Neuro 2 > Headache > Flashcards

Headache Flashcards

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1
Q

headache

A
  • Headache is one of the most common medical complaints
  • 50% of adults have recurrent headache
  • 50-75% of adults 18-65 years have had a headache in the last year
  • > 30% of these have had a migraine
  • > 90% of headaches are due to primary headache disorders
  • Namely migraine and tension-type headache
  • Headache is disabling:
  • Migraine 6th highest cause worldwide of years lost due to disability (2013)
  • Headache disorders collectively were the 3rd highest
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2
Q

anatomy of head pain

A
  • Head pain is sensed by the trigeminal
    nerve (CN V)
  • The parenchyma (tissue) of the brain
    is insensate
  • There are intra- and extra-cranial
    pain-sensitive structures
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3
Q

intracranial vs extracranial pain

A
  • Intracranial pain-sensitive structures:
  • The arteries of the circle of willis
  • Meningeal / dural arteries
  • Large veins and dural venous sinuses
  • Portions of the dura near blood vessels
  • Extracranial pain-sensitive structures
  • External carotid artery
  • Scalp and neck muscles
  • Skin and cutaneous nerves
  • Cervical nerves and nerve rots
  • Mucosa of sinuses
  • Teeth
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4
Q

primary vs secondary headache

A
  • Important distinction
  • Primary headaches have symptom-specific treatments
  • Secondary headaches are a symptom of an underlying illness
  • Secondary headaches require treatment of the underlying medical
    disorder
  • Eg. A brain tumor causing a headache – diagnosing and treating the brain
    tumor is more important than managing the headache symptoms
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5
Q

causes of headache - primary

A
  • = a headache due to an underlying headache condition
  • Primary Headache Disorders:
  • Migraine headache
  • Tension type headache
  • Cluster headache
  • Other primary headaches
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6
Q

causes of headache - secondary

A
  • A headache due to an underlying condition, attributable to…
  • Trauma or injury to the head or neck
  • Cranial or cervical vascular disorder
  • Non-vascular intracranial disorder
  • Substance or its withdrawal
  • Infection
  • Disorder of homeostasis
  • Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure
  • Psychiatric disorder
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7
Q

specific causes of secondary headaches

A
  • Cranial or cervical vascular disorder
  • TIA or stroke
  • Intracranial hemorrhage
  • Unruptured vascular malformation (aneurysm, AV malformation)
  • Arteritis (eg. Giant cell arteritis, vasculitis)
  • Carotid or vertebral artery dissection
  • Cerebral venous thrombosis
  • Reversible cerebral vasoconstriction syndrome
  • Non-vascular intracranial disorders
  • Idiopathic intracranial hypertension
  • Intracranial hypotension – CSF leak
  • Intracranial neoplasm
  • Infection
  • Intracranial infection
  • Bacterial, viral, fungal meningitis, encephalitis, abscess
  • Systemic infection
  • Disorders of Homeostasis
  • Hypertensive headache
  • Pheochromocytoma, eclampsia, hypertensive crisis
  • Hypothyroidism
  • Fasting
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8
Q

approach to headache

A
    1. Rule out serious underlying pathology and look for
      secondary causes of headache
    1. Determine the type of primary headache using the
      patient history as the primary diagnostic tool
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9
Q

headache hx - OPQRST

A
  • Onset
  • Time and mode of onset
  • Age at onset (of first headache)
  • Palliating / Provoking factors
  • Response to previous treatment
  • Headache triggers
  • Effect of activity on pain
  • Quality / Quantity
  • Burning / stabbing / tingling / squeezing / pounding / electric
  • Intensity (on a scale of 10)
  • Radiation
  • Where is the headache on the head?
  • Does it spread / shoot / radiate?
  • Symptoms– what symptoms are associated with the headache?
  • Change in vision
  • Numbness or tingling of the limbs
  • Nausea / vomiting
  • Presence of aura or prodrome
  • Timing
  • Frequency, intensity, duration of attack
  • Number of headache days per month
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10
Q

additional hx

A
  • State of general health
  • Recent trauma
  • Changes in sleep, exercise, weight, diet
  • Change in work or lifestyle due to headache (does it cause disability?)
  • Women
  • Change in birth control method
  • Effects of menstrual cycle and exogenous hormones
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11
Q

red flags - SNOOP

A

Systemic - symptoms of underlying illness
- B symptoms
- cancer, pregnancy, immunocompromised state

