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Flashcards in Headache Deck (37):
1

Define Primary Headache

Headache with no underlying disease process

Generally benign and will not be fatal or cause long term neuro deficit

2

Define Secondary Headache

Headache as a secondary manifestation for another disease process

Much more concern about imminent death or neuro deficits

3

What are some "red flags" for Aneurysmal SAH or cerebellar hematoma?

Split second, unexpected worst headache of life

LOC

Vertigo

Vomiting

4

What are some "red flags" for meningitis?

Headache, fever, skin rash

5

What are some "red flags" for cryptomeningitis or toxoplasmosis?

Immunocompromised

6

What are some "red flags" for subdural or intradural hematomas?

Coagulopathy or the patient is on anticoagulation therapy

7

What is a migraine?

Genetic condition in which a person has a predisposition to episodic headaches, GI disturbance (nausea) or neuro dysfunction

8

How often do migraines typically occur? Where? What kinds of patients tend to develop migraines?

Typically once or twice a month

Unilateral

Often begin in late childhood or early adulthood (menarche to menopause)

9

What are the 4 typical phases of a migraine?

1. Prodrome
2. Aura
3. Pain
4. Postdrome

10

Describe the Prodrome phase of a migraine

Occurs days-hours before the migraine begins

May develop depression, irritability, drowsiness, fatigue, hunger/thirst, rhinorrhea/lacrimation, yawning

11

Describe the Aura phase of a migraine

Often visual aura ("fortification phenomenon")

Usually develops over 5-20 min and lasts over an hour

Numbness/tingling of face or arm
Dizziness
Diplopia

12

How would you differentiate between the aura of a migraine versus the aura of Retinal Detachment?

Retinal detachment-- flashing lights that come and go after a few seconds

Migraine Aura--stay for an extended period of time before the migraine

13

Describe the Pain phase of a migraine

Pain may be in head, abdomen, or chest

Onset is gradual, over min-hours

May last for hours or days

Maybe associated with photophobia, phonophobia, nausea

14

People who get migraines are often genetically setup for them. What is the mutation and how does it cause the migraines?

Gain of function mutation in an NMDA receptor, which is excitatory

NMDA receptor activation leads to burst of focal cerebral activity, which leads to local hyperemia and increased blood flow

15

Describe the feedback loop that allows migraines to persist

Trigeminal nerves become activated and they release neuropeptides (CGRP, substance P, neurokinin A)

CN V sends a message to dilate blood vessels in brain

Creates a constant feedback loop

16

Describe the Postdrome phase of a migraine

Present for several hours after the pain ends

Mood changes (euphoria, fatigue)

Impaired concentration

Scalp and muscle tenderness

17

What is the first line treatment for mild migraines? What if that doesn't work?

First line treatment is NSAIDs

Move on to stronger drugs if that fails (triptans)

18

Triptans
MOA

Agonists of the 5-HT 1B/D receptors

Cause vasoconstriction of blood vessels

19

Triptans
Contraindications

Do NOT use in pregnant women or in patients who are at risk for ischemic heart disease

Also avoid with renal disease or HTN

Avoid if on MAO inhibitor

20

Triptans
Adverse Effects

Warm/hot sensations

Chest tightness

Tingling

Pressure sensations

Potential risk for serotonin syndrome

21

What is Serotonin Syndrome?

Excess activation of 5HT 1A and 5HT2 receptors

Leg rigidity
Lacrimation
Excess bowel sounds
Myoclonus
Hyperreflexia
Seizures

22

Ergotamine
Indications

Less specific than triptans

Potent arterial vasoconstrictors

23

DHE = Dihydroergotamine

Indications

Significant arterial and venous vasodilator

More side effects associated than ergotamine

24

When are ergots (DHE, ergotamine) contraindicated?

Ischemic heart disease

Collagen vascular disease

cardiac valve disease

HTN

Hemiplegic/basilar migraine

Pregnant women

25

When would Botox be indicated for migraines?

Only for chronic migraine headaches

Only after patient has failed many other meds and has frequent headaches

26

Cluster Headaches
Who is most likely to get one?

Males, typically in their 40s, who smoke and drink alcohol

27

Cluster Headaches
How long do the headaches tend to last? Where are they?

Usually unilateral headaches

Clusters last 6-12 weeks and occur every 1-2 years, but the headaches themselves occur 1-4x per day and last 20-30 min each

28

Cluster Headaches
Effective therapies?

Inhaled O2

Injectable sumatriptan

Nasal sprays

Prednisone is a last ditch option

29

What is the most common form of headache in adults?

Tension-type headache

30

Tension-type headache
Clinical Features

Bilateral pain, lasting over 30min

Band-like, pressing or tightening pain

No nausea and not aggravated by activity

Could have photophobia or phonophobia, but NOT BOTH

31

Tension-Type Headaches
Treatment

Go to sleep,
Eat better,
Don't smoke

32

Trigeminal Neuralgia
Clinical Features

Shooting pain radiating down jaw is classic distribution

33

Trigeminal Neuralgia
Causes

Likely due to tortuous artery compressing the trigeminal nerve in older people

In young people, often caused by MS

34

Trigeminal Neuralgia
Treatment

Carbamazepine is first line therapy for pain control

35

Pseudotumor Cerebri
Who gets it?

Often overweight females

36

Pseudotumor Cerebri
What is it?

Neurologic emergency

Weight increase --> inc in intraabdominal pressure --> impairs venous outflow and increases intracranial pressure

May cause blindness

37

Primary Exertional Headache
Clinical Features and treatment

Pulsating HA occuring only during or after physical activity

Treat with Indomethacin before they exercise

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