Flashcards in Neurology: Headache and Migraine Deck (34):
What are the criteria for the International Headache Society (IHS) for migraines without aura (common migraine)?
5 attacks lasting 4-72 hrs.
At least two of these characteristics:
-moderate to severe intensity
-aggravated by physical activity
At least one of these symptoms:
What are the criteria for the International Headache Society (IHS) for migraines with aura (classic migraine)?
2 attacks with at least 3 of these characteristics:
-One or more reversible aura
-at least one aura symptom develops over 4 minutes
2 more symptoms develop in succession
-no aura lasting more than 1 hour
-headache follows aura
What is the most common type of aura?
Visual: scintillating scotoma, fortification spectra
In regard to migraines, what is a prodrome?
Premonitory phenomena preceding headache by hours to days
ex. mental and mood changes, stiff neck, chilled feeling, bowel changes, food craving.
What is oligemia?
Reduction in the amount of blood flow in the body.
What is the cause of the aura in migraines?
Not well defined. It is associated with the "spreading depression" or decrease in cerebral blood flow due to slowing of neuronal activity.
It is important that the actual aura is a product of the neuronal activity and NOT the ischemia.
What causes the pain in migraines?
Trigeminal nerve endings detect the oligemia and release Calcitonin Gene Related Protein (CGRP) in response. This protein is a potent vasodilator and inflammatory mediator.
The inflammation and dilation of the blood vessels causes the pain signals to be transmitted to the Trigeminal Nucleus Caudalis.
The trigmeinal nerve relays pain and general sensation from the face. Why do some migraines manifest on the back of the head and neck?
The trigeminocervical network includes innervation from C1-C3 and causes neck pain thru a referred pain mechanism.
What are differentiating factors inthe IHS classification between common migraines and tension headaches?
1. Bilateral in tension headaches
Unilateral in common migraines
2. Not aggravated by exertion in TH
Aggravated by exertion in CM
3. No nausea and vomitting in TH
Nausea and vomitting in CM
4. There isn't always photophobia or phonophobia in TH
At least 1 (phono or photo) in CM
Describe the difference between Episodic Tension type headaches and Chronic Tension type headaches.
Episodic: 6 months/year, <15 days/month
Most frequently reported trigger of migraines.
IHS criteria for tension headaches
At least two characteristics:
-pressure and tightening
-mild to moderate intensity
-not aggravated by exertion
Both of these:
-no nausea or vomitting
-with or without photophobia and phonophobia
IHS criteria for cluster headaches
5 attacks: UNILATERAL, orbital, supraorbital, temporal
-lasts 15 to 180 minutes
At least one of the following:
-forehead and facial sweating
IHS criteria for sinus headache
Secondary to acute sinusitis
Must have both:
-purulent nasal discharge
-pathological sinus finding on X-ray, CT, or MRI
How is a migraine often misdiagnosed as a sinus headache?
Migraines can manifest with nasal and ocular symptoms simlar to those found in sinus headaches. The differential is found in the treatment. If treating sinusitis does not relieve the headaches, then it is a migraine.
What type of headache is associated with pressure, throbbing, or pounding?
What type of headache is assocaited with a sharp/dull sensation?
What type of headache is associated with motion sickness?
What type of headache can be relieved if a patient stops smoking, drinking, or drug use?
What do migraines do to blood pressure?
Symptomatic treatment for migraines.
-intramuscular, oral, or sublingual "-triptans"
(5-HT agonist that causes vasoconstriction in cerebral vessels)
OTC analgesics (not taken too often)
Prophylaxis for migraines
1. Beta Blockers: propranolol
2. Calcium Channel Blocker: Verapamil
3. TCA: Amitriptyline
4. SSRI: fluoxetine
-Valproic Acid (not in pregnant women without folic acid supplements)
6. Cyproheptadine: in children
Symptomatic treatment for cluster headaches
3. IM sumatriptan
4. sphenopalatine block
5. intranasal lidocaine
Pain is so bad in these that this is the primary concern
Prophylaxis for cluster headaches
1. Stop smoking, drinking, and using drugs
5. Valproic Acid
7. Triptans or Ergots
Treatment for tension headaches.
Midrin, Fioricet, Phrenilin
Physical Therapy, Manipulation, Psychosocial counseling
Describe a Rebound Headache
1. Must occur in someone with a pirmary headache (like a migraine)
3. Relief with analgesics, sedatives, caffeine, ergots
4. Often occurs in early morning
5. Withdrawal symptoms when medication is removed BUT headache improves
6. Prophylaxis doesn't work
Treatment for rebound headaches
1. Avoid triggers, drug rehab, modify diet
2. Proper Sleep
3. Prophylaxis of primary headache once the rebound headache is controlled
What is an Intractable Migraine?
Sustained severe migraine, requires treatment for a day or more that matches the intensity. May require hospitalization if it affects vitals.
Main treatments for intractable migraines.
Rehydration, control N/V, support.
If hospitalized: IV opioids, IV morphine, Subcutaneous sumatriptan, IV ketorolac, IV hydrocotrisone
(basically the only thing that requires IV intervention)
Describe serotonin syndrome.
Reaction to drugs that can have minor or major symptoms. Can include mild increased heart rate to cardiac arrest, coma, or death.
Types of drugs that can cause serotonin syndrome.
Anti-depressants, LIthium, Parkinson medication (L-Dopa), cocaine, MDMA, sub Q sumatriptan
What are some signs and symptoms of 5HT syndrome?
hyperreflexia, myoclonus, cramping, rigidity, shivering, restlessness, opisthotonus (rigid hyperextension of whole body), trismus (chornic tension of mastication muscles)
diaphoresis (excessive sweating), hyperthermia, sinus tachycardia, flushing, diarrhea
Agitation, confusion, anxiety, insomnia, hypomania, hallucinations, lethargy
Best way to diagnose 5HT syndrome.
H and P
-try to correlate meds to the symptoms
-most tests will show up negative