Neurologic S+S
- confusion, impaired altertness or LOC
- focal neuro symptoms
- papilledema, meningismus, seizures

Onset is new - (esp >40) or sudeen (thunderclap)

Other associated conditions or features
- head trauma
- illicit drug use or toxic exposures
- headache awakens from sleep
- worse with valsalve
- precipitated by cough, exertion, sexual activity

Previous headache hx with change in status
- worsening severity, increased attack frequency or new clinical features

**need further investigation - MRI or CT

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12
Q

symptoms of increased ICP

A
  • Blurring of vision on forward bending of head
  • Headaches upon waking early in the morning that improve with sitting up
  • Double vision
  • Loss of coordination and balance
  • Chronic, daily, progressively worsening headache with nausea
  • May indicate a tumor or other enlarging lesion
    • neuroimaging is recommended!
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13
Q

symptoms of intracranial hypotension

A
  • headache worse when standing
    and relieved when lying down
  • Due to a leak of CSF out of
    meninges
  • Cause by a spontaneous tear in
    the dural sheath or after a
    lumbar puncture
  • MRI findings – ‘sagging’ of the
    brain
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14
Q

symptoms of temporal arteritis

A
  • Patient >50 years
  • Unilateral temporal headache
  • Jaw claudication – pain, cramping with chewing
  • Symptoms of polymyalgia rheumatica – proximal muscle pain and weakness
  • High ESR
  • Can progress to unilateral vision loss
  • Diagnosis – temporal artery biopsy
  • But don’t wait for the biopsy – treatment with steroids can prevent blindness
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15
Q

subacrachnoid hemorrhage

A
  • ‘ Thunderclap headache’
  • = a headache that goes from
    nonexistent to 10/10 severe pain in a
    matter of seconds
  • CT scan – without contrast – look for
    blood in the subarachnoid space
  • If CT scan is negative, consider a
    lumbar puncture to look for blood
    cells in the CSF
  • Medical emergency – can lead to
    death
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16
Q

other secondary headache S+S

A
  • Glaucoma- Impaired vision or seeing halos around light
  • Pituitary mass - Visual field deficit suggesting lesion of optic pathway
  • Optic neuritis (MS) – acute, severe unilateral vision loss, eye pain
    with movement
  • Pheochromoctyoma– intermittent headaches with flushing,
    sweating, high blood pressure
  • Sleep apnea – morning headache and daytime sleepiness, snoring
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17
Q

headache during pregnancy or postpartum

A
  • Cerebral venous sinus thrombosis
  • Carotid dissection (hormone changes and straining during labour)
  • Pituitary apoplexy
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18
Q

primary headache disorders

A
  • migraines
  • tension headache
  • cluster headache
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19
Q

migraines

Study These Flashcards
A
  • Common – up to 12% of general
    population
  • Women > Men (~2.5 : 1)
  • Most common in those aged 30-39 years,
    but can occur in children or older adults
    as well
  • Tends to run in families
  • A leading cause of disability
20
Q

migraine pathophysiology

Study These Flashcards
A
    1. Cortical spreading depression
  • A self-propagating wave of neuronal and glial depolarization that spreads
    across the cortex
  • Responsible for aura symptoms
    1. Trigeminovascular system
  • Spreading depression activates the
    trigeminal pain sensory afferents
  • Activation of the trigeminovascular system
    results in a release of vasoactive
    neuropeptides
  • Substance P, calcitonin gene-related protein,
    neurokininA
  • These neuropeptides result in neurogenic
    inflammation and vasodilation
  • This results in prolonged and intensified
    pain
    1. Sensitization
  • Neurons become increasingly
    responsive to painful and non-painful
    stimulation
  • Occurs in both peripheral (trigeminal
    neurons) and central neurons
  • allodynia - sometimes the hair hurts for ex
21
Q

