Headaches

Question 1

Migraine Tx

Answer 1

-Acute: rest rest (dark, quiet room), aspirin, NSAID (ASAP may abort), sumatriptan (Imitrex), butorphanol (Stadol), ergotamine/caffeine, dihydroergotamine (DHE), valproate
-Dopamine antagonists – metoclopramide (Reglan), droperidol, prochlorperzine (Compazine)
-Consider steroids (e.g dexamethasone) may reduce recurrence

Question 2

Migraine Prophylaxis

Answer 2

-Beta blockers (propranolol)
-antiepileptics (valproic acid, topiramate)
-antidepressants (amitriptyline, venlafaxine)
-anabotulinumtoxin A (Botox)

Question 3

Treatment considerations

Answer 3

-Triptans: avoid with coronary or risk of coronary disease/stroke
-Eergotamine: black box-peripheral ischemia/gangrene
avoid if history of ischemic disease, PAD, etc.
-Consider use of TCA in patients with depression
-Avoid CCB-in patients of childbearing age
-Pregnancy: Triptans contraindicated, avoid NSAIDs in 3rd trimester, avoid ergotamine
-Consider baseline EKG-Many drugs prolong QTc

Question 4

Tension Headaches

Answer 4

-Most common
-Mild to moderate severity-bilateral “headband” or “vice”-like, non throbbing, may involve neck or occipital area, no neurologic symptoms, may last 30 min to hours or days
-Triggers – tension, anxiety, eyestrain, posture, etc.
-Treatment- Relaxation, heat, ice, massage, sleep, acetaminophen, aspirin, NSAIDs

Question 5

Cluster Headache

Answer 5

-More common among males, nighttime, substantial impact on daily life, bouts may last 4-8 weeks and occur several times yearly
Unilateral, behind the eye, throbbing or piercing, severe, may last 15 min to 2 hours, alcohol possible trigger
-Associated symptoms – conjunctival redness, ipsilateral nasal congestion or rhinorrhea, ptosis, miosis (Horner syndrome)
-Treatment : 100% oxygen, triptans (Imitrex), ergotamine
-Prophylaxis – avoid potential triggers, verapamil, lithium, anticonvulsants

Question 6

Meningitis classic triad

Answer 6

-Fever, altered mental status, headache/neck stiffness (nuchal rigidity)

Question 7

Temporal Arteritis

Answer 7

“Giant cell arteritis”
-Inflammation of small and medium intracranial vessels
-Predominantly > age 50, history polymyalgia rheumatica
-Headache, fatigue, fever, muscle weakness, jaw claudication, transient visual loss
-Untreated – may lead to permanent vision loss
-Elevated ESR and CRP
temporal artery biopsy
-Treatment – high dose steroids