Headaches Flashcards
(98 cards)
1
Q
90% of benign headaches fall into these three categories
A
Migraine
Cluster
Tension
2
Q
What types of HA are vascular events?
A
Migraine
Cluster
3
Q
What types of HA are the result of muscle contraction?
A
Tension
4
Q
Traction HAs are the result of…
A
Organic diseases of the head such as an intracranial mass
5
Q
Inflammatory HAs can be from…
A
Meningitis, giant cell arteritis, etc
6
Q
HAs are considered primary if…
A
They occur independently of other conditions
7
Q
HAs are considered secondary if…
A
Associated with another disorder
8
Q
Most commonly diagnosed HA
A
Migraine
9
Q
Most debilitating type of HA
A
Cluster
10
Q
Most frequently occurring type of HA
A
Tension
11
Q
Less common types of HA
A
Chronic daily HA
Primary stabbing
Primary exertional
Hypnic (“alarm clock”)
12
Q
What is the most important factor in establishing a diagnosis for HA?
A
Thorough History 🙄
13
Q
What types of things do you wanna ask when taking hx for a HA patient?
A
Frequency, duration, intensity, location
Quality (dull, achy, sharp, throbbing, tight, radiating)
Time and setting of onset
Aggravating/alleviating factors (meds, light/dark, mvmt, food, drink)
Age of onset
Associated Sx: N/V, photophobia, phonophobia, focal neuro sx
PMH: trauma, previous tx, changes in presentation
FHx
SHx: alcohol, caffeine, work, life changes, diet
14
Q
What are some common dietary triggers for HAs?
A
Alcohol Chocolate Caffeine MSG Nuts Nitrates Aspartame
15
Q
What are some common hormonal triggers for HAs?
A
Menses
Ovulation
HRT (progesterone)
16
Q
What are some common sensory triggers for HAs?
A
Strong light
Flickering light
Odor
Sound
17
Q
What are some common stress triggers for HAs?
A
Intense activity
Let-down periods
Loss/change
Crisis
18
Q
What are some common environmental triggers for HAs?
A
Weather
Elevation
Time zone change
19
Q
What are some common habitual triggers for HAs?
A
Dietary changes
Sleep changes
Physical activity
20
Q
Who gets migraines more, men or women?
A
W>M 3:1
21
Q
Name that headache:
Throbbing, pulsating, typically unilateral
A
Migraine
22
Q
Name that headache:
Duration = 4-72 hours
A
Migraine
23
Q
Name that headache:
Photophobia, phonophobia, n/v
A
Migraine
24
Q
What are the different theories of pathogenesis of migraines?
A
Vascular (not really considered anymore) - pain assoc with dilation/constriction of arteries
Cortical spreading depression - wave of neuronal and glial depolarization that spreads across cerebral cortex
Central - pain mediated by unstable serotonergic neurotransmission
Neurogenic inflammation - trigeminovascular system activation w/ release of vasoactive neuropeptides
Sensitization - spontaneous neuronal activity develops as neurons increase responsiveness to stimuli
25
What are the two main types of migraine?
“Common” - migraine w/o aura
“Classic” - migraine w/ aura
26
Other types of migraines that you don’t really need to know
```
Migraine with brainstem aura
Retinal migraine
Ophthamoplegic neuropathy
Vestibular migraine
Menstrual migraine
Hemiplegic migraine
Status migrainosus
```
27
Which main type of migraine is more common?
Migraine w/o aura (“common”) - 75% of migraines
28
Name that migraine:
Occurs without warning
Common
29
Name that migraine:
Most frequent type
Common
30
Name that migraine:
Four phase migraine attack
Classic
31
Name that migraine:
Triggers often associated with HA onset
Classic
32
What are the four phases of migraine attack for classic migraines?
Prodrome 24-48 hours prior (food cravings, mood change, yawning, fluid retention, constipation, neck stiffness)
Aura prior to or concurrent with onset
Headache
Post drone (confused/exhausted)
33
What are some examples of positive aura sx for classic migraines?
Visual
Auditory
Sensory
Motor
34
What are some examples of negative aura sx for classic migraines?
```
Loss of function
Loss of vision
Loss of hearing
Loss of sensation
Loss of motor function
```
35
Describe the classic migraine headache
Builds gradually in intensity following aura
Commonly unilateral, pulsatile, or throbbing
May also experience n/v, photophobia, phonophobia
36
Abnormal pain response from things like combing hair, shaving, wearing glasses, contact lens, earrings, tight fitting clothes
Cutaneous allodynia
37
How are migraines diagnosed?
Based on Hx and PE
No imaging necessary
Follow International Classification of HA Disorders
38
Clinical scenarios that warrant imaging for a HA
“Worst HA of my life”
Changes in HA presentation
New or unexplained neuro sx
HA not responding to treatment
New onset after 50 or in pt with CA or HIV
(CT typically recommended vs MRI)
39
How do you treat an acute migraine?
