Headaches (Week 2--Charles) Flashcards Preview

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Flashcards in Headaches (Week 2--Charles) Deck (18)
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Primary vs. secondary headache

Primary: intrinsic to brain without any underlying structural, infectious, toxic/metabolic cause (migraine, tension headache, cluster headache)

Secondary: identifiable underlying cause (tumor, hemorrhage, meningitis)


Reasons to consider neuroimaging for headache

Abnormal unexplained neurological exam

Onset of headache over age 55

Associated fever

Headache with extremely abrupt onset

Headache refractory to aggressive treatment

First or "worst" headache ever experienced

Increasing frequency and/or severity of headaches

Change in headache clinical features

Headaches that don't "fit" primary headache criteria


Studies for investigating primary headaches

Space occupying lesions: brain scan, preferably MRI with contrast

Hemorrhage: brain scan, consider lumbar puncture with negative scan

Increased intracranial pressure: brain scan, lumbar puncture if scan is negative

Toxic/metabolic, inflammatory: lab studies


Does cutting brain parenchyma cause pain?


That's why you can do awake neurosurgery


Is it blood vessels (vasodilation/constriction) that cause migraine symptoms?


Dilation of blood vessels is neither necessary nor sufficient for causing migraine pain

Migraine is primarily a disorder of brain excitability

Vasodilation may occur as part of disorder but is not required for migraine pain


What can cause headache?

Lesions or electrodes in the periaqueductal grey region in the brainstem

Head pain can be evoked by stimulation of insular cortex


LIfetime cumulative incidence of migraine

43% of women have had a migraine, and 18% of men


Approach to treatment of headache patient

Diagnose patient and reassure them that they do not have a brain tumor

Identify and change exacerbating environmental factors, medications

Establish regimen for acute therapy of headache

Determine if preventive therapy is appropriate


ICHD criteria for migraine w/o aura

At least 5 attacks fulfilling the following:

Headaches lasting 4-72 hours

During headache at least one of: nausea and/or vomiting, photophobia and phonophobia

At least 2 of: unilateral location, pulsating quality, moderate or severe intensity, aggravated by physical activity


ID migraine validated screener

Has a headache limited your activities for a day or more in the last 3 months?

Are you nauseated or sick to your stomach when you have a headache?

Does light bother you when you have a headache?


Migraines can be mis-diagnosed as being what?

Sinus headache


Tension headache/cervicogenic headache


Common headache triggers

Irregular meals

Irregular caffeine, chocolate, nuts, bananas

Irregular sleep (particularly excessive sleep)

Stress or "let-down" from stress

Any combination of the above


Medications that may make migraines worse

Oral contraceptives

Hormone replacement

SSRI antidepressants

Steroids (tapering)


Benzodiadepines (maybe?)

Bone density medications (maybe?)


Acute therapy for migraine

Triptans: selective serotonin 1B/1D agonists (sumatriptan, rizatriptan, etc)

DHE nasal spray


Migraine prophylaxis drugs

Beta blockers


Ca2+ channel blockers

Serotonin uptake inhibitors

MAO inhibitors



New: valproic acid, divalproez sodium, memantine?, topiramate, BoTox


Cluster headache

Predominantly in men

"Eye pain"

Clusters of episodes with long periods of remission

Unilateral tearing/nasal discharge (autonomic phenomena)

Typically has circadian pattern, often same time each night

Therapy: short course of steroids taken early in cluster, verapamil for prevention, triptans (frovatriptan)


Tension headache

Often daily

Continuous, not in discrete episodes

Not disabling in severity

Typically worsens as day proceeds

Usually bilateral, constant

Doesn't respond to triptans


How do you treat exertional headache?


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