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Flashcards in Headaches Deck (30)

"red flag" symptoms of headache

-sudden onset maximum severity ("worse headache of my life"),
-headaches increasing in severity/frequency brought on by valsalva/exertion
- headache beginning after age 50, usually with jaw pain
- headache with systemic symptoms
- headache in someone immunocompromised, HIV, or with cancer
- headahce with focal neurologic signs
- headache after trauma
- headache with papilledema


sudden onset headache maximum severity "worst headache", new/different headache

ddx: subarachnoid hemorrhage, pituitary apoplexy, hemorrhage into a mss leson/AVM, mass lesion

eval with imaging, LP if imaging negative


headaches increasing in seveirty and frequency, brought on my valsalva/exertion

mass lesion, subdural hematoma, med overuse

eval with imaging/drug screen


headache beginning after age 50, esp with jaw pain/claudication

temporal arteritis; mass lesion

eval with imaging, ESR


new-onset headache in patient with risk factors for HIV/cancer

meningitis, brain abscess (including toxo), metastases

eval with imaging first, then LP if imaging negative


headahe with systemic symptoms (fever, rash, stiff neck)

meningitis, encephalitis, lyme dx, systemtic infection, collagen vascular disease

eval with imaging, LP, serology


focal neurologic signs

mass lesion, avm, stroke, collagen vascular disease

eval with imaging, collagen vascular evaluation, including antiphospholipid antibodies)



mass lesion, pseudotumor cerebri, meningitis

neuroimaging and LP


headache after trauma

intracranial hemorrhage, subdural hematoma, epidural hematoma, post traumatic headache

image brain, skull, and cervical spine


Diagnostic criteria for migraine

Repeated attacks of headache lasting 4-72 hours in patient with normal physical; no other reason for headache and...

at least 2:
unilateral pain, throbbing pain, aggravation by mvmt, moderate/sever intensity

at least 1
n/v, photophobia/phonophobia


What to ask when evaluating headache

- associated symptoms (esp neurologic)
- prior headaches/episodes
- age of onset
- frequency/duration
-amount of disability/distress
- what patient has done to treat headache/past headaches, medication details


status headache

headache lasted more than 72 hours


When to do neuroimaging for headache

when there is an unexplained neurologic deficit or if headache is different from a primary headache disorder


Nonpharm treatment of migraines

patient education, bed rest in dark room, avoiding triggers, lifestyle modifications (diet, exercise, sleep, alcohol/caffeine, stress management), acupuncture, cold applications, constant temporal artery pressure


Components of migraine treatment

patient education, simple analgesics/NSAIDS (acetaminophen, naproxen, ibuprofen), migraine specific agents (triptans, dihydroergotamine, etc), oral vs nasal route, rescue medications, migraine prophylaxis


Who should get migraine specific agents like triptans ?

Severe migraines refractory to NSAIDS or analgesics


Who should get nasal route of migraine treatment?

Migraines assocaited with nausea or vomiting


Who should get migraine prophylaxis

patients who require acute treatment two or more times per week; guard against med overuse or rebound headaches


What classes of drugs can be used for migraine prophylaxis?

beta blockers (propanolol, metoprolol), antidepressants (amitriptyline, venlafaxine)
anticonvulsants (topiramte, valproate)
serotonergic drugs, calcium channel blockers


most prevalent form of primary headache disorder

tension headaches


typical presentation of tension headache

pericranial muscle tenderness; description of bilateral band-like distribution of pain. can last 30 min - 7days


How are tension headaches different from migraines?

unlike migraines, tension headaches aren't aggravated by physical exertion, aren't usually associated with n/v, and you won't see photo and phonophobia together (maybe one or the other, if any at all)


Episodic vs chronic tension headaches

180 days/year (chronic)


Initial medical therapy for tension headaches and second line

aspirin, ,acetaminophen, NSAIDS

second line - combo analgesics containing caffeine


presentation of cluster headache

STRICTLY UNILATERAL, usually seen in orbital, supraorbital, or temporal region
- described as deep, excruciating pain between 15 mins and 3 hours
-frequency can vary day by day (up to 8 attacks per day)
- associated with ipsilateral autonomic signs
- more prevalent in men


How are cluster headaches different from migraines?

unlike migraines, patients with cluster headaches cannot find comfortable position (sitting in dark room doesn't help)


first line treatment for cluster

100% oxygen and triptans


second line treatment for cluster

intranasal lidocaine, dihydroergotamine, prednisone, octreotide, somatostatin


organic causes/conditions that can cause headaches

uncontrolled HTN, brain metastases, infection,


What medications can cause headaches

analgesics or headache meds (ironically) via "rebound heaches" (if used frequently and then withdrawn), caffeine