Headache (Ferguson)

Question 1

____ of the population has >1 headache annually

• 5-7% of the population seeks medical attention
• Reason for 2% of doctor visits, 3% of ER visits
• 15% women, 6% men, 4% children
• 5.5-17 billion dollars lost in productivity

Answer 1

65-85%

Question 2

Which structures of the brain are pain sensitive?

• Pain is a normal response from a healthy nervous system

Answer 2

• Scalp
• Sinuses
• Meninges
• Pial arteries
• Arteries and major veins

Question 3

Which cranial structures are not pain sensitive?

Answer 3

• Ventricles
• Choroid
• Brain parenchyma(except one part of midbrain)
• Small parenchymal and dural veins

Question 4

What are some anatomic etiologies for pain?

1. distention, traction, dilation, irritation, contraction, displacement, inflammation, or activation of… (5)

Answer 4

1. Vasculature
2. Nerve
3. Meninges - dura
4. Muscles - cranial or cervical musculature
5. Brain stem (small area near the dorsal raphe nucleus [high concentration of serotonin])

Question 5

Headaches are classified by the ________

and classified as either: (3 types)

Answer 5

International Headache society

• Primary HA
• Secondary HA
• Cranial neuralgias

Question 6

What type:

• Primary
  
  • benign reoccuring disorder that has associated symptoms which can include: photophobia, phonophobia, nausea, vomiting, worsening with exertion, neurologic sx.

Answer 6

Migraine

Question 7

What is thought to be the current pathophysiology behind migraines?

Answer 7

• Begin in the brainstem, with activation of cells that spreads peripherally to stimulate the trigeminal system
• May also affect other local systems - chemoreceptors and autonomic nervous system

Question 8

What kind of migrane?

• unilateral, often descibed as a deep ache or throbbing sensation
• Photophobia, phonophobia, nausea, vomiting
• Worsened by exertion and relieved with rest
  
  • 30 minutes - 6 hours, can last longer

Answer 8

Migraine without aura

Question 9

What kind of migraine?

• unilateral, often descibed as a deep ache or throbbing sensation
• Photophobia, phonophobia, nausea, vomiting
• Worsened by exertion and relieved with rest
  
  • 30 minutes - 6 hours, can last longer
• Preceded by aura up to 30 mins before, and up to 1 hr into the headache

Answer 9

Migraine with aura

Question 10

What is an aura?

• Types?

Answer 10

Perceptual disturbance experienced prior to headache and/or into headache that can manifest as:

• Visual aura - eg scintillating scotoma, central scotoma, zig-zag lines, kaleidoscope, tunnel vision, vision loss
• Sensory aura - pins & needles
• Motor aura - focal weakness, paralysis
• Auditory aura - buzzing, amplitude modulation, heightened sensitivity to sound

Question 11

What kind of migraine?

• dramatic, same as migraine with aura - but can last for an extended period of time
• can ​mimic the appearance of STROKE

Answer 11

Complicated Migraine

Question 12

What kind of migraine?

• Have associated brainstem and posterior cerebral circulation symptoms: vertigo, diplopia, dysarthria, ataxia
• Headache follows neurologic symptom after 20-30 mins; often occipital throbbing pain

BONUS: what type is the most severe form of this, with total blindness and admixtures of vertigo, ataxia, dysarthria, and tinnitus?

Answer 12

Basilar Migraine

BONUS: Bickerstaff’s migraine

Question 13

What kind of migraine?

• CLinically appears as repeated attacks of severe noncolicky midline abdominal pain
• Associated with typical migraine prodromes and auras
  
  • 2-4% prevalence in children; uncommon in adults

Answer 13

Abdominal migraine

Question 14

What is the non-pharmacologic approach to migraine treatment?

Answer 14

AVOID TRIGGERS - e.g. red wine, certain foods (chocolate, cheese, msg, processed meats, nitrites); increased hunger, sleep deprivation, stress

Question 15

What are the abortive/rescue therapies used to treat migraines?

