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Headaches Flashcards

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1
Q

Considerations for sudden (thunderclap) headaches

A

Subarachnoid hemorrhage
Pituitary apoplexy
Bleed into a tumor/AV malformation
Brain tumor

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2
Q

Tests for sudden headache

A

CT
MRI/MRA
Lumbare puncture

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3
Q

Considerations for headache that presents during exertion

A

Leaking cerebral aneurysm

AV malformation

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4
Q

What are the most common congenital cerebral aneurysms?

A

Anterior circulation-related (85%)

Specifically:
Anterior communicating
Middle cerebral

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5
Q

What are signs of meningeal irritation?

A 
Kernig sign (resistance to full extension of leg at knee when hip flexed)
Brudzinski sign (flexion of both hips and knees when neck flexed passively)
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6
Q

What are signs of pituitary apoplexy?

A 
Abrupt headache
Followed by:
Loss of sight
Diplopia (pituitary is right near optic chiasm)
Drowsiness
Confusion/AMA
Coma
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7
Q

What is the intracranial pressure triad?

A

Headache (frontal, parietal, or occipital)
Nausea/vomiting
Papilledema

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8
Q

Considerations and clinical approach for headaches that show an accelerating pattern

A

Brain tumor
Subdural hematoma
Medication overuse

What should be done:
MRI / MRA
Drug History / Drug Screen

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9
Q

Considerations and clinical approach for new onset headache in a patient with history of cancer or HIV

A

Meninigitis
Brain abscess (including toxoplasmosis)
Metastasis

What should be done:
MRI / MRA
LP

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10
Q

Considerations and clinical approach for new onset headache with fever, stiff neck, or rash

A 
Meningitis
Encephalitis
Lyme disease
Systemic infection
Connective tissue disease

What should be done:
MRI / MRA
LP
Blood tests (CBC, ESR, ANA, Lyme Titre)

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11
Q

What is the difference between encephalitis and meningitis?

A

Encephalitis: infection of brain substance
Meningitis: infection of spinal fluid

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12
Q

Headaches associated with high/low blood pressure

A

Hypertensive/ischemic headache

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13
Q

Course of action if the patient has nuchal rigidity on physical exam

A
  1. Rule out subarachnoid hemorrhage–immediate CT scan
  2. If normal, hospitalize and perform LP to rule out meningitis
  3. Blood in fluid–>transfer to neurologist
  4. Clear fluid–>send to lab for cell count, gram stain, glucose, protein, and culture
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14
Q

What is meningism and what is it associated with?

A

The symptoms and signs of meningitis associated with an acute febrile illness or dehydration, but no actual infection of the meninges. Work up for meningitis anyway.

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15
Q

Possible etiologies for papilledema

A
  1. Brain tumor
  2. Meningitis
  3. Idiopathic intracranial hypertension (pseudotumor cerebri)
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16
Q

What does papilledema most likely represent?

A

Increased intracranial pressure

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17
Q

What are the Big Four headaches?

A
  1. Migraine
    - -with aura
    - -without aura
    - -atypical
  2. Muscle contraction headache
    - -episodic
    - -chronic
    - -atypical
  3. Cluster headache
    - -episodic
    - -chronic
  4. Secondary headache disorders
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18
Q

Patient presents with throbbing headache and associated nausea, vomiting, photophobia, and sonophobia. Neuro exam normal. What is the most likely diagnosis?

A

Migraine

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19
Q

25 y/o male presents with headache that woke him from sleep throughout the night. States pain moves around–not focused in one place. Presents with unilateral conjunctival injection, nasal congestion, and rhinorrhea. Neuro exam relatively normal. What is the most likely diagnosis?

A

Cluster headache

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20
Q

When do cluster headaches typically occur?

A

Fall or spring
Usually nocturnal
Average frequency 1-3 in 24 hours, lasting 15 minutes-3 hours

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21
Q

If a patient prefers to be upright and moving around, as opposed to lying still, what type of headache do they likely have?

A

Cluster

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22
Q

What is the principal source of pain in cluster headaches?

A

Dilation of the internal and external carotid arteries

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23
Q

Which serum levels are increased during a period of cluster headaches?

A

Serotonin and histamine (may be allergy-related)

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24
Q

What OMT should be utilized during a cluster headache?

