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Flashcards in Headache Deck (75):
0

HA epidemiology?

90-95% are benign
1% are life threatening

1

Migraine pathophysiology?

cortical spreading depression/depolarizing wave
trigeminovascular system transmits the stimuli to pain (what is normal)
sensitization - nerves become hypesensitized so they have a higher magnitude of response (migraines) - tx ASAP
serotonin deficit

2

Cluster pathophysiology?

activation of trigeminal -autonomic pathway
(starts to tear)

3

Tension HA pathophysiology?

start centrally
the common headache
CNS stimuli misinterpreted as pain
pain of the head muscles

5

Classification of headaches?

primary
secondary

5

Secondary HA - cx?

systemic infxn (when you have a cold, dehydrated)
head injury*
vascular disorders*
subarachnoid hemorrhage*
brain tumor*
*rare
*underlying condition

7

Secondary HA - cx?

systemic infxn (when you have a cold, dehydrated)
head injury*
vascular disorders*
subarachnoid hemorrhage*
brain tumor*
*rare
*underlying condition
pituitary adenoma
optic neuritis
temporal arteritis

7

Concerning exam?

HTN, bradycardia, fever - LP (unless you can find the source)
papilledema (d/t ICP)
neck stiffness --> meningitis
focal neurologic finding --> CVA
ataxic gait

8

Concerning Hx?

"worst headache"
"thunderclap"-subarachnoid hemorrhage
onset of HA after 55yo (HA should be getting better)
recent change in pattern
HA w/ exertion (increased pressure --> aneurysm)
worsening despite tx
seeing holes/light/diplopia (abducens not working, glaucoma)

9

Common triggers of primary HA?

diet (caffeine)
stress
sleep
*finding trigger will help tx HA

10

Primary HA - tx?

HA subtype
impact on ADL
response to tx
pt education (inherited? - control but will NEVER go away!)
avoid triggers

11

Primary HA - tx failures?

wrong dx
wrong medication
suboptimal dosing
unrealistic expectation (they expect to be "cured" but they're not so they get frustrated!)

12

Migraine diagnosis?

two of following:
unilateral pain
throbbing pain
aggravating w/ movement
mod/severe
one of the following:
N&V
photophobia

13

Migraine HA - sx?

nasea
photophbia
lightheadnes
scalp tenderness
vomitting
visual disturbances
prodromal and aura

14

When to use prophylaxis of MHA?

recurring MHAs that interfere w/ ADL
5+/mo
failing tx/contraindication
prevent neurologic damage: hemiplegic migraine, migrainous infarct

15

Preventative therapy for MHA?

ASA - CVA pts
Naproxen - little more effective
B Blockers (propranolol) - good w/anxiety but causes fatigue
TCA = tension + MHA
Valproate - prolonged HA, aytpical migraines

16

Pt education for prophylatic MHA?

meds take wks - must be tried for 3 mo before "failed tx"
start low and slow, effective? - taper down after 6mo

17

MHA tx?

ASAP
once it starts - it doesn't stop! --> pain relief (keep them comfortable)
just sleep it off
r/o concerning hx & PE

18

abortive therapy for MHA-mild?

1) Naproxen (do not give to peds and preg)
2) Tylenol
*BENADRYL!- adjunct (helps them sleep

19

abortive therapy for MHA-mod?

1) Excedrin
2) Triptan (acts on 5HT receptors- cxs vasoconstriction: chest pains)
-Sumitriptan
-Rizatriptan
LAST RESORT: Ergotamines
AVOID: opioids (Codeine - cx rebound HA)
*BENADRYL!!
Dexamethasone - to avoid rebound

20

abortive therapy for MHA-severe?

1) Ketorlac
2) Sumitriptan (SQ); dopamine agonist - Metoclopramide, prochlorperzine, droperidol) + benadryl
LAST RESORT: ergotamines (dihydroergotoamine) - do not give if they had triptan
AVOID OPIOIDS - cx rebound HA
Dexamethasone to avoid rebound

21

Tension HA - classification?

infrequent (14days/mo)

22

Tension vs MHA?

same sx EXCEPT NO photophobia and N&V

23

Diagnostic cluster headaches?

trigeminal autonomic response - weeping

24

Tension HA - Tx?