Answer 15

• NSAIDS - ibuprofen, naprosyn, ketorolac
• 5HT1 antagonists - sumatriptan (short acting), zolmitriptan (intermediate acting), frovatriptan (long acting)
• Dopamine Agonists - metoclopramide, prochlorperazine
• Combinations - excedrin, fiorcet, midrin

Question 16

What are the prophylactic therapies used to treat migraines?

BONUS: when should these be used?

Answer 16

• Beta-blockers - propranolol, atenolol
• Calcium channel blockers - verapamil
• TCA’s - amitriptyline, nortriptyline
• Anticonvulsants - gabapentin, valprioic acid, topiramate, levetiracetam
• Serotonergic drugs - cyproheptadine

BONUS: used when migraines are severe enough to cause functional impairment, and occur at least 3x/month

Question 17

What are the trigeminal autonomic cephalagias?

pathophysiology: ________ pathways are involved in pain modulation = evolution of the headache

• _____ is a neuropeptide made in the hypothalamus
• trigeminovascular and cranial parasympathetic pathways are responsible for the ipsilateral pain/autonomic features
• Pain sensitive intracranial structures are innervated by ___________

Answer 17

headaches with autonomic features:

• Cluster headaches
• Paroxysmal hemicranias
• SUNCT
• Hemicrania continua
• Orexinergic
• Orexin
• Ophthalmic branch of the Trigeminal nerve

Question 18

Which trigaminal autonomic cephalagia? (primary)

• Uncommon, 0.1% of population, more males, 20% familial
• Episodic headaches - 1 to 3 short duration (15 min to 3 hr) attacks of severe unilateral stabbing periorbital/temporal pain
• Occur in groups for 3-6 weeks, with at least 1: conjunctival injection, lacrimation, miosis, ptosis, edema, rhinorrhea, congestion, persperation
• CIRCADIAN rhythm - same time of day

Answer 18

Cluster headaches

Question 19

What are the Acute treatments of cluster headaches?

• via? for how long?
• what route?

Answer 19

• OXYGEN 12 L/min via - non-rebreather face mask for 15 minutes (most affective abortive agent)
• Instranasal, subcutaneous Triptan - short onset, short duration

Question 20

What agents are used prophylactically for Cluster headache treatment?

• s
• s
• s
• s

Answer 20

• High dose steroids - prednisone (60-80 mg/day) 2 weeks + taper
• Calcium channel blockers - verapamil, 160 - 480 mg CR daily; baseline EKG
• Lithium - 300 - 1200 mg, check TSH and renal fxn
• Valproic acid (250-750 mg bid), monitor CCP, CBC

Question 21

What type of trigeminal autonomic cephalagia? (primary)

• Uncommon, episodic headache occurs at least 20x - severe unilateral, orbital/supraorbital/temporal pain lasting 2-30 minutes
• Must have at least 1: conjunctival injection, lacrimation, edema, miosis, ptosis, rhinorrhea, congestion, persperation
• CIRCADIAN rhythm - same time

Treatment: *** responds to Indomethacin 150 mg/day (25 tid to 50 tid, check baseline renal fxn, no skipping doses)

Answer 21

Paroxysmal Hemicrania

Question 22

Which type of trigeminal autonomic cephalagia? (primary)

• Uncommon, the rarest
• Ultra-brief paroxysmal headache lasting seconds, 1 second to 10 minutes
• stabbing in nature
• Recurs many times over several minutes and may be superimposed on a dull ha (100x per day)
• Must have at least 1: conjunctival injection, lacrimation, tearing
• Sx can mimic pathology of the posterior fossa or pituitary

Answer 22

SUNCT (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing)

Question 23

Treatment for SUNCT?

Answer 23

Lamotrigine - first line, 75% responder rate, 100-400 mg daily titrated slowly

Question 24

What type of primary headache?

