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Flashcards in headache Deck (56):
1

how many visits/yr

13 million visits annually
Brill usually starts with tylenol or ibuprofen

2

what percentage of ER visits
serious?

4%
1%


3

pathophys: Irritation of pain-sensitive intracranial structures

Large arteries
Venous sinuses
Trigeminal nerve (5th cranial nerve)

4

pain-insensitive structures


Choroid plexus
Brain parenchyma
Ventricles ( ependymal lining )
( attributing to little or no headache mass lesions

5

painful stimuli arising from brain tissue above the tentorium cerebelli are conveyed by the

trigeminal nerve

6

primary

Tension-band like
Cluster-in/or around one eye
Migraine-28 million americans
sinus: behind brows

7

secondary

Stroke
Trauma
Brain lesion
Cocaine
Sinus Disease

8

migraine ha

Episodic Headache
Associated with
Gastrointestinal changes*
Neurologic*
Autonomic*
Unilateral*

One of the three is necessary for the diagnosis ? + 1 phobia

Pulsating; Unilateral
Frontotemporal

9

migraine sn

Phono-phobia Sound sensitivity
Osmo-phobia Odor sensitivity
Photo-phobia* Light sensitivity

10

migraine timing

May begin in childhood- don't give dx till 5 or 8
Peak ages adolescence and
Young adulthood
Greater in woman then men

11

aura

focal neurologic symptoms precede, accompany, follow(rarely) ha
-develops over 5-20 min
visual disturb.*
-language, sensorimotor, brainstem disturbance

12

migraine classes

Migraine With aura
Migraine without aura
Hemiplegic Migraine
Confusional Migraine
Ophthalmoplegic Migraine
Basilar Migraine

13

complicated migraines usually have..

Major neurologic dysfunction
( hemiplegia and coma )
admit*

14

basilar migraines usually...

Primarily in children
Episodic headache
Signs of .....
Brainstem dysfunction
Cerebellar dysfunction
(Dysarthria, diplopia, ataxia)

15

aura ddx

Seizure
Transient ischemic attack

16

cluster ha

Intense steady and unilateral
Temporal location (trigeminal cephalgia) Associated with
Nasal congestion
Conjunctival injection
Ipsilateral forehead sweating
Men > Women
Late in life onset
Rarely in childhood
Attacks often awaken patients
“Alarm-clock headache”
Periods of frequent headaches are separated by headache-free periods of varying duration

17

tension ha

Most common ( primary )
Pressure feeling
Not unilateral
Frontal / occipital
“Pain in the neck”
Pain last for days

band-like

18

Pseudotumor cerebri

IC hypertension
Worse with straining
Diplopia
Papilledema
Abducens palsy

19

Pseudotumor cerebri

Thrombosis of transverse or sagittal sinus venous thrombosis
Chronic pulmonary disease
SLE
Uremia
Endocrine disorders
Drugs (tetracycline, vitamin A, OCP)
*Idiopathic* (most common): overweight women age 20-44

20

imaging

Ct brain without contrast to look for space occupying lesion
MRI
MRV

21

this confirms increased intracranial pressure

LP with opening pressure

22

tx:

Acetazolamide
Topiramate
Prednisone
Weight loss
LP
Shunt
Optic nerve fenestration
Stop causative agent

23

migraine tx:

1. Acetaminophen
2. Aspirin
3. NSAIDs
4. Opioid ( limited use )-CI: rebound ha
5.Sumatriptan“triptans” (Serotonin agonist )
6. Droperidol
7.Quiet / Dark room
8. Metoclopramide (Reglan)
(dopamine interaction )

24

tension tx

same + OMM
muscle relaxers: valium, diazepam

25

cluster tx

1. Oxygen
2. Dihydroergotamine
3. Sumatriptan
(Serotonin agonist )

26

secondary

SAH
meningitis
mass lesions
intraparenchymal hemorrhage

27

SAH

1 in 10,000 headaches in the United States
1 percent of non traumatic headaches
Normal findings
*Thunder clap*
“ Worst headache of life”
Onset with exertion
may have neck pain

