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Flashcards in Headache (Hon) Deck (35):

What are primary headaches?

Benign HA disorders
Migraine (with or without aura)
Chronic migraine
Tension type
Cluster HA
Post-traumatic HA
Drug rebound HA


What are secondary headaches?

Sign of organic disease


Describe headache history

How many types of HA?
Frequency: previous, current, mode of increase (gradual or sudden)
Associated symptoms
Current and previous medications tried


Describe prodrome of headaches

Changes in energy levels, mood, appetite
Muscle aches


Describe associated symptoms of HA

Stuffy/runny nose
Watery eyes
Behavior: retreats to dark room, paces, rock


What are triggers of HA?

Hormones (menstrual cycle, OC's, HRT)
Diet: alcohold (esp beer, red wine), chocolate, aged cheese, MSG, aspartame, caffeien, nuts, nitrates/nitrites, citrus fruits, others
Stress: let down periods, times of intense activity, major life changes
Environmental changes: weather, seasons, altitude
Sensory stimuli: bright or flickering lights, odors
Others: travel, sleep pattern (too little, too much, or changes from usual pattern), skipping meals


Describe history of current and previous medications tried for HA

For both prophylactic and abortive therapy
Side effects


Describe good medical/surgery history and family/social hx

Co-morbidities: sleep disturbances, mood disturbances
Other medications
Head trauma
Previous LOC
Seizure D/O

Family illnesses including HAs


Describe good general exam for HA

Vital signs (BP/pulse)
Cardiac status
Extracranial structures
ROM & presence of pain in C-spine


Describe neuro exam for HA

Neck flexion
Presence of bruits over head and neck
Optic fundi, pupils, visual fields
Thorough cranial nerve exam
Motor power in limbs
Muscle reflexes
Plantar responses
Sensory exam


What are the worrisome signs that may indicate HA of pathological origin (secondary HA)

"Worst HA"
Onset of HA after age 50
Atypical HA for pt
HA with fever
Abrupt onset (max. Intensity in sec. To min)
Subacute HA with progressive worsening over time
Drowsiness, confusion, memory impairment
Weakness, ataxia, loss of coordination
Paresthesia/sensory loss/ paralysis
Abnormal medical or neuro exam


Describe diagnostic evaluation

Lab testing (appropriate for variant or atypical forms)
Neurodiagnostic tests
Other: WSR, TSH, CBC, glucose
CT, MRI/MRA, EEG, LP, arteriogram
Dental, ENT, allergy evaluation

As a general rule, many physicians (including neurologists) believe that any person with HA should have a one-time thorough neuroimaging study (CT head with and without contrast or MRI of head)

*Clearly, any pt with a worrisome history or abnormal examination needs urgent imaging study and perhaps even an LP and possibly arteriogram. (CT can miss 5-10% of subarachnoid hemorrhages, and an LP may be needed if CT is normal)


What are primary HA disorders?

Common migraine (without aura)
Classic migraine (with aura, consider chronic migraine)
Tension-type HA
Cluster HA


Describe common migraine

Intensity: *moderate to severe*
Disability: inhibits or prohibits daily activities. Pain aggravated by activity
Age of onset: late teens to early 20's. Prevalence peaks between *35-40 years*
Gender ratio F:M: = 3:1
Frequency: 1-4 attacks per mo. (Occ infreq) but 14 days or fewer per month
Duration: 4-72 hr, usually 12-24 hr
Location: *unilateral or bilateral
Description: *throbbing/sharp/pressure*
Prodrome: mood changes, myalgias, food cravings, sluggishness, excessive yawning
Postdrome: fatigue, irritability, "fog"
Behavior: *retreat to dark, quiet room*
*Aura: None*
80-90% of migraine sufferers do not experience aura


Describe the most and least common associated symptoms of common migraine

Most common:
Nausea (90%)
Vomiting (30%)

Least common:
Conjunctival injection
Stuffy nose


Describe classic migraine aura

Usually lasts 15-30 min but sometimes longer
Commonly visual symptoms (scintillations, scotoma, often hemianopic) but can be anything neurological


Describe chronic migraine

Many patients with episodic migraine will ultimately develop chronic migraine
History of headaches consistent with migraine, now with HA *15 or more days per month*, HA lasting 4 hrs or longer for a period of *at least 3 months*, not attributed to another disorder


What causes migraine?

Theory is "neurogenic inflammation"
Trigeminal nerve becomes activated, releasing neuropeptides, causing painful neurogenic inflammation within meninges, with subsequent effect on dural vasculature (vasodilation, plasma protein extravasation, and mast cell degranulation)


Describe tension-type HA

Intensity: mild to moderate
Disability: may inhibit but *does not prohibit daily activities*
Age of onset: variable. Generally peak incidence 20-40 yr
Gender ratio F:M = 3:2
Frequency: episodic type = 15 days/month
?Analgesic rebound HA's
Duration: episodic = several hours. Chronic type = all day, waxing and waning
Location: *bifrontal, bioccipital*, neck, shoulders, band-like
Description: *dull, aching, squeezing, pressure*
*No prodrome or aura*
Behavior generally not affected