• Most prevalent headache syndrome - squeezing/pressure sensation, light and/or sound sensitive
• Never have nausea/vomiting
• Treatment:
  
  • Decrease stress, biofeedback, CBT, sleep
  • Abortive?
  • Prophylaxis?

Answer 24

Tension headaches

• Abortive - Acetaminophen, NSAIDs
• Prophylaxis - TCA’s, Antiepileptic - gabapentin

Question 25

What secondary headache disorder? * Predominantly affects **obese** **women** of **childbearing age** * 8:1 female to male ratio * Pathophysiology: obstruction of segments in the distal transverse sinus, increased venous pressure in the superior sagittal sinus - CSF production = CSF reabsorption, but higher pressure is needed to achieve this balance 2/2 **increased resistance at arachnoid granulations**

Answer 25

Idiopathic Intracranial Hypertension

Question 26

How does obesity contribute to IIH?

Answer 26

Increases intra-abdominal pressure, and raises cardiac filling pressures, lead to impeded venous return form the brain, with a subsequent elevation in intracranial venous pressure \* if not treated, interruption of the axoplasmic flow of the optic nerves with papilledema - may lead to irreversible optic neuropathy

Question 27

What are some symptoms of idiopathic intracranial hypertension? * kind? * what sound? * Signs: **PAPILLEDEMA**

Answer 27

* Headaches - nonspecific with variable location, throbbing/pressure, worse with valsalva * Pulsatile tinnitus - whooshing sound * Vision impairment - flashes, floaters, diplopia (trochlear, abducens palsy), decreased acuity and impaired visual fields (nasal inferior quadrant, then loss of the central visual field), dimming with valsalva

Question 28

For IIH, disc edema necessitates neuroimaging with ____ and _____ to rule out mass or dural venous sinus thrombosis * What might you see on MRI? For **LP** required pressures are? (CSF can be drained to normal closing pressures)

Answer 28

* MRI * MRV * Normal-small slit like ventricles, enlarged optic nerve sheaths, empty sella LP: \> 250 mm H2O

Question 29

What are the non-pharmacologic treatments for Idiopathic Intracranial Hypertension? - failed medical management resulting in elevated ICP, progressive visual deterioration, worsening disc edema, necessitates? * CSF shunts - vp, lp * optic nerve sheath fenestration

Answer 29

* Weight loss * Diet * Bariatric surgery * Surgical management

Question 30

What are some drug classes used to treat idiopathic intracranial hypertension? * * * *

Answer 30

* Acetazolamide - **_4g daily_** (start at 250 mg), helps improve visual outcome * Furosemide * Corticosteroids - transient use * Anticonvulsants - topiramate; weak carbonic anhydrase inhibitor, side effect of weight loss

Question 31

What are some alternate causes of idiopathic intracranial hypertension?

Answer 31

- Vitamin A toxicity - Minocycline - Dural venous thrombosis

Question 32

Waht secondary headache disorder? * Vasculitis that is almost exclusively found in \>50 year olds * Presents as progressive, unilateral, throbbing headache with **tenderness of the temporal scalp area** * Often complain of concomitant: **_jaw claudication, joint aches, visual disturbance, monocular transient vision loss_** * Elevated ESR, CRP

Answer 32

Giant Cell Arteritis

Question 33

What is the gold standard for diagnosis of giant cell arteritis? Treatment?

Answer 33

**Temporal artery biopsy** **-** Obtain a large section of artery, known to skip sections * Tx: high dose steroids (typically resolve in 3 days)

Question 34

Evaluation of this should hinge on obtaining a complete history and thorough neuro examination - urgent CT to rule out hemorrhage, large mass lesion, or hydrocephalus - MRI is much more sensitive to subtle pathology and should be considered - LP in setting of febrile illness, immunocompromised patient, and when hemorrhage is suspected even when CT is normal

Answer 34

Acute , new-onset, severe headache