Treat early with abortive meds
Decrease triggers
Rest in dark/quiet environment
Cool cloth on forehead
Fluids
Caffeine in early stages
40
First line meds for mild-moderate acute migraine
Oral NSAIDs, acetaminophen, or OTC combo (ie Excedrin, Midrin)
N/V: add antiemetic
41
First line meds for moderate-severe acute migraine
Oral Triptans or combo med with NSAID (Sumatriptan and naproxen)
N/V: SQ or nasal sumatriptan, nasal zolmitriptan, antiemetic, parenteral dihydroergotamine
42
What are the main side effects of triptans?
“Tripton Sensation”
Injection site reaction, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, malaise, feeling of warmth, paresthesias (WARN YOUR PATIENT BEFORE GIVING)
Usually resolves in 30 min
43
Contraindications for Triptans and Ergotamine
It’s a vasoconstrictor, so HTN, Hx of MI, Cerebrovascular disease, PVD
PREGNANCY (avoid triptans, absolutely NO ERGOTS)
44
Lifestyle changes to prevent migraines
Appropriate amount of sleep
Routine meal schedule
Regular exercise
Avoidance of triggers
45
Preventative migraine meds
Beta blockers: metoprolol, PROPRANOLOL***, timolol
Antidepressants: TCA (Amitriptyline***), SSRI (Venlafaxine)
Anticonvulsants: Valproate and Topiramate****
NSAIDs
Others: Coenzyme Q10, Riboflavin, Calcitonin, Botox, Feverfew, CCB, CGRP antagonists
46
Name that headache:
Bilateral, band-like pressure
Tension
47
Name that headache:
Non-throbbing, mild-moderate intensity
Tension
48
Name that headache:
Duration = 30 min to 7 days
Tension
49
Name that headache:
Associated Sx: anorexia, head/neck pain with muscle tenderness, bruxism
Tension
50
Do you get phonophobia/photophobia with tension headaches?
Nope
No N/V either
51
Triggers for tension headaches
```
Stress
Jaw clenching
Missed meals
Depression
Too little sleep
Head/neck strain
```
52
Tension headaches are considered infrequent if...
<12 days/year and lasting <1 day/month
53
Tension headaches are considered frequent if...
1-14 days/month lasting 30 min to several days
54
Tension headaches are considered chronic is...
>15/month, last hours to days, may be unremitting
55
How are tension headaches diagnosed?
Based on Hx and presentation
Imaging not needed unless unexplained abnormal neuro findings or atypical presentation
56
How are tension headaches managed?
Treat underlying cause (corrective devices for jaw/mouth, sleep study, less stress)
Acute: NSAIDs****, acetaminophen, aspirin, combo
Usually high dose, can be preemptive
Hot shower or heat to back of neck
57
Additional treatments for patients with chronic tension headaches and comorbidities (stress, anxiety, depression)
Antidepressants
Alternative therapy: biofeedback, relaxation training, meditation, CBT, massage
AVOID OPIOID/BARBITURATES - high potential for overuse headache
58
Which type of headache is more common in men?
Cluster headaches (M>F 3:1)
59
Cluster headaches are due to...
Trigeminal autonomic cephalgias (TACs)
60
Sharp, boring, unilateral, periorbital HA with autonomic sx
Cluster headache
61
Which type of headache is linked to suicide?
Cluster headaches
Excruciatingly painful
62
Duration for cluster headaches
15-180 minutes
63
Why are they called cluster headaches?
They occur every other day up to 8x/day for 6-12 weeks (a “Cluster”) then remission for up to 12+ months
64
When are cluster headaches considered chronic?
Clusters lasting >1 year or remission <1 month
65
Clinical presentation of cluster headache
Restless, paces, sits and rocks
Severe orbital, supraorbital, or temporal pain
Autonomic sx: conjunctival injection, lacrimation, eyelid edema, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis
Associated sx: similar to migraine aura
66
In cluster headaches, the autonomic sx are _______ to the pain
Ipsilateral (on the same side)
67
Triggers for cluster headaches
Alcohol, smoking, smells, stress
68
How are cluster headaches diagnosed?
Hx and clinical presentation, +/- FHx
MRI W/ AND W/O CONTRAST or plain CT with initial dx
***NEVER A CLINICAL DX****
Evaluate brain and pituitary gland to r/o potential secondary cause (ie brain lesion)
69
DDx for cluster headaches
Secondary HA
Trigeminal neuralgia
Other trigeminal autonomic cephalgias:
SUNCT, SUNA, paroxysmal hemicrania (they differ in presentation, duration, tx though)
70
Treatment for acute cluster headaches
O2 ****Nonrebreathing face mask 100% O2 at >12L/min****
• Sitting upright
• Continue x 15 min even if attack ends in less time
• Do not use in pt with severe COPD
Triptan: SQ sumatriptan, intranasal sumatriptan or zolmitriptan, oral zolmitriptan
71
Why don’t you want to treat a patient who has an acute cluster headache and COPD with 100% O2?
