What are the 3 main types of primary headache?
What is hte most common type of primary headache? What is the most common one you'll see in a primary care office?
tension headaches are most common overall, but migraines will predominate in-office
FOr tension headaches... age of onset? gender difference? other social factors?
under 40 yrs of age
increased with higher educational attainment
When do you consider tension headaches chronic?
when they happen every other day or more often
What is the pathophysiology behind tension headaches?
muscle contraction of neck and upper back
greater occipital nerve compression
irritation of nerve causing pain that starts in back and wraps around the sides like a headband
How will tension headahces present?
- last 30 min to a week
- pressing/tighening/constant pain (not throbbing)
- mild to moderate intensity
- not aggreavated by routine physical activity
- NO nausa or vomiting
- can hav ephono or photphobia but not both
True or false: physical therapy is very effective at eliminating tension headaches.
Who is at higher risk for cluster headaches?
male: female is 4:1
mean age of onset is 27-31
What do they think causes cluster headache?
posibly hypothalamic activation of the trigeminovascular autonomic system, innervating the dura and cerebral vasculature and other targets
What is the clinical presentation for a cluster headache?
severe, unliteral orbital/supraorbital/temporal pain lasting 15-180 minutes
frequency is every other day to 8/day during a cluster
associated with autonomic symptoms: lacrimation, nasal congestion, rhinorrhea, forehad sweating, miosis, ptosis, eyelid edema, conjunctival injection
What is the treatment for cluster headches?
Oxygen at high levels thorugh a nonrebreathing mask for 15 minutes
triptan medications - SUBQ OR NASAL - oral won't reach high enough plasma levels to be effective in the amount of time the headache lasts
WHo gets migraines most often?
females (3 to 1)
onset before 40 yrs of age
prevalence is 18% in women and general lifetime prevalence is 25%
What are some theories as to the cause of migraines?
spreading cortical depressoin
possible neurotransmitter dysfunction (NO or CGRP)
Dorsal pontine activation
What is the typical clinical presentation for a migraine headache?
can be associated with aura first, sometimes photophobia, and phonophobia
intermittent, unilateral throbbing headache lasting hours to days. Can generalize to both sides if not treated
nausea and vomiting often
exacerbated by activity - typically makes normal daily life impossible
True or false: there is no genetic component to migraines.
What should you really thinking about in a young sexually active women with migraines + aura?
If they're on an estrogen-containing birth control, they're at higher risk for stroke
What affect might Viagra have on migraines?
if a guy already has migraines, taking viagara may increase the risk of a migraine attack occurring
What is the first line of drugs for the treatment of migraine attacks?
triptans or DHE if those don't work
also antiemetics - perchlorperaxine or metoclopramide
aspirin, ibuprofen and naproxen may be helpful
What is the counterintuitive effect over extensive medication use in migraine treatment?
frequent use of OTC analgeis, triptans, and opioids significantly increase the risk for medication overuse headache
What medications are best for prophylactic medications in migraine headache treatment?
propanalol beta blockers
What neurotransmitter is largely targetted in treatment of migraine headaches?
How is 5HT synthesized, stored and metabolized?
made from tryptophan
stored in vesicles at pre-synaptic terminal
brought back in thorugh a reuptake transporter and broken down by MAO
WHere else does 5HT work esides the CNS?
in the GI tract
its produced and stored in enterochromaffin cells of gastric mucosa and will be released in response to mechanical stretch from eating
metabolized by MOA in the liver
In the vascular system, what does 5HT do?
it produces vascoconstriction of the cerebral vasculature and splanchnic/renal/pulmonary vasculature
Which 5HT receptors are targeted for migraine treatment?
5HT 1B and 1D
What happens to 5HT levels as a trigger for migraine?
increases - so it starts with vasoconstriction
Are migraine treatments 5HT receptor agonists or antagonists? Why is this weird?
agoanists - weird because a spike in sterotonin was the trigger for the migraine
What ion channels are affected by 5HT 1Ba nd D receptors and what does this mean for the membrane?
activates K+ channels
inhibits Ca2+ channels
this means the membrane becomes hyperpolarized
If Tritans are 5HT 1b and 1d receptor agonists, what do they do?
they cause vasoconstriction
and decreased release of pro-inflammatory neuropeptides
What are the general pharmacokinetics of triptans?
metabolized by MOA
1-3 hour half-life
urinary and fecal excretion
When woul dyou NOT want to prescribe triptans and why?
In cariovascular disease, uncontrolled HTN, current use of Ergots, liver disease
vascular stuff because it increases risk of stroke or heart attack due to the vasoconstrictive/vasospasmic effects
How does Ergot work in treatment of migraines? Why are they given less often?
same way as the triptans - agonist for the 5HT 1B and 1D receptors
not used as often because they can cause severe nausea and vomiting
Why do you need to be careful about drug interactions with Ergots like DHE?
It is metabolized by the CYP3A4 pathway in the liver, so if they'r eon drugs that reduce this, ergot iwll build up to dangerous levels quickly
What are the headache red flags for life threatening underlying causes?
sudden onset of severe thunderclap headache = subarachnoid
headache with exercise = ruptured aneurysm
new HA onset after age 50 = temporal arteritis or mass
HA with fever, nucla rigidity, etc = meningitis
HA onset hours to weeks after trauma = subdural
HA with focal neurological signs, papilledema = tumor, subdural, epidural
multiple people with similar new onset HA = environmental exposure like CO
Wheen do you order neuroimaging in headche?
with focal neuro exam findings
abrupt onset of headaches
change in character/intensity/frequency