Headache

Question 1

tension type headache?

Answer 1

episodic, can become chornic

Question 2

migraine headache?

Answer 2

episodic & recurring

Question 3

cluster headache

Answer 3

episodic & returning

Question 4

epidemiology of headaches?

Answer 4

• 50% of population reports HA/year, 90% w/ lifetime prevalence
• most prevalent neurological disorder and most frequent symptom seen in primary care
• 18% lifetime prevalence of migraine
• tension HA more common than migraines (52%)
• chornic headache (a daily HA) occurs in ~3%

Question 5

epidemiology of subtypes of headaches

Answer 5

• migraines: women>men
• tension HA: women = men
• cluster HA: men > women

Question 6

primary vs secondary HA

Answer 6

primary: not associated w/ organic disease or structural neurologic abnormality. testing and imaging normal
secondary: associated w/ abnormality on clinical exam, testing & imaging confirming diagnosis. symptoms are caused by something else going on

Question 7

pathophysiology of headaches

Answer 7

• not well understood
• migraine & cluster: believed to begin as a neurologic dysfunction w/ subsequent involvement in trigeminal nerve and cranial vessels. mot cluster HA involve the PNS

-tension: central neurologic disturbance as a result of increased cervical and pericardial muscle activity. flexion-extneion injury to neck, poor posture, anxiety, clenching/grinding teeth.

Question 8

migraine pathophysiology?

Answer 8

1. episodic instability of serotonin and neurotransmitters. serotonin may be diminished or receptors less sensitive
2. trigeminal nerve may become hyperactive - efferent impulses over branches of trigeminal nerve go to the innervated cranial vessels, causing release of substances promotion perivascular inflammation and vascular dilation
3. dysfunction of brainstem and hypothalamus are responsible for s/s such as N/V photophobia, photophobia & osmophobia
4. central sensitization occurs. inflamed perivascular structures irritate nerve endings of trigeminal nerve->afferent stimuli back to trigeminal neurons -> sensitizing and continuing to fire. this causes the scalp to become painful and tender

Question 9

cluster pathophysiology

Answer 9

1. episodic neuronal dysfunction
2. likely involving the hypothalamus more than brainstem
3. marked increase in blood flow of ICA on side of HA during the attack of pain

Question 10

before saying it’s just a headache, think…

Answer 10

• new onset neurologic or cognitive deficit
• worsening with fever
• thunderclap or worst head of life
• clinical features of glaucoma
• impaired LOC
• head trauma in past 3 months
• triggered by cough, sneeze vasalva or exercise
• changes with posture
• clinical features of GCA
• significant change in characteristics of HA
• personality changes
• atypical aura
• h/o malignancy, HIV, immunocompromised

Question 11

signs & symptoms of tension

Answer 11

• a dull every day headache
• mild to moderate generalized pressure or tightness
• nausea, photophobia, photophobia may occur but not prominent
• increased muscle tension
• scalp tenderness
• TMJ, cervical or trapezius muscle groups w/ tightness & tenderness

Question 12

signs & symptoms of migraine

Answer 12

• 15-20% with aura (visual or neurologic deficit lasting < 1 hour followed by migraine)
• prodromal symtoms - changes in mood, personality, failure or hyperactive in the day prior
• moderate to severe pounding/throbbing generally unilateral
• photophobia, phonophobia, osmophobia, N/V

Question 13

cluster signs & symptoms

Answer 13

• steady, boring, intense pain behind one eye
• can spread to temple, face and upper neck
• unilateral tearing, nasal congestion, conjunctival injection (usually in the morning)
• often at same time each day (waking hours)
• short in duration, 30-45 minutes
• once to several times a day for a period of weeks to months then remit for months to years

Question 14

history & examination for headaches

Answer 14

-detailed history including last 3 months. TEMPORAL profile: onset to peak, time of onset, frequency, duration, stable or evolving. AUTONOMIC features: nasal congestion, rhinorrhea, tearing, ptosis, edema. description, location, severity, percipitating or relieving factors, effective vs. ineffective treatment, aura, other PMH

physical exam: VS, extra cranial structures, neck flexion/rotation

neurologic exam: mental status, cranial nerves, motor, sensory, reflexes, coordination, gait

Question 15

how do you diagnose headaches?

