Headaches Flashcards
(50 cards)
1
Q
Migraine Pathophysiology (7)
A
- Not well understood
- Related to neurovascular dysfunction
- Dilation of bv’s innervated by CN5
- Change in brainstem sensory nuclei
- Initially: cerebral blood flow decreases
- Later: cerebral blood flow increases, hyperemia
- Cortical spreading depression of leao (starts in occipital region and spreads forward)
2
Q
Migraine Clinical Presentation
A
- Lateralized, throbbing headache
- Onset: adolescents, early adulthood
- Gradual onset with aura
- Visual field defects
- Scintillating scotoma (flashing lights)
3
Q
Migraine S/S (14)
A
- Anorexia
- N/V
- Photobia
- Phonophobia
- osmophobia
- cognitive impairement
- blurred vision
- aphasia
- numbness
- paresthesia
- clumsiness
- dysarthria
- dysequilibrium
- weakness
4
Q
What are some triggers for migraines? (7)
A
- Stress
- sleep disturbance
- missed meals or specific foods
- alcohol
- bright lights
- loud noise
- menstruation or OC
5
Q
Atypical Migraines (3)
A
- Basilar artery migraine
- opthalmoplegic migraine
- Familial hemiplegic migraine
6
Q
Basilar Artery Migraine (4)
A
- Blindness or bilateral visual disturbances
- accompanied by dysarthria, dysequilibrium, tinnitus, perioral or distal paresthias
- Loss of consciousness or confused state sometimes
- followed by a throbbing occipital headache and N/V
7
Q
Opthalmoplegic Migraine (5)
A
- Lateralized pain around eye
- Accompanied by N/V and diplopia
- Diplopia may outlast headache for days
- CN5 opthalmic division may be involved
- Rare
8
Q
Familial Hemiplegic Migraine (2)
A
- Autosomal Dominant
- Attacks of lateralized weakness on one side
9
Q
Overview of Tx for Migraines (3)
A
- avoidance of precipitating factor
- symptomatic tx
- prophylactic pharmacologics
10
Q
Symptomatic Tx of Migraines (7)
A
- Rest, quiet dark room
- OTC analgesics
- Cafergot
- Antiemetics
- Sumatriptan/ Zolmatriptan
- Opioids
- propofol
11
Q
Preventative Tx of Migraines
A
- If headaches occur more than 2-3x per month
- If headaches are very severe
- Try in succession
- Continue for several months then slowly taper
12
Q
Prophylactic Drugs for Migraines
A
- Topiramate
- Valporic acid
- candesartan
- propanolol
- timolol
- verapamil
- amitriptyline
- Botulinum toxin A
13
Q
Cluster Headaches (5)
A
- M>F 10:1
- No FmHx
- Episodic, severe retro-orbital or periorbital pain or Horner’s syndrome
- Occur daily for several weeks and then remit
- Pts are restless and agitated
14
Q
Cluster Headache Clinical Presentation (7)
A
- Unilateral nasal congestion (may happen)
- lacrimation (may happen)
- rhinorrhea (may happen)
- redness of the eye (may happen)
- Often occur at night, waking the pt
- Last 30mins-3hrs
- Last 4-8 wks and recur 3-4x per yr
- EtOH, certain foods, bright lights, stress are all triggers
15
Q
Symptomatic Tx for Cluster Headaches (6)
A
- oral drugs don’t really work
- SQ or intranasal sumatriptan
- intranasal zolmatriptan
- O2 NRB mask high flow (12-15L)x15mins
- Dihydroergotamine
- Viscous lidocaine intranasal
16
Q
Prophylaxis Tx of Cluster Headaches (8)
A
- Lithium
- Verapamil
- Topiramate
- Valproate
- Suboccipital corticosteroid injection
- ergotamine
- prednisone
- occipital nerve stimulation
17
Q
Hemicrania Continua (3)
A
- Unilateral head pain a/w autonomic symptoms
- Not episodic
- Completely treated with indomethacin
18
Q
What is the most common type of headache?
A
Tension Headache
19
Q
Tension Headache Clinical Presentation (7)
A
- pericranial tenderness
- Occiptal region radiating to the forehead
- “vise like” not pulsatile
- daily
- poor concentration
- No focal neurological symptoms
- Exacerbated by: emotional stress, fatigue, noise, bright light
20
Q
Tx of Tension Headaches (6)
A
- Similar to migraine
- Triptans don’t help
- Tx associated anxiety or depression
- massage
- hot baths
- biofeedback
21
Q
Depression Headache (4)
A
- Worse when you wake up in am
- A/w other symptoms of depression
- antidepressant drugs
- psychiatric consultation
22
Q
Posttraumatic Headaches
A
- Follow a closed head injury
- independent of loss of consciousness
- Variety of non-specific symptoms
- Common
- Appear within a day or two of injury
- Worsens then subsides over weeks
- Constant dull ache with throbbing
- May be localized
23
Q
Posttraumatic Headache Clinical Presentation (8)
A
- N/V
- Scintillating scotomas (flashing lights)
- If they start 2 weeks after injury, may be something else
- dysequilibrium enhanced by movement
- impaired memory
- poor concentration
- emotional instability
- increased irritability
24
Q
Post Traumatic Headache Tx (8)
A
- CT/MRI to r/o focal symptoms
- encouragement
- NSAIDs
- Tylenol
- Amitriptyline
- Propanolol
- ergotamines
- antiseizure meds
25
Cough Headache
- Last several minutes
- 10% have chiari malformations (part of cerebellum through the foramen magnum)
- Brain tumors may present this way
- CT/MRI is indicated
- Should repeat imaging for 3 yrs to r/o lesion
26
Cough Headache Tx
- Self limited, may last several years
- May be relieved by LP (decrease ICP)
- Indomethacin
27
What arteries are affected by Temporal Arteritis?