28

mass lesion

70 % of tumors have “headache” as the initial presenting complaint
-look for brain metastasis

29

meningitis

Viral / Bacterial infection
Fever
Nuchal rigidity
Kernig’s sign ( knee extension )
Brudzinski’s sign ( leg lift )

30

Intraparenchymal Hemorrhage

50 % of patients with IPH tumors have “headache” as the initial presenting complaint

31

Critical secondary causes requiring emergent identification and treatment

1. Subarachnoid hemorrhage- need MRI, look for aneurysm
2. Meningitis-start abx
3. Brain tumors-increased ICP
start steroids if not resectables

32

Critical secondary causes not requiring emergent treatment

Brain tumor (without increase in ICP)

33

Generally benign and reversible secondary causes

Sinusitis
Hypertension
Post-lumbar puncture headache

34

Primary headache

Migraine
Tension
Cluster

35

how to tx LP puncture ha

typ. tx (NSAIDs, tylenol)
then caffeine
then anesthesia: "blood patch" over LP site, dec. CSF leakage
better when lie flat

36

Ha eval

pattern (worst?)
onset (SAH)
location
assoc.
meds
comorb

37

assoc. symps

Visual changes
Fever
Seizure
Neck stiffness

38

meds that may cause ha

nitro
coumadin

39

comorbiditis

AIDS-fungal mening., cryptococcal
Malignancies
Coagulopathy-IC hem

40

Physical Exam red flags

Abnormal vitals
Neurological exam
Fundoscopic exam
Kernig sign
Brudzinski sign
Temporal artery tenderness (scalp
giant cell arteritis, bruits

41

prior hx of ha does not rule out...
and if tx and gets better, does not rule out...

serious pathology


same! could still be SAH

42

ha preventiaon

topamax, topiramate?
valproic acid (seizure, mood stab, trig. neuralgia)
candesartan
propanolol
timolol
verapamil
amitriptyline (antidep)
botulinum toxin A
butterbur-herb

43

ppx for ha that..

Headaches that occur more then two or three times a month
Significant disability with attacks
Alteration of central neurotransmission

44

ha ppx

Valproic acid
Propranolol
Timolol
Verapamil
Amitriptyline
Botulinum toxin A
Acupuncture

45

CT scan for....
before LP

Worst headache of life
Abrupt onset
Neurologic deficits
Persistent vomiting
Fever
Trauma
Loss of consciousness
Altered mental status
Sinus imaging


HIV
>50 w. normal neuro exam
if abnormal ???

46

get MRI/MRA with

Posterior fossa lesion (cerebellar issues)
SAH unable to perform Lumbar puncture
Venous thrombosis
persistent neuro deficit with tx

47

ha management

Identify the correct diagnosis of headache
Diminish pain associated with an acute attack
Prevent pain / associated symptoms of recurrent headaches

48

ha diary

-ID triggers
-monitor frequency
-involves pt
-Record response to treatment

49

signs that suggest pathology

Fever
Nuchal rigidity
Reflex asymmetry
Altered mental status
Papilledema

50

symptoms that suggest pathology

Worst headache of life
Age over 50
Progressive
Awakens patient-every morning, doesn't go away: mass
Neurologic dysfunction

51

ddx ha

ocular: glaucoma
environmental: high altitude
metabolic: hypoglycemia
toxicology: CO poisoning (cherry red macula, can measure on ABG)
vascular: HTN

52

special pops for has

preggos: preeclampsia-->eclampsia: seizure

immcomp: cryptococcal (HIV)

kids: Dental infection
Sinus infection
Neoplasm
Febrile illness

53

read pages 954-958

in current

54

floaters
aura
photophob
norm exam
lay in dark with cold rag

UCG

repeat triptan dose
rest, darkness

55

sev. pain around left eye
tearing, congestion

cluster

56

sev. pressure-like
worse when bending down, stren activity

papilladema
CT, LP
pseudotumor cerebri