What are Primary Headaches?
HA without intracranial Pathology (like tumors etc)
Definition of Migraine and Pattern for Migraine
3 Types of Migraine:
Migraine = HA + Autonomic symptoms; often associated with depression, anxiety, insomnia etc
Pattern = Acute and Recurrent, severe, unilateral or bilateral, relieved with sleep, pulsating pain, can have photophobia and phonophobia and nausea
Migraine with Aura
Migraine without Aura
What is cutaneous allodynia?
Skin hurts when its not supposed to!!!
Means that pain/headache has gone from easily treatable peripheral condition to hard to treat central condition
RACE against the clock to prevent this!
Criteria for migraine without aura?
2 of the following:
- pulsating pain
BOTH of the following:
- similar pain in past
- no organic disease
What is a complicated migraine?
Migraine with the following:
- Hemiplegic - neuro findings of weakness etc
Opthalmoplegic - double vision
Basilar Artery Migraine - problems with balance, almost like a stroke
Alice in Wonderland - perceive things as big/small
*TRYPTANS CONTRAINDICATED IN COMPLICATED MIGRAINES
What is a tension-type HA?
Squeezing pain - worse as day goes on
Less severe than migraine
*NO AUTONOMIC SYMPTOMS
Causes of Secondary HA?
Acute hemorrhage (like Sub-Arachnoid Hemorrhage)
Pattern for secondary HA from Tumor
Chronic Progressive pain
worse in morning (ICP increased)
Exacerbated by valsalva
HTN as a cause of secondary HA?
Rare, if real think brain, kidney, thyroid, drugs or tumors secreting vasoactive substances to cause it
--> usually secondary to pain
*Malignant HTN can lead to dysregulation of BBB and cause HA (but little increase in BP not going to cause HA)
Primary Intracranial HTN = Pseudotumor
- can cause tumor pattern (chronic progressive pain worse in AM)
Presentation of Acute Hemorrhage?
Thunderclap HA usually from a slow vessel leak that then bursts (aneurysm in head that blows - can kill you!!)
Neck stiffness - blood in neck
GET a CT (bc fast) and then LP which can also help relieve pressure
Other secondary causes of HA?
Primary Intracranial HTN
Chiari Malformation - cerebellar herniation that occludes spinal canal but rarely causes HA and more likely causes intermitten neurological hands/feet symptoms
Red Flags for secondary HA?
Systemic symptoms - weight loss, stop mensturating
Onset - rapid or chronic
Older - (pts >40)
Previous HA history is different
Whta is Chronic Daily HA and how does it present?
>15 HA /month and >4 hours a day
Get adjunct symptoms from having HA all the time: Anxiety, depression, insomnia
Type of Chronic Daily HA and Presentations?
Transformed Migraine - Migraines that occur closer and closer together; harder to prevent spike/onset of migraine bc already have baseline of HA symptoms
Chronic Tension-Type HA = HA moving closer and closer togeter, same pattern but no migraine spikes bc never had them in the first place
New Persistent Daily HA - new chronic HA without history of TT or migraine - BAD
Physiology of HA?
Genetic Predisopsition + Stimulus (internal - stress or external - light) lower thresholds for HA
*Decreased serotonin in Medium Dorso Raphenucleus and Trigeminovascular System opens the 5Ht1-D receptor gate and allows inflammatory cytokine soup to be released from brain - PG, Histamines, Subs P
Meninges get inflamed = HA
STrategy for Medicine?
Acute HA treatment regimes?
PG inhibiters and Antihistamines - work on the soup that's there
5-HT agonists = Triptans - help to close gate and stop acute mediators of inflammation and put 5-HT back to close the gate
Adjuncts: Antiemetics and anxiolytics
Rescue Meds (once cutaneous allodynia has already happened)
- DHE, Opioids, Reglan, Odansentron (antiemetic, serotonin antag)
What are the different triptans?
Sumatriptan - quick in and out
Zolmitriptan - good tastes, easy to administer
Rizatriptan - need for GI absorption, placebo?
Naratriptan - Long acting - good for recurrence problems and used for Menstrual migraines
Dihydroergoatamine (IV) -DHE different mechanism and can be used as rescue
Drugs for prevention of mirgrains?
Amitriptyline - TCA, SNRI anti-depressant also can be used for chronic or neuropathic pain
Cyproheptadine - antihistamine that increases hunger
Divalproex sodium - Anticonvulsant
Gapapentig - Anticonvulsant, analgesic, used for neuropathic pain
Topiramate - anticonvulsant, decreases hunger....makes you skinny!
Propanolol - lowers BP
Verapamil - CCB