migraine clinical features

Study These Flashcards
A
  • A disorder of recurrent attacks
  • Each attack has four phases:
  • Prodrome
  • Aura
  • Headache
  • Postdrome
  • Not each phase is experienced by each migraineur
22
Q

migraine prodrome

Study These Flashcards
A
  • 24-48 hours prior to the attack
  • In ~75% of migraineurs
  • Increased yawning, depression,
    irritability, food cravings,
    constipation, neck stiffness
23
Q

migraine aura

Study These Flashcards
A
  • 25% of people experience one or more focal neurological symptom =
    migraine aura
  • May occur before or with the headache, or without headache at all
  • GRADUAL development (~5-20 min) of TRANSIENT symptoms (< 1 hr)
  • Positive symptoms – discharges from CNS
  • Visual – bright lines, shapes, objects
  • Auditory – tinnitus, noises, music
  • Somatosensory – burning, pain, paresthesias
  • Negative symptoms – depression of CNS
  • Loss of vision, hearing, feeling or even paralysis (hemiplegia)
24
Q

migraine headache - POUND

Study These Flashcards
A

pounding/pulsating

Photophobia/phonophobia
Onset - 4-72 hours (natural hx untreated)
Unilateral
Nausea +/- vomiting
Debilitating - mod to severe intensity, avoidance of physical activity

