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Clin Med IV - Geriatrics & Neuro > Headaches > Flashcards

Headaches Flashcards

1
Q

What quality descriptors may clue you into a migraine?

A

“Pulsating”
“Throbbing”
Lateral

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2
Q

What quality descriptors may clue you into a tension headache?

A

Tightness/pressure

Band-like

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3
Q

What quality descriptors may clue you into a neuritis headache?

A

Sharp

Lancinating

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4
Q

What quality descriptors may clue you into an intracranial lesion?

A

Dull or steady

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5
Q

What quality descriptors may clue you into a headache due to ophthalmologic disorder?

A

Pre-ocular pain

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6
Q

What quality descriptors may clue you into a migraine caused by neuralgia?

A

Localized division of trigeminal nerve

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7
Q

What 5 things do you need to ask a pt with a headache?

A
  • Quality
  • Intensity
  • Location
  • Onset/timing
  • Relation to biologic events
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8
Q

What do you mean when you ask a pt about the intensity of a headache?

A

Degree to which the pain incapacitates the patient and disrupts their quality of life

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9
Q

If a headache awakens the pt from sleep, what are 3 possibilities?

A
  • Meningitis
  • Subarachnoid hemorrhage
  • Cluster headache
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10
Q

Location of migraine headache

A

Unilateral

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11
Q

Migraine is associated with what sx’s?

A
  • N/V

- Sensitivity to light, sound, smells

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12
Q

Intracranial lesions in posterior fossa would lead to headache in what region?

A

Occipitonuchal region, lateral if one-sided lesion

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13
Q

Supratentorial lesions would lead to headache in what region?

A

Frontotemporal or approximate site of lesion

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14
Q

Onset of subarachnoid hemorrhage

A

Abrupt onset, with maximum severity in sec. or min.

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15
Q

What “thunderclap headaches” may mimic SAH?

A
  • Cerebral venous thrombosis

- Vasospasm syndromes

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16
Q

What headaches may last minutes to hours?

A
  • Migraines
  • Cluster headache
  • Intracranial tumor
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17
Q

What headache usually occurs at the same time each day/night?

A

Cluster headache

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18
Q

What headaches tend to be worse with awakening?

A

Intracranial mass

Sleep apnea

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19
Q

Which headaches tend to have more gradual onset, over several hours or days?

A
  • Meningitis

- Tension headache

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20
Q

What headaches tend to be worse at the end of the day?

A

Tension headache

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21
Q

Pharyngeal cooling is more common in what type of headache pts?

A

Migrainers

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22
Q

What might you suspect in a pt with intense headache after inactivity (e.g. sleep), where the neck is initially stiff/painful?

A

C-spine disease

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23
Q

Describe sinusitis headache

A
  • Face ache
  • Midfrontal/maxillary tenderness
  • Clock-like regularity
  • Worsens by stopping/changes in atmospheric pressure
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24
Q

Describe bursting headache

A

Initiated by alcohol, intense exercise, stooping, straining

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25
Q

What headache occurs hours to days after intense activity/stress? i.e. “weekend”/”letdown”

A

Migraine

26
Q

Allodynia is common in what headache?

A

Migraine (but could be GCA)

27
Q

Most common type of primary headache

A

Tension headache

28
Q

Presentation of tension headaches

A
  • NO photophobia, phonophobia, N/V but can worsen with stress/noise/glare
  • Band-like tightness/pressure
  • Worse at end of day
29
Q

What should also be on your differential if you are considering tension h/a in an elderly pt?

A

GCA

30
Q

What findings would make you more suspicious of GCA than tension h/a in elderly pt?

A
  • Elevated ESR (>65)
  • Transient visual loss/changes
  • Jaw claudication
31
Q

Dx tension headache

A
  • At least 10 episodes but <180/yr or <15/mo
  • Lasts 30min to 7 days
  • At least 2:
    •Pressing/tightening but not pulsating quality
    •Mild to moderate intensity (nonprohibitive)
    •Bilateral
    •No aggravation from normal ADLs
  • NO N/V
  • NO photo/phonophobia or just one
32
Q

Dx chronic tension-type headache

A

≤ 15 days/month for at least 6 months

33
Q

Tx tension headache

A
  • Treat comorbid anxiety or depression
  • Behavioral therapy
  • Relaxation training
  • Massage
34
Q

Most common presenting headache

A

Migraine

35
Q

Presentation of migraine

A
  • Triggered by environmental or physical stimuli

- Many pts experience aura

36
Q

2 types of migraines

A
  • Migraine with aura

- Migraine without aura

37
Q

Dx migraine with aura

A
  • 5+ attacks that last 4-72 hrs
  • At least 2:
    •Unilateral
    •Pulsating
    •Moderate-severe (interferes with ADLs)
    •Aggravated by stairs
  • During headache, at least 1:
    •Nausea and/or vomiting
    •Photo and phonophobia
38
Q

Dx migraine with aura

A

2+ attacks with at least 3 w/ no underlying disorder

  • Fully reversible aura sx’s
  • Aura developing gradually >4 min. or 2+ in succession
  • Aura doesn’t last >60 min
  • H/A <60 min. after aura
39
Q

Tx migraine

A
  • During acute attacks, rest in dark/quiet room + simple analgesic
  • Triptans (may be better with naproxen)
  • Cafergot
  • Prochlorperazine
  • Metoclopramide (Reglan)
  • Butalbital-containing analgesics
40
Q

What dosage forms do triptans come in?