Risk of hypercapnia and CO2 narcosis
72
What is the best preventative treatment for cluster headaches?
CCB (Verapamil****)
Start at onset of cluster episode
Goal is to suppress attacks and minimize need for abortive meds
Other options: glucocorticoids, lithium, topiramate
73
How should you treat extreme chronic cases of cluster headaches
Electrical stimulation or glucocorticoid injections of occipital nerve
Deep brain stimulation of hypothalamus
Surgery targeting trigeminal nerve or autonomic pathways
74
Chronic daily headaches are defined as...
HA ≥ 15 days/month during 3+ months
Can be chronic migraine, chronic tension, hemicrania continua, or new daily persistent headache (NDPH)
75
Continuous, fluctuating pain on same side of face/head lasting minutes to days
Hemicrania continua
Associated sx: tearing, irritated eyes, rhinorrhea, swollen eyelids
76
Dx and Tx of Hemicrania continua
Indomethacin
77
Describe New Daily Persistent Headaches (NDPH)
Abrupt onset and does not remit
Pain ranges from mild to severe, throbbing/tightening on both sides of head
Associated sx: light/sound sensitivity
78
NDPH may occur following:
Infection, medication use, trauma, or other condition with no previous hx of HA
79
Treatment for NDPH
Muscle relaxants
Antidepressants
Anticonvulsants
80
Primary stabbing headaches are also called...
“Ice pick” or “Jabs and Jolts” headaches
81
Describe primary stabbing headache
Pain intense and strikes w/o warning, lasts 1-10 seconds
Usually around eye but may occur anywhere along trigeminal nerve
May occur anywhere from daily to yearly, often associated with other headaches
82
Treatment for primary stabbing headaches
Indomethacin or abortive meds if multiple episodes occur
83
Primary exertional headaches can be triggered by...
Coughing, sneezing, intense activity
Last minutes to days
Associated with N/V
84
How do you diagnose primary exertional headaches?
MRI/MRA to r/o vascular abnormalities
Risk increases ≥40 yo and focal neuro sx
85
Tx for primary exertional headaches
Warm-up exercises, NSAIDs, Indomethacin (prior to exercises or daily)
86
What are hypnic headaches?
Occur later in life (≥50)
Develops during sleep and awakens people at night
≥10 episodes/month lasting 15 min to 3 hours
Mild-moderate throbbing pain on both sides of head
Associated sx: nausea, photo/phonophobia
87
How do you diagnose Hypnic HA?
Imaging for new presentation MRI preferable to CT
88
Tx for hypnic HA
Caffeine at night > Indomethacin > lithium
89
Red flags for secondary headaches
```
First HA in patient over 50
Sudden intense HA w/o previous Hx of HA
Nuchal rigidity (+) Kermit/Brudzinski signs
Diplopia
Papilledema/retinal hemorrhage
Persistent/new neuro signs
Fever
Excessive BP elevation
Hx of head trauma, malignancy, coagulopathy
Change in previous HA presentation
```
90
What is the mnemonic for working up secondary HA?
SNOOP
Systemic sx/illness (HIV, CA, infection etc)
Neurologic (mass/lesion, vascular problem, SUD)
Onset sudden (SAH, mass, lesion)
Older (>50)
Previous Ha Hx (is it new?)
91
Examples of structural abnormalities —> secondary HA
Chiari malformation, syringomyelia
Septum deviation causing obstruction
TMJ dysfunction
92
Examples of cranial neuralgias —> secondary HA
Trigeminal neuralgia
Occipital neuralgia
93
HA sx that increase with cough, exertion, straining, position
Papilledema, vision loss, pulsatile tinnitus
Increased ICP without associated disease
Idiopathic intracranial hypertension (pseudotumor cerebri)
94
What are two examples of secondary headaches caused by CSF pressure
Idiopathic intracranial hypertension (pseudotumor cerebri)
Post-LP headache
95
Vascular defects that can cause secondary HA
Subarachnoid HA (“thunderclap”)
CVA (unilateral on affected side)
Temporal arteritis (elevated ESR with throbbing temporal pain and TTP)
Aneurysm
Arteriovenous malformation
96
Primary HA that develops or worsens with medication overuse, typically preceded by an episodic HA disorder
Medication Overuse Headache (MOH)
97
Which drugs are riskiest for MOH?
Opioids
Barbiturates
Aspirin/acetaminophen combos
Triptans
NSAIDs are low risk
98
When should you refer a HA patient?
```
Upon request
Provider has low comfort level with Dx
Dx is questionable
Pt does not respond to tx
Condition worsens or changes
Unable to treat as outpatient
```