A

NONE, YOU DUMB SHIT

OMT can exacerbate or prolong the head pain

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25
Abortive treatment for cluster headache
100% O2 15-20 minutes Subcutaneous sumatriptan injection (6 mg) IM or IV dihydroergotamine 1.0 mg Intranasal lidocaine 4-6% drops
26
Which headache type is most similar to a cluster headache?
Chronic paroxysmal hemicrania
27
30 y/o female presents with series of acute headaches, approximately 10 episodes per day lasting 5-20 minutes. Pain localized to one side of head. Denies lacrimation, rhinorrhea, nausea or vomiting. Neuro and CT normal. What is the most likely diagnosis and course of action?
Chronic paroxysmal hemicrania Give NSAID or indomethacin
28
Which cluster headache symptoms are absent in CPH?
Symptoms of unilateral headache (lacrimation, rhinorrhea, and miosis)
29
Considerations for headache associated with nausea and vomiting
``` Migraine Cluster Brain tumor Vascular bleed Meningitis Idiopathic intracranial hypertension Encephalitis ```
30
When is the typical onset of migraines?
Puberty
31
What is the possible genetic etiology of migraines?
Associated with a locus on chromosome #19
32
What is the classic migraine?
Migraine with aura (any transient neurologic disturbance lasting 15-30 minutes preceding the headache)
33
Typical symptoms of migraine with aura
Visual: blurred, cloudy, scotomata, teichopsia, flashes of light, metamorphopsia Other: aphasia, vertigo, thick speech, tremor, unilateral numbness or weakness, auditory hallucinations, olfactory hallucinations
34
16 y/o female presents with acute on chronic headache. Complains of nausea, vomiting, and vertigo. Mother notes marked photophobia prior to onset, ending just before the headache began. CT and neuro exam otherwise normal. What is the most likely diagnosis?
Migraine with aura
35
What is scotomata?
Spots in front of the eyes
36
What is teichopsia?
A luminous appearance before the eyes, with a zig-zag, wall-like outline
37
What are the atypical migraines?
Ophthalmoplegic Hemiplegic Basilar artery
38
25 y/o male presents with headache beginning four days ago. Pain constant since onset, waxing and waning in severity. Denies nausea, vomiting, photophobia, sonophobia. Pupils unequal and reactive to light. Extraocular motions not intact. What are your differential diagnoses?
1. Ophthalmoplegic migraine (most likely) | 2. Carotid artery aneurysm (angiography or MRA to rule out)
39
What does a hemiplegic migraine mimic?
TIA (appropriate diagnostic studies must be done to rule out)
40
What does a basilar artery migraine mimic?
Wallenberg syndrome
41
What type of headache is associated with increased risk of stroke later in life?
Migraines
42
Which somatic dysfunctions are common migraine triggers?
Upper four thoracic or costal segments (often T4ERrSr or inhaled/exhaled rib 4)
43
Which OMT should be utilized during a migraine?
Indirect techniques and cranial (CV-4)
44
Which OMT should not be utilized during a migraine?
ME or HVLA
45
Level I, 1-6, migraine treatment
Non-Pharmacologic - -OMT - -Acupuncture - -Biofeedback
46
Level II, 1-6, migraine treatment
NSAIDs with or without caffeine
47
Level III, 1-6, migraine treatment
Triptans Dihydroergotamine Other Ergots
48
Level IV, 1-6, migraine treatment
Mixed analgesics | Class III opioids
49
Level II, 7-10, migraine treatment
Non-oral abortive migraine medications Antiemetic Prochlorperazine suppository
50
Level IV, 7-10, migraine treatment
IM/SC DHE | SC Sumatriptan
51
Level V, 7-10, migraine treatment
IV DHE IV/IM Neuroleptics IV/IM Corticosteroids IV/IM Opioids
52
When do rebound headaches occur?
With overuse of analgesic medications
53
What are the symptoms of hemicrania continua?
A continuous, unilateral headache that varies in intensity, waxing and waning without disappearing completely. Frequently associated with stabbing headaches. Patient may experience photophobia, phonophobia, and nausea.
54
What is the main difference between migraine and hemicrania continua?
Migraines typically last 4-24 hours. | Hemicrania continua episodes last at least one month.
55
What are the criteria for hemicrania continua from the International Headache Society?
1. Headache present for at least one month 2. Strictly unilateral headache 3. Pain has all of the following present: a. Continuous, but fluctuating b. Moderate intensity c. Lack of a precipitating mechanism 4. Absolute response to indomethacin OR one of the following autonomic features with severe pain exacerbations: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, ptosis, or eyelid edema.
56
Which headaches are exclusively responsive to indomethacin?
Hemicrania--chronic paroxysmal or continua.
57
Which medications do not work for hemicrania continua?
Triptans
58
Who is most often affected by muscle contraction headaches?
Women F:M 4:1
59
Pain characterization for muscle contraction headaches
Band-like around the head, a vise-like squeezing or just general tightness. Palpation over the involved muscles reproduces tenderness or head pain.
60
Considerations if the headache is always in EXACTLY the same place
Local disease: Sinsusitis Brain tumor AV malformation Circle of Willis aneurysm
61
Considerations if a patient over 50 presents with new onset headache
Temporal arteritis | Brain tumor
62
Physical examination for ALL patients with new onset headaches
Complete neurologic examination | Ophthalmoscopy of the retina
63
Physical examination for patients over 50 with new onset headaches
Neuro exam ESR CT or MRI
64
Most worrisome diagnoses for headache w/ fever
Meningitis or encephalitis
65
Most common diagnosis for headache w/ fever
URI
66
New onset headache w/ abnormal neuro exam. What is the most pressing etiology?
Intracranial pathology
67
If the headache is throbbing in character and associated with nausea, vomiting, photophobia, and sonophobia, and the neuro exam is normal--what is the most common cause?
Migraine
68
If the headache is accompanied by UNILATERAL conjunctival injection, nasal congestion, and rhinorrhea, and the neuro exam is normal--what is the most common cause?
Cluster headache
69
If it's not migraine or cluster, what type of headache is it most likely going to be?
Muscle contraction headache
70
What are the big things that a CT will miss?
Tumors (especially those in the posterior fossa--show up very nice on MRI) Vascular disease
71
What are the red flags for headache presentation?
``` New onset headache Abrupt onset Progressive symptoms Abnormal neurological signs Headache with exertion Change with head position Change with Valsalva maneuver, such as cough, sneeze, strain Symptoms consistent with a trigeminal autonomic cephalalgia (TAC) diagnosis ```
72
Typical age of onset for cluster headaches
20-30
73
What are the symptoms of Horner syndrome? What headache is it associated with?
``` Ptosis, miosis, anhydrosis, flushing Cluster headache (except anhydrosis-sweating instead) ```
74
How does Horner syndrome present in patients with cluster headaches?
Partially... Ptosis Miosis Flushing NO anhydrosis-sweating instead

OMM headaches&shit (5 decks)

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