1) ASA, naproxen, acetaminophen, caffeine combos
RESCUE: toradol, reglan + bendaryl
ADJACENT: Occipital nerve block, trigger point injection

lifestyle modification (less stress)
cognitive behavioral therapy

*TCA - amitryptiline (associated analgesic effect that is not found in SSRI)

25

Primary HA - categories?

tension
cluster
migraine

26

Cluster HA - tx?

PREVENTATIVE: verapamil (HD), lithium, topiramate + verapamil (to avoid HD), prednisone
ABORTIVE: O2, sumitriptan
ADJUNCT: glucocortioids (prednisone, dexamethasone)
SURGERY: trigeminal denervation, deep brain stimulation

27

HA hx to ask?

-site
-time/onset
-response to tx
-age
-how many
-birth control
-head trauma

28

Time course - primary?

pattern

29

Time course - secondary?

NEW ONSET

30

Time course - migraine?

episodic
disabling

31

Time course - cluster?

"clusters"
long inactive phases

32

Time course - rebound?

daily breakthrough
requires rescue meds

33

HA that is bilateral?

tension

34

HA that is unilateral, orbit, temple?

cluster

35

HA that wax and wane?

tension

36

HA that is sudden

cluster

37

HA that needs to be quiet in dark room?

migraine
tension

38

HA that is variable in duration?

tension

39

HA that is 4-72 hrs long?

migraine

40

HA that is 30-180 min long?

cluster

41

HA that has photophobia and aura?

migraine

42

HA that has tearing, stuffy nose, sweating?

cluster

43

HA that is unilateral?

migraine
cluster

44

HA that is unilateral, bifrontal?

migraine

45

HA that has gradual onset?

migraine

46

Pt has pain on the back of the head and upper neck; band like tightness?

tension

47

Tension HA - PE?

band like tension
back of the head and neck

48

Tension HA - neurological?

NORMAL

49

Which HA goes away w/ age?

tension
migraine

50

MHA cx?

stress
hormones (females)
not eating
weather/lights
family hx

51

Prodromal?

24-48hrs before migraine
odd sensation (GI upset, behavioral changes, binge eating)
*time to take meds - ASAP tx for migraines

52

Aura?

min - hrs before migraine
visual (spots, lights) aura - common
sensory (tingling)
motor and speech

53

How long does MHA take?
resolve?

10-45min to start
resolves 4-72 hrs later

54

How do children present w/ migraine?

abdominal - no HA just vomit

55

Cluster HA - RF?

smoking (incr risk)
men

56

Cluster HA - sx?

quickly
no warning - peak w/in min
lasts from 30min-3hrs
ipsilateral redness, runny nose, weeping
moving around makes HA better

57

Rebound/Withdrawal HA?

OD on drugs - side effect HA

58

Rebound/withdrawal HA - sx?

daily HA

59

Rebound/withdrawal HA - tx?

wean off meds

60

HA from tumor?

secondary
NEW HA - concerning for adults

61

HA from tumor - sx?

vomiting d/t incr ICP (tumor takes up space in brain)
papilledema
no venous pulsation (eye exam)

62

Concerning medical hx?

cancer
postpartum headache

63

Increased ICP - sx?

blurry vision
diplopia (no venous pulsation, papilledema)
ataxia (cerebellar issues)

64

Pseudotumor cerebri?

idiopathic
increased ICP

65

Pseudotumor cerebri - population?

obese
female
20-40yo

66

Pseudotumor cerebri - sx?

HA is worse w/ exertion (or anything that increases ICP)
papilledema in both eyes

67

Pseudotumor cerebri is ruled in until...?

brain tumor is ruled out

68

Pseudotumor cerebri - labs?

1) CT/MRI - r/o abscess/lesion of brain
2) LP to confirm ICP - CSF labs
*LP w/ brain abscess/lesion can cx hemorrhaging!!

69

Pseudotumor cerebri- tx?

cont LP to release ICP
Acetazolamide

70

Temporal arteritis?

giant cell arteritis
near the ear
can cx hearing loss
vasculopathy
untreated = blindness

71

Temporal arteritis - sx?

sudden TEMPORAL HA
visual disturabance
systemically ill
POLYMYALGIA RHEUMATIC SX (pain, stiffness)
jaw pain

72

Temporal arteritis - labs?

ESR (systemic illness)
CRP

73

Temporal arteritis - dx?

temporal artery bx

74

Temporal arteritis - tx?

HD steroids