Headache

Question 1

Characteristics of primary headache syndrome

Answer 1

• episodic or chronic
• 90% of headaches = primary
• no identifiable underlying pathology/systemic disease
• Types
  
  • Tension headaches
  • Migrain headaches
  • trigeminal autonomic cephalgia

Question 2

Characteristics of secondary headache syndrome

Answer 2

• constant
• associated w/underlying cranial or systemic pathology
• possible causes:
  
  • meningitis
  • hemorrhage
  • intracranial HTN
  • giant cell arteritis
  • traumatic injury

Question 3

Signs/symptoms of migraine headache

Answer 3

• recurring headaches lasting 4-72 hours
• unilateral in location
• pulsating
• moderate-sever intensity
• pain increases w/physical activity
• nausea/vomiting OR photophobia and phonophobia

Question 4

Phases of migraine headache

Answer 4

• Premonitory = may include changes in mood, alertness, apetite
• Aura = neuro sx before headache (~30% of pts)
• Headache + associated sx
• Resolution = post-headache exhaustion/lethargy

Question 5

Migraine treatment

Answer 5

• abortive tx
  
  • aspirin, acetominophen, NSAIDs
  • combo medication: e.g. ibuprofen/caffeine/asprin
  • serotonin receptor agonists: selective vs. non-selective
• prophylactic tx
  
  • beta-blockers
  • calcium channel blockers
  • tricyclic antidepressants
  • anti-epileptics
• alternatives
  
  • supplements
  • sleep
  • acupuncture**
  • biofeedback

Question 6

**FYI: Standard Tx vs. Acupuncture in Migraine

Answer 6

“Acupuncture was found to be associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment.[92] A systematic review and meta-analysis of acupuncture for the management of chronic headache (including chronic migraine) concluded that acupuncture is superior to sham acupuncture and medication therapy in decreasing headache intensity and frequency and in improving response rate to treatment.[93] In sum, current evidence clearly suggests that acupuncture is effective as an adjunct to usual care in the treatment of migraine” -*Integrative Medicine, *Rakel, David

[92] Linde K., Allais G., Brinkhaus B., et al: Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev, 2009. (1):CD001218

[93] Sun Y., Gan T.J.: Acupuncture for the management of chronic headache: a systematic review. Anesth Analg 2008; 107:2038-2047.

Question 7

Tension-type headache signs/symptoms

Answer 7

• generally lasts 30 min ==> 7 days
• pressing/tightening sensation
• mild to moderate severity
• bilateral sensation
• not aggravated by physical activity
• W/OUT: nausea/vomiting
• may have either photophobia or phonophobia
• “feature-less” headache (i.e. not a migraine)

Question 8

Tension-type headaches tx

Answer 8

• acute
  
  • NSAIDs
  • aspirin
  • acetaminophen
• prophylactic
  
  • tricyclic antidepressants
  • SSRIs
  • psychotherapy
  • PT

Question 9

Cluster headache signs/sx

Answer 9

• duration: 15-180 mins & reccuring
• severe
• unilateral pain
• periorbital and/or temporal pain
• • one of the following:
    
    • conjuctival injection
    • lacrimation
    • nasal congestion or rhinorrhea
    • eyelid edema
    • ptosis
    • miosis
    • facial swelling
    • ear fullness
    • restlessness/agitation

Question 10

Men vs. Women headache syndromes

Answer 10

• women = much more likely to experience migraine
• men = much more likely to experience cluster headache

Question 11

Cluster headache tx

Answer 11

• abortive
  
  • O₂
  • triptans
  • ergotamine derivative
  • lidocaine
  • corticosteroids
  • nerve blocks
• prophylaxis
  
  • calcium channel blockers
  • lithium
  • anti-epileptics

Question 12

Characteristics of headache due to head injury

Answer 12

• e.g. concussion
• pain w/in 7 days of injury ==> resolution @ 3 mo.
• usually w/:
  
  • dizziness
  • poor concentration
  • irritability and insomnia

Question 13

Characteristics of headache due to meningitis

Answer 13

• pain is acute
  
  • hours for bacterial; 1-2 days for viral
• onset w/fever, neck stiffness, nausea/vomiting, altered consciousness and Kernig/Brudzinski signs
• Dx by lumbar puncture
  
  • elevated WBCs
  • normal/low glucose
  • normal/elevated protein
  • CSF gram stain/PCR viral identification

Question 14

Characteristics (sx) of subarachnoid hemorrhage ==> headache

Answer 14

• vascular disorder
• sudden, intense headache
• diffuse pain
• mechanisms: trauma, ruptured aneurysm**, and arteriovenous malformation
• other sx: neck stiff, photophobia, nausea, vomiting, neuro signs
• dx via CT or LP or cerebral angiography

Question 15

Clinical evaluation of subarachnoid hemmorrhage

Answer 15

• CT scan
  
  • decreasing sensitivity with longer time from sx onset
• LP needed for suspected SAH w/negative CT
  
  • less sensitive @ <12 hrs of sx
• Cerbral angiography
  
  • confirms presence of aneurysm/vascular malformation

Question 16

Tx for subarachnoid hemorrhage

Answer 16

• surgery or intravascular intervention in some cases
• supportive tx

Question 17

Characteristics (sx) of giant cell arteritis (GCA) ==> headache

Answer 17

• affects the elderly
• headache = primary complaint
• other sx:
  
  • jaw claudication
  • temporal artery region tenderness
  • blindness
  • joint pain
  • fever, malaise, weight loss

Question 18

Clinical evaluation of GCA

Answer 18

• Blood tests
  
  • ESR = elevated
  • C-reactive protein = elevated
• biopsy of temporal artery ==> dx

Question 19

Tx of GCA

Answer 19

• corticosteroids

Question 20

Characteristics of increased intracranial pressure ==> headache

Answer 20

• headache worsened by exertion
• retrobulbar pain
• nauseau/vomiting
• pusatile intracranial noises
• visual sx:
  
  • transient visual obscurations
  • photopsias (flashes of light)
  • diploplia
  • vision loss
• other neuro findings

Question 21

Characteristics of pseudotumor cerebri/idiopathic intracranial hypertension (IIH)

Answer 21

• increased ICP
• w/normal CSF, neuroimaging, normal neuro exam except
  
  • papilloedema
  • sixth nerve palsies
• obesity and female = risk factors