and eight per day; during part (but less than half) of the active time-course of cluster headache, attacks may be less frequent ●At least five attacks ●Attacks characterized by severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes when untreated; during part (but less than half) of the time-course of cluster headache, attacks may be less severe and/or of shorter or longer duration ●Either or both of the following: *At least one of the following symptoms or signs ipsilateral to the headache: -Conjunctival injection and/or lacrimation -Nasal congestion and/or rhinorrhea -Eyelid edema -Forehead and facial sweating -Miosis and/or ptosis
30
# Cluster HA Acute Tx
**High flow oxygen first** Subcutaneous Sumatriptan if no response Intranasal lidocaine as alternative treatment
31
# Cluster Preventative
Verapamil and/or Steroids Home O2 Avoidance of triggers
32
# HA red flags
33
Causes of thunderclap headache
34
Lumbar puncture
After the CT Still needs to be done if your index of suspicion is high for SAH Confirm for presence of RBCs and xanthochromia (bili) in CSF Most sensitive 12 hours after SAH Gives information regarding pressure, bleeding, infection
35
‘Other’ headaches
Temporal arteritis/Giant cell arteritis Cervical artery dissection Abdominal migraine Basilar / vestibular migraine Ocular migraine Trigeminal neuralgia Occipital neuralgia Venous sinus thrombosis CO poisoning Intracranial Mass Post-traumatic (covered later) Meningitis (covered later)
36
# Temporal Arteritis/Giant cell arteritis general
Pathology Inflammation of large to medium vessels Remodeling can lead to vessel occlusion Epidemiology Age >50, Caucasian / Scandinavian, W>M
37
# giant cell arteritis S/Sx
Symptoms HA, scalp tenderness, temporal pain, jaw claudication, fever, amaurosis fugax (temp loss of vision)
38
# giant cell arteritis Dx and Tx
Diagnosis History and exam ESR >50, CRP less sensitive Biopsy Treatment Prednisone IV or PO, high dose Immunosuppressive drugs
39
GCA Headache
HA usually throbbing and continuous. Focal tenderness on direct palpation typically present. Patient may note scalp tenderness with hair combing, or with wearing a hat or eyeglasses.
40
# GCA Jaw claudication
Jaw claudication: **fatigue or discomfort of the jaw muscles during chewing of firm foods or prolonged speaking.** Result of ischemia of maxillary artery supplying masseter muscles. Highly predictive of temporal arteritis
41
# GCA Vision
Around 50% experience visual symptoms Initial visual symptoms may be transient and intermittent, typically unilateral visual blurring or vision loss. Vision loss may not be reversible if treatment with steroids isn’t started immediately within the first few days
42
# GCA polymyalgia rheumatica
About 50% of patients with GCA have underlying polymyalgia rheumatica (pain and stiffness of the shoulder and hip girdle) About 15% with polymyalgia rheumatica develop GCA
43
# GCA Tx
Steroids early to avoid permanent vision loss High dosing of oral prednisone Monitored for side effects
44
# Cervical artery dissection general | patho and epi
Pathology Separation of layers of the vessel Major cause of morbidity is thrombi -> stroke Epidemiology Young Associated with minor trauma, spontaneous, connective tissue disease
45
# Cervical artery dissection Sx
HA progressive vs thunderclap, neck pain, ischemic changes
46
# Cervical artery dissection Dx and Tx
Diagnosis: CTA, MRA Treatment: Anticoagulation
47
# Migraine variants Hemiplegic migraine
Unilateral weakness with migraine with aura attack
48
# Migraine variant Abdominal migraine
Abdominal pain is primary complaint Same triggers as migraines
49
# migraine variant Vestibular migraine and Ocular migraine
Vestibular migraine Vertigo associated with headache Ocular migraine Transient vison loss
50
# Occipital neuralgia general | patho and Sx
Pathology Entrapment of occipital nerve by scalp and neck muscle Symptoms Brief episodes of pain electric like pain in Occipital nerve distribution Allodynia, can lead to occipital constant headache
51
# Occipital neuralgia Dx and Tx
Diagnosis Clinical, may consider CT / MRI Treatment **Occipital nerve block Carbamazepine Gabapentin**
52
# Venous sinus thrombosis General | Patho and Epi
Pathology DVT of brain Leads to ischemic changes, disruption of BBB Epidemiology W>M, pregnancy, thrombophilia
53
# Venous sinus thrombosis Sx
Headache, nausea, vomiting, seizure, drowsy
54
# Venous sinus thrombosis Dx and Tx
Diagnosis: MRV, D-dimer, thrombophilia screen Treatment: Anticoagulation, endovascular
55
# Carbon monoxide poisoning
56
# Intracranial Mass Epi
Occurs during course of disease within 40-60% of patients MC masses include gliomas, meningiomas, and pituitary adenomas
57
# intracranial mass Sx
Vary widely due to size and location of mass Nausea and vomiting may be seen Moreso tension-type headache Red flags in history such as fever, neurologic signs, over age 50, etc.
58
# intrcranial mass Dx and Tx
Diagnosis MRI exceeds CT imaging for tumors Treatment Depends on tumor type, status of patient, and extent of disease Early – glucocorticoids and simple analgesics

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