A

SC
PO
Intranasal

41
Q

Common side effects of triptans

A

Nausea, vomiting

42
Q

AVOID triptans in these pts (5). Why?

A

Triptans cause vasoconstriction, esp. in cranial vessels

  • Hemiplegic
  • Basilar artery migraine
  • Uncontrolled HTN
  • Risk factors for stroke
  • Coronary or peripheral vascular disease
43
Q

Dosage forms of cafergot

A

IV or suppository

44
Q

Avoid cafergot in these pts

A
  • Pregnancy
  • CVD
  • CYP3A4 inhibitors (supratherapeutic)
45
Q

Caution with butalbital-containing analgesics. Why?

A

Habit forming

Rebound h/a

46
Q

When is preventative therapy indicated for migraines?

A

> 2-3/month

47
Q

Preventative therapy for migraines

A
  • Avoid ppt factors (homeostatic imbalances)
  • Diary to identify triggers
  • Rx ppx with triptans
  • Botulism toxin
  • Acupuncture
  • Neurostimulation
48
Q

Presentation of cluster headaches

A
  • Unilateral
  • Lasts 1-2 hrs
  • Associated ipsilateral autonomic signs (tearing, miosis, ptosis, rhinorrhea)
  • Deep, usually retro-orbital nonfluctuating pain
  • NO focal neuro signs
  • Daily at same time***
49
Q

Dx cluster headaches

A
  • 5+ attacks
  • At least every other day
  • Severe unilateral periorbital and/or temporal pain, last 15-180 min. untreated
  • At least 1, ipsilateral to pain side:
    •Lacrimation
    •Nasal congestion
    •Rhinorrhea
    •Forehead/facial sweating
    •Miosis
    •Ptosis
    •Eyelid edema
50
Q

Tx cluster headache

A
  • SC or intranasal sumatriptan (PO ineffective)
  • 100% O2 via non-rebreather
  • Zolmitriptan nasal spray
  • Dihydroergotamine IM or IV
  • Viscous lidocaine intranasal
51
Q

Ppx for cluster headache

A
  • Lithium carbonate
  • Verapamil (monitor PR interval)
  • Topiramate
52
Q

Dx post-traumatic headache

A
  • 1 day to 1 week after injury

- Can be accompanied by N/V, scintillating scotomas

53
Q

Presentation of intracranial mass lesions

A

Headaches worsen when supine, awaken at night, peak in AM

54
Q

When should you be concerned about a headache (i.e. needs further investigation)?

A
  • New or worsening in mid-life (need CT)

- Signs of cerebral dysfunction or increased ICP

55
Q

What neurologic conditions can cause headache?

A
  • Cerebrovascular disease
  • Internal carotid artery occlusion
  • Carotid dissection
  • S/p carotid endarectomy
  • SAH
  • Meningitis
  • S/p LP
56
Q

When to refer headache pt for urgent evaluation (5-ish)

A
  • Thunderclap onset
  • Refractory to simple measures
  • Trauma, HTN, fever, visual changes
  • Neuro signs
  • Scalp tenderness
57
Q

Presentation of psuedotumor cerebri

A
  • Diffuse headache
  • Papilledema
  • CSF >250mm H2O
  • Sx’s of increased ICP
  • No localizing sx’s
  • Nonspecific or normal imaging
58
Q

Imaging for pseudotumor cerebri

A

CT to differentiate from space-occupying intracerebral mass - CT will be normal or nonspecific

59
Q

Tx pseudotumor cerebri

A
  • Repetitive LPs
  • Acetazolamide
  • Thiazide diuretics
  • Corticosteroid for visual complaints
  • Surgery: lumbar-peritoneal shunting, optic nerve sheath decompression
60
Q

Population most at risk for psuedotumor cerebri

A

Obese women, esp. in 20s

61
Q

Tx post-herpetic neuralgia

A
  • Anticonvulsants (carbamazepine, oxcarbazepine)
  • Gabapentin
  • Antispasmodic agents alone or w/ anticonvulsant
  • Botox injection
  • Surgery (microvascular decompression)
  • Brain stereotactic radiosurgery
  • Glycerol injection
  • Balloon compression

Clin Med IV - Geriatrics & Neuro (2 decks)

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