Describe cluster HA

Intensity: *severe, excruciating*
Disability: prohibits daily activities
Age of onset: 20's to 50's
Gender ratio F:M = *1:6*
*Recent association with obstructive sleep apnea*
Monthly frequency: episodic = 1 or more attacks/day for 6-8 wks. Chronic = several attacks per week without remission
Duration: 30 min to 2 hr
Location: *100% unilateral, generally orbitotemporal*
Description: nonthrobbing, excruciating, sharp, boring, penetrating
Prodrome: may include brief mild burning in ipsilateral inner canthus or internal nares
No aura
Behavior: *Frenetic, pacing, rocking*
Associated symptoms: *ipsilateral ptosis, miosis, conjunctival injection, lacrimation, stuffed or runny nose*


Describe acute treatment of migraine

OTC analgesics
NSAID's: Naproxen, Ketorolac, Diclofenac
Isometheptene (Midrin)
Butalbital (Fiorinal, FIoricet)
Opioids: demerol, morphine, codeine, oxycodone, hydrocodone
DHE nasal spray
Triptans (5HT1 agonists):
-Sumatriptan (Imitrex)
-Zolmitriptan (Zomig)
-Naratriptan (Amerge)
-Rizatriptan (Maxalt)
-Almotriptan (Axert)
-Frovotriptan (Frova)


Describe contraindications to Triptan usage

Documented or strong risk factors for ischemic heart disease, other CV, cerebrovascular, or peripheral vascular disease, Raynaud's syndrome, uncontrolled HTN, hemiplegic or basilar migraine, severe renal or hepatic impairment, use within 24 hr of tx with ergotamines, MAOI's, or other 5HT1 agonists


Describe DHE protocol (Raskin protocol)

Metoclopromide or prochloperazien 10 mg IV over 60 sec. Wait 5 min to allow distribution
Give DHE 0.5 mg IV over 60 sec. Wait 3-5 min
May repeat 0.5 mg IV if no relief. May repeast every 8 hr for short-term use
*Same general contraindication as triptans*
Side effects: chest pressure, anxiety, speeding or dissociation of thoughts, nausea


Describe adjunctive agents in migraine

If nausea/vomiting are a major feature of migraine, consider using antiemetic (often before analgesic medication): metoclopramide, prochlorperazine
If insomnia is a major feature of migraine, consider a sedative/hypnotic (diazepam or temazepam) or major tranquilizer (thorazine) to help pt sleep off migraine
Prednisone taper can sometimes be used to break cycle of prolonged migraine or several weeks of frequent migraines


Describe preventative treatment of migraine

In general, if pt is experiencing one or more HA's per week, consider preventative medication in attempt to decrease frequency and severity
Antidepressants: TCA's (amitriptyline, nortriptyline), SSRI's (fluoxetine, sertraline, escitalopram), MAOI's (phenelzine)
Beta-blockers: propranolol
Calcium channel blockers (verapamil)
Anticonvulsants (topiramate, valproic acid, gabapentin)
Ergot alkaloids (ergotomine+phenobarbital)
NSAIDs (ASA, naproxen)
Muscle relaxants (tizanidine)
Methysergide (Sansert)


Describe preventative treatment of chronic migraine

Many used to prevent episodic migraine will also work for chronic (propranolol, amitriptyline, topiramate, valproic acid)

BOTOX injections: only FDA approved treatment for chronic migraine
155 units injected into 31 different sties, repeated every 3 months
May see some improvement after 1st treatment but need multiple treatments over 9-12 months to determine if working. 70-80% improvement
Minimal side effects: typically mild, temporary ptosis. Rarely can see widespread effect, ineffectiveness d/t antibody formation


Describe nonprescription tx of migraine

Stop smoking
HA education
Riboflavin (400 mg daily)
Magnesium (325 mg daily for menstrual migraine)
Biofeedback/relaxation/stress management (one of best preventative tx of migraine and tension-type HAs)


Describe acute tx of tension HA

OTC analgesics
NSAID (ibuprofen, naproxen)
Opioids (codeine, hydrocodone)


Describe preventative tx for tension HA

Antidepressants (TCA's, SSRI's, MAOI's)
Muscle relaxants (Tizanidine)
Anticonvulsants (valproic acid, gabapentin)
BOTOX injections
Ergot alkaloids (DHE sometimes used to break cycle of chronic daily HA)


Describe acute tx of cluster HA

DHE 1 mg IM or ergotamine 2 mg SL
Lidocaine 4% - 1 ml intranasal
Narcotics (meperdine, morphine)
Oxygen 100% 8 L/min by mask
Sumatriptan 6 mg SQ


Describe preventive tx for cluster HA

Calcium channel blocker (Verapamil)
Anticonvulsant (valproic acid)
Prednisone x 10-14 days
Capsaicin 0.025% intranasal tid x 1 wk
Ergotamine tartrate


Describe trigeminal neuralgia

Excruciating sharp, shooting, electrical quality pain occurring in paroxysms in one or more distributions of trigeminal nerve, often frequent throughout day.
Treatment is usually carbamazepine or oxcarbamazepine. Other anticonvulsants or rarely surgery can be considered


Trigeminal autonomic cephalgias (TAC's)

Group of headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features
Include: cluster headache, paroxysmal hemicrania, hemicrania continua, SUNCT syndrome


Describe SUNCT syndrome

Shortlasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing
Excruciating, burning, stabbing electrical HA in periorbital area lasting seconds to a few minutes, occurring frequently throughout the day
Onset typically over 50 in men
Treatments usually anticonvulsants (**particularly lamotrigine**)


Describe paroxysmal hemicrania

Very similar to cluster headache (unilateral, periorbital, severe, excruciating, often with lacrimation, conjunctival irritation) but shorter duration (often only a few minutes) and increased frequency (usually > 5 times per day)
**Exquisitely responsive to indomethacin**