Headaches Flashcards
Headaches
Headache red flags (SNOOP)
Systemic Neurologic Onset (sudden) Onset (age < 5 or > 40) Pattern change
Headaches
What are 4 categories of non-migrainous headaches? Describe each.
New Daily Persistent Headache
- daily unremitting from time of onset
- bilateral/pressing/tightening
- mild to moderate intensity
- possibly one of: phono-phobia, photophobia, mild nausea
Tension-Type Headache
- episodic, minutes to days
- mild to moderate
- bilateral/pressing/tightening
- pain does not worsen with activity
- peri-cranial muscle tenderness
- prevalence 31-74%
- age > 40
- possibly one of: phono-phobia, photophobia, mild nausea
Cluster Headache
- episodic or chronic attacks separated by pain-free periods
- pain almost always unilateral
- provoked by histamine, alcohol, nitroglycerin
- ipsilateral sx: rhinitis, eye tearing, peri-orbital swelling
- clusters up to 8/day (20 min to an hour)
- age 20-50 & male
Medication over-use headache - variable (migraine --> TTH) - peculiar pattern - drugs that increase risk • Nitroglycerine • Nifedipine • Dipyridamole • SSRI's - 20-36% adolescents with headaches
Headaches
H&P approach to all headaches
PAMPROSSTI
• Inquire about functional disabilities at work, school, housework, leisure activities during the past 3 months
• Pain assessment (OLDCARTS, PQRST)
• Aura
• Medical history
• Pharmacological & non-pharmacological treatments that are effective or ineffective
Focused physical exam
• Vitals
• Extracranial structure evaluation
• MSK exam of head and neck
Focused neurological exam
• Assess level of consciousness, confusion, memory
• Ophthalmological examination
• Pupil symmetry & reactivity, visual fields, ocular motility, fundus exam (papilledema, retinal hemorrhages)
• Cranial nerve examination to include corneal reflexes, facial sensation & facial symmetry
• Symmetry of muscle tone, strength & deep tendon reflexes
• Gait, arm & leg coordination
Headaches
Diagnostic criteria for New daily persistent headache
New daily persistent headache - daily HA > 3 months - At least 2 of: 1) bilateral 2) pressing/tightening (non-pulsatile) quality 3) not aggravated by routine physical activity - BOTH: 1) no more than one photophobia/phonia, nausea 2) neither moderate or severe N/V - not attributed to another disorder
Headaches
Dx criteria for TTH
TTH
- infrequent: > 10 episodes (ever), less than 1 day/month
- frequent: 1-14 days per month for more than 3 months/yr (12 to 180 episodes/yr)
- chronic: >15 days/month for over 3 months
- 30 min to days
- 2 of the following
- bilateral location
- pressure/tightening, non-pulsatile quality
- mild to moderate quality
- no increase with routine physical activity such as walking or climbing stairs
- BOTH: no N/V, no more than one phono/photophobia
Headaches
Dx Criteria for Cluster Headache
Cluster - at least 5 attacks - severe unilateral orbital or supraorbital and/or temporal pain lasting 15-180 min if untreated - accompanied by at least ONE of: conjunctival injection/lacrimation rhinitis (ipsilateral) peri-orbital swelling ipsilateral facial sweating - restlessness or agitation (pacing) - frequency 1 Q2 days to 8/day
Headaches
Dx Criteria for MOH
MOH
- > 14 days/month
- regular overuse for 3 or more months of one or more drugs for HA treatment
- developed or markedly worsened during medication overuse
- headache resolves or reverts to its previous pattern within 2 months after D/C medication
medications include:
- ergot
- triptans
- analgesics (tylenol/ibuprofen)
- opioids
Headaches
Epidemiology of migraines (age, sex, risks)
- age: 30-49
- female>male
- risks
- fmhx
- triggers (environmental, lifestyle, hormonal, emotional, dietary, medications)
Headaches
Migraine patho
- Broad sensory processing dysfunction, with a prominent perception of pain in the dense somatosensory innervation of intracranial vessels.
- dysfunction of neuromodulator structures in the brainstem and cortical spreading depression (CSD).
Headaches
What are the 4 clinical phases of migraines?
- Premonitory or prodrome phase
• Up to 1/3 experience this stage
• Occurs hours or days before onset of aura or headache
• Tiredness, irritability, loss of concentration, stiff neck, food cravings - Migraine aura
• Up to 1/3 experience this stage
• May last up to 1 hour
• Visual symptoms → seeing bright lights, zigzag lines or hallucinations
• Sensory symptoms → unilateral tingling or numbness in face or limb
• Motor symptoms (rare) → Unilateral weakness of face or limbs (hemiplegic migraine)
• Dysphasia - Headache phase
• 4 – 72 hours (typically 24 hours)
• Throbbing pain usually begins on one side & spreads to entire head
• Fatigue, N&V, dizziness, sensitive to head being touched - Recovery or postdrome phase
• Hours-days
Irritability, fatigue, depression
Headaches
migraine duration
4-72 hours
begins as episodic and occurs at least 15 days in a month or more than 3 months
Headaches
Migraine common signs and symptoms
- usually unilateral
- pulsing or throbbing
- aggravated by activity
- allodynia
- pain severe/can be debilitating
- photo/phonophobia, nausea
- aura common (1/3)
- prodrome common (1/3)
Headaches
migraine Dx criteria
2 or more of the following:
- Unilateral location - Throbbing/pulsating - Moderate to severe - Aggravated by activity
PLUS 1 or both of the following: - Nausea/vomiting - Photo/phonophobia & Previous similar headaches
Aura criteria
- 1 or more reversible aura symptoms
- 1 or more aura symptoms develop over more than 4 minutes, or 2 or more symptoms occur in succession
- Symptoms do not last more than 60 minutes
- Headache follows within 60 minutes
Headaches
Treatment
- Nonpharm: diet, hydration, sleep etc…
- Behavioral: CBT, relaxation techniques
- Complementary and alternative: acupuncture, vitamins etc…
- Pharmacological interventions