Answer 15

• based on patient history of signs, symptoms and duration
• for females investigate correlation with menstrual cycle - requires observation over 2-3 months, headache diary is useful

neuroimaging: not recommended unless strong suspicion for underlying intracranial abnormality. incidental abnormalities lead to increased anxiety. would do it on someone who’s 50 with their first occurence of headache.

Question 16

tension treatment

Answer 16

prophylaxis not recommended.

• pharmacologic: ASA, acetaminophen, NSAID
• acupuncture
• chronic tension may overlap w/ chronic migraine. if so then migraine prophylaxis may be utilized

Question 17

factors to consider for migraine prophylaxis

Answer 17

consider: frequency (>2 migraines per week), severity, comorbid conditions, risk of medication overuse and patient compliance

Question 18

non pharamcoloic measures for migraine prophylaxis

Answer 18

acupuncture

Question 19

first line pharmacologic agents for migraine prophylaxis

Answer 19

Topamax/propranolol are first line agents.

Question 20

side effects of topamax?

Answer 20

topamax: side effect profile and teratogenic potential may preclude (short term memory loss)

Question 21

other medications used for migraine prophylaxis

Answer 21

gabapentin found to show some benefit

commonly used but lacking evidence: amitriptyline (used more often in those w/ depression too), valproate, pizotifen

Question 22

how long should you stay on migraine prophylaxis

Answer 22

once migraine controlled utilize for 6 months, then consider weaning

Question 23

what are options for migraine rescue therapy?

Answer 23

combination therapy superior to monothreapy (triptan + acetaminophen OR triptan + NSAID)

Question 24

if you fail one triptan does that take the whole class of the plate?

Answer 24

no!

lack of effectiveness of triptan is not class effect

Question 25

additional pharmacologic measures for migraine rescue therapy

Answer 25

antiemetics may be used in combo therapy regardless of N/V due to dopaminergic action

can consider non-oral therapy when oral not effective (SubQ, IM, intranasal, sublingual, suppository)

Question 26

migraine considerations….?

Answer 26

women of childbearing age suffering from migraines with aura should not use hormonal contraception d/t increased risk of ischemic stroke

perimenstrual prophylaxis with frovatriptan or zolmitriptan on expected migraine days

migraine w/out aura often improves during pregnancy. acetaminophen is first line drug of choice, triptan can be considered but discussed with provider.

Question 27

what is status migrainosus

Answer 27

migraine > 72 hours

dihydroergotamine mesylate (given in monitored setting)

• IV DHE most frequently used for intractable migraine attacks and status
• effective in 90% of patients within 48 hours
• effective in terminating acute cycle of cluster HA
• contraindicated in cerebrovascular disease, heart disease, HTN, within 24 hours of receiving triptan

chlorpromazine, valproate, Mg sulfate
-if h/o dystonic reaction may pre-medicate with benadryl

Question 28

cluster treatment?

Answer 28

• oxygen and/or subQ or nasal triptan
• oral triptans should not be used (not effective)
• prophylaxis: verapamil - dosage is much higher than utilized for cardiovascular indications, should be managed by a specialist

no used for opioids which may result in medication overuse

Question 29

additional therapies for headache

Answer 29

acupuncture
biofeedback 
butterbur root
coenzyme Q10
cognitive therapy
feverfew
lifestyle / diet modification (avoid tyramine, sulfites, artificial sweeteners, processed foods)
magnesium
botox
physical therapy
relaxation therapy
riboflavin
cervical manipulation
TENS unit

Question 30

outcomes for headaches

Answer 30

• early treatment improves duration, severity and associated disability
• comprehensive outpatient treatment centers are promising for chronic daily HA and medication overuse patients.
  - program includes detox from overuse medications, initiation of prophylactics, psychotherapy, PT, relaxation and biofeedback techniques, education of triggers
• acute migraines treated with triptans are associated w/ reduced ED & primary care visits, fewer lost days and reduced disability