Arteries affected:
- temporal
- vertebral
- opthalmic
- posterior ciliary
28
Temporal Arteritis (7)
- Affects elderly
- Headache= major symptom
May be a/w:
- myalgia
- malaise
- anorexia
- wt loss
- non-specific complaints
29
Temporal Arteritis PE (4)
- Scalp tenderness over temporal arteries
- Jaw claudication
- Increased sed rate
- Can cause monocular blindness if untreated
30
Temporal Arteritis Tx (2)
- Prednisone
| - Biopsy promptly
31
Intracranial Mass Lesions (6)
- Displacement of vasculature/tissue causes headaches
- Headaches range from mild to severe
- Non-specific
- Worsened with exertion or postural change
- N/V
- Progressive headaches/ new onset in adulthood merits further imagining, not normal
32
Medication Overuse Headache (4)
- Responsible for half of daily chronic headaches
- Severe headache unresponsive to meds
- Hx of pain meds
- Start a migraine prevention regimen
33
Pseudotumor Cerebri (3)
- AKA benign intracranial HTN
- Headache is worse on straining
- visual disturbances are common d/t papilledema and Abducens nerve palsy (diplopia)
34
Pseudotumor Cerebri Causes (6)
```
- Thrombosis of the transverse sinus d/t sinusitis or mastoiditis
– Thrombosis of the sagittal sinus
– Chronic pulmonary disease
– Endocrine disturbances
- (Hypoparathyroidism)
- (Addison’s disease)
– Vitamin A toxicity
– Tetracycline or OCs
```
35
Pseudotumor Cerebri Diagnosis (5)
- CT/MRI should be done to r/o mass lesions
- Small or normal ventricles may be seen
- MR venography:
– thrombosis of the intracranial venous sinuses
– LP confirms intracranial hypertension, CSF is normal
36
Pseudotumor Cerebri Tx (6)
– Untreated, PC will cause optic atrophy and blindness
– Acetazolamide – reduces CSF formation
– Prednisone may also be helpful
– Obese patients should be counseled to lose wt
– Repeat LP to lower ICP
– Medical treatment is mainstay – monitored by checking fundoscopic exam, visual fields and acuity and CSF pressure
37
What do you do if you cannot treat pseudo tumor cerebra?
If unresponsive to medical therapy, surgical lumboperitoneal shunt can be done or fenestration of the optic nerve sheath to preserve vision
38
Trigeminal Neuralgia (4)
- AKA Tic Doloureux
- Common in mid and later life
- F>M
- Facial Pain
39
Trigeminal Neuralgia Clinical Presentation (7)
- Stabbing pain on one side of the face
- Distribution of 2nd & 3rd branches of CN5
- Brief episodes of pain
- Exacerbated by touch, cold, moving, chewing
- Starts near mouth, radiates to ear, eye, nose
- Episodes become more frequent
- Dull ache may persist between episodes
40
Trigeminal Neuralgia PE
- Negative neurological exam
- CT/MRI normal
- If the patient is young, suspect MS
- Check CSF and evoked potentials
41
Trigeminal Neuralgia Pharmacological Tx
- Oxacarbazepine or carbamazepine
- Phenytoin
– Baclofen
– Lamotrigine
– Gabapentin
42
Trigeminal Neuralgia Ablative Tx
– Posterior fossa exploration to decompress the nerve (not in MS)
– Radiofrequency rhizotomy can be used in elderly patients
– Gamma knife on the root
43
Atypical Facial Pain
* Burning, constant pain, starts as localized but spreads
* May cross the midline, go to neck or posterior scalp
* Common in middle-aged women
* Associated with depression
44
Atypical Facial Pain Tx
* Treat with analgesics and TCA, carbamazepine, oxcarbazapine, phenytoin
* NO SURGERY
45
Glossopharyngeal Neuralgia (5)
* Similar to trigeminal neuralgia but affects the throat
* Peri-tonsillar or posterior tongue pain
* Pain may be precipitated by swallowing, chewing, yawning, talking
* Sometimes accompanied by syncope
* Rule out MS
46
Glossopharyngeal Neuralgia Tx
* Rule out MS
* Treat with carbamazepine, oxcarbazapine first
* Consider surgical exploration with decompression second
* Ablation is generally not used
47
Postherpetic Neuralgia
```
- Develops in 15% of ppl who had shingles
Most likely in:
- elderly
- immunocompromised
- severe rash
- 1st division of CN5 is affected
```
48
Postherpetic Neuralgia Tx (4)
– Simple analgesics
– TCA
– Carbamazepine, phenytoin, gabapentin, pregabalin
– Topical capsaicin cream or lidocaine
49
What are other causes of facial pain? (7)
* TMJ dysfunction
* Giant cell arteritis (masticatory claudication)
* Dental pain
* Sinusitis
* Ear infections
* Glaucoma
* Pain in the jaw may be angina
50
When should you refer a facial pain pt?
* Acute onset of “the worst headache in my life”
* Increasing headache unresponsive to simple measures
* History of trauma, hypertension, visual changes, fever
* Presence of neurologic signs or scalp tenderness