  • not everyone gets all features with each attack
25
migraine postdrome
* Feeling drained / exhausted * Head movement can increase pain where the headache was
26
migraine triggers
●Emotional stress (80 percent) ●Hormones in women (65 percent) ●Not eating (57 percent) ●Weather (53 percent) ●Sleep disturbances (50 percent) ●Odors (44 percent) ●Neck pain (38 percent) ●Lights (38 percent) ●Alcohol (38 percent) ●Smoke (36 percent) ●Sleeping late (32 percent) ●Heat (30 percent) ●Food (27 percent) ●Exercise (22 percent) ●Sexual activity (5 percent)
27
migraine tx
- acute abortive tx - prophylactic tx - prevent attacks
28
acute migraine tx
* Treat as soon as possible! * Harder to abort the episode once established * Caffeine, fluids and rest * General analgesics: * NSAIDs (ibuprofen), acetamoniphen * Migraine-targeted treatments: Triptans
29
triptans
* = Serotonin agonists * Inhibit release of vasoactive peptides, promote vasoconstriction, block pain pathways * MANY formulations * Sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan… * Differ in dosage, onset and duration of action, route * oral, sublingual, nasal, subcutaneous injection * Because they cause vasoconstriction, avoid in: * Hemiplegic and basilar migraine – migraines with focal motor symptoms (genetic condition - Ca channel mutation. Migraines cause hemiplegia with aura - have medical alert bracelet and can't have triptans) * History of ischemic stroke or heart disease * Uncontrolled hypertension * Pregnancy
30
prophylactic tx
* Not for every migraineur * Indicated for: * Frequent or long-lasting migraine headaches * Migraines that cause significant disability or diminished quality of life * Contraindication to or failure of acute therapies * Goals * Reduce attack frequency, severity, duration * Improve response to acute treatment * Improve function and reduce disability **8 headache days a month - should be on tx
31
prophylactic tx options
* MANY options * Should be selected based on patient factors * Classes of treatments * Beta blockers * Antidepressants * Anticonvulsants * Beta-blockers * Good for patients with hypertension and <60 years of age * Adverse effects – bronchoconstriction, dizziness, depression * Antidepressants - in patients with concomitant mood disorder * Tricicylc antidepressants (amitriyptiline etc) * useful with insomnia * Anticholinergic side effects – sedation, cognitive blunting, dry mouth, weight gain * Venlafaxine – good if concomitant fatigue * Anticonvulsants * Topiramate – good if obesity (cause weight loss) * Valproic acid – good if epilepsy
32
CGRP monoclonal antibodies
* CGRP is a neuropeptide found throughout the CNS and PNS * Involved in migraine pathogenesis * Monoclonal antibodies developed against either CGRP or its receptors * Can be self-administered subcutaneous injections (monthly or quarterly) * One is available as IV infusion * On average – 50% of patients have a 50% reduction in headache frequency – may be even greater in clinical practice (75% of patients) *very expensive and only covered for some people depending on what they tried
33
tension headache
* Most prevalent headache in the general population * Relatively ‘featureless’ headache * Ie NOT migraine * Multifactorial pathogenesis * Myofascial noniceptors * Central sensitization * Pain tolerance *tight muscles around face and neck
34
tension headache - clinical features
* “Not migraine” * Last 30 minutes to 7 days * Bilateral, pressing, non-pulsating * Mild-moderate intensity * No nausea or vomiting * No photophobia or phonophobia * Not disabling * Treatment with simple analgesics – ibuprofen, acetaminophen
35
cluster headache
* Rare * Prevalence is <1% * Affects mostly men (4:1) * Severe, unilateral headache attacks associated with autonomic symptoms
36
cluster headache - clinical features
* Severe or very severe * Unilateral – orbital, supraorbital or temporal * Comes in attacks: Lasting 15-180 minutes * Attacks can come in clusters: one every other day up to 8 per day * With ipsilateral autonomic features: * Conjunctivitis / tearing / eyelid edema * Nasal congestion / rhinorrhea * Forehead and facial sweating * Miosis and/or ptosis
37
cluster HA tx
* Acutely: * Subcutaneous sumatriptan * High flow oxygen inhalation * Preventative * Verapamil * Lithium, Topiramate
38
trigeminal neuralgia
* Incidence 5-10/100,000 * But more frequent in older population * Recurrent brief episodes of unilateral electric shock-like pains * Abrupt in onset and termination * In the distribution of one or more divisions of the trigeminal nerve
39
trigeminal neuralgia - tx
* Paroxysmal intense, sharp, stabbing pain * Last <1 second – 2 minutes * In one or more divisions of trigrminal nerve * Can be triggered (eg touching the face) * Can be associated with ‘aberrant loop’ * Artery irritating the trigeminal nerve root * Treatment: * Carbamazepine, gabapentin * Surgical decompression
40
idiopathic intracranial HTN (IIH)
* aka. Pseudotumor cerebri * clinical presentation is similar to a brain tumor: symptoms of increased ICP * Incidence is 1-2/100,000 * Higher incidence in young, obese women (ages 15-44) Key features: * Symptoms and signs of increased intracranial pressure * Elevated intracranial pressure, but normal CSF composition * No other cause of intracranial hypertension
41
idiopathic intracranial HTN - risk factors
Although ‘idiopathic’ associated with a number of risk factors: * Obesity * Medications * Tetracyclines (ie for acne) * Hypervitaminosis A * Growth hormone * Other – corticosteroids, lithium * Systemic illnesses: - many
42
IIH symptoms
* Headache * Transient visual obscurations * Precipitated by bending over, valsalva * Pulsatile tinnitus * Diplopia * Due to compression of the 6th cranial nerves * Sustained vision loss * Due to the effect of papilledema on the optic nerve
43
IIH and papilledemma
* Swelling of the optic disc * May indicate increased CSF pressure, which is transmitted to the eye along the optic nerve * Swelling of the disc causes an enlarged blind spot
44
evaluation of IIH
* Must do neuroimaging! * Rule out a brain tumor or other causes of increased ICP * Neuroimaging should also evaluate the cerebral veins and sinuses: CT or MR venogram * To rule out thrombosis of these vessels, which could also cause increased ICP * If neuroimaging is normal, must check the CSF pressure: Lumbar puncture * Also take samples for CSF analysis * (protein, cells, glucose) * Normal opening pressure is <200 mm H20
45
IIH - opthalmologic evaluation
* Essential * Visual field testing important to document the severity of optic nerve involvement and monitor response to treatment
46
IIH tx
* Principles: manage headache, prevent vision loss, reduce pressure * Lifestyle management: * Weight loss! * Medical management: * Carbonic anhydrase inhibitors: reduce the production of CSF * Acetazolamide * Topiramate (also good to treat headache and weight loss) * Surgical * Lumbar shunt * Optic nerve sheath fenestration
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