Headache

Question 1

2 classes

1ary vs 2ary

Answer 1

1ary EXCUSION Dx = migraine, tension, cluster HA

2nary = bleeding, NOT STROKE, hydrocephalus, meds, CO poisoning

Question 2

Path

Answer 2

1ary - don’t know

Combo of these:

• Genetics
• Triggers
• CNS pain pathways
• Med overuse

Question 3

History Most important question

Answer 3

Have you ever had like this before?

Question 4

1ary likely if:

Answer 4

• Typical HA (character)
• Ran out of meds
• Slow onset (over 10-15 minutes)

Question 5

Concerning Factors in assessment

Answer 5

• NOT Typical HA
• Worst of Life
• Onset quick
• progressively worsening daily HA = growing tumor
• Toxic appearing
• altered neuro (Focal) - consciousness change

Question 6

Time course of HA

Migraine
Tension
Cluster
Tumor

Answer 6

Migraine = regular periodic

Tension = constant (a few breaks)

Cluster= 6-8 SEVERE together in 3 week period, then nothing for months, then cluster

Tumor - growing

Question 7

Tension HA

Answer 7

Spread to neck muscles

Question 8

• 10 previous
• 30 mins - 7 days (long)
• 2 of follwing
• NO N/V
• Photophobia OR phonophobia

Dx

Answer 8

Tension

Question 9

Tension HA

Risk factors

Answer 9

• women slightly more
• lower SES
• Cause: TMJ, Stress, Analgesic overuse, Depression

Question 10

Tension HA

Tx

Answer 10

• NSAIDs/Acetamenophen
• combo products w/ caffeine
• Trigger ID
• Heat, warm, bath, muscle relaxants
• PT
• severe = anti-emetics, barbituates, opiates
• Treat depression (also CSD - serotonin action)

Question 11

Tension headache

Chronic Daily Headache

Cause

Answer 11

• 2ndary to med overuse
• depression
• PTSD
• Hx sexual abuse

Question 12

Tension headache

Chronic Daily Headache

Tx

Answer 12

• underlying issue
• wean off meds - support with ADD
• psycotherapy, cognitive therapy

*healthy lifestyle

Question 13

• unilateral, throbbing, behind eye
• w/. Or w/o aura
  
  • visual/taste + smell/depression out of nowhere
• N/V
• photophobia, phonophobia
• want to NOT MOVE, NO SOUND/LIGHT

S/s

Answer 13

Migraine

Question 14

Migraine

Who?

Answer 14

*more women
(“Menstrual migraines”)
*heredity
*impairs life function

Question 15

Aura types

Answer 15

Scotoma

Fortification spectra

Question 16

Classic Migraine

Answer 16

• aura
• focal neuro deficits
• N/V

Question 17

Common Migraine

Answer 17

NO aura

No focal neuro definitions

Question 18

Migraine

Tx

Answer 18

*Triptans (BEST)
*ergots
Right at beginning
WATCH w/ Vascular problems = Rx vasoconstricts

• anti-emetics
• Steroids
• opiates = rebound HA possible!!

Question 19

Acute Migraine

Tx

Answer 19

1st line = Triptans
*5HT1 ags = vasoconstrict

• ASA, tylenol, NSAIDS
• usually tried something b/f
• steriods, opiates

Question 20

Migraine Triggers

Answer 20

Caffeine
Foods
Strong scents
Change in weather
SLEEP HYGIENE
Mood
stress 
Meds
Period

Question 21

Cluster HA

Tx

Answer 21

• High flow O2
• abortive Tx (triptan, ergotamines)
• opiates
• steroid = break cluster cycle

Question 22

Cluster HA

Prevention

Answer 22

1st line = CCB (verapamil)

• lithium (but S.E.)
• NO BBlocker = not like migraine

Question 23

Subarachnoid Hemorrhage

Ateriorvenous Malformation (AVM)

Answer 23

Venous + artery hooked together w/o capillary = too much pressure to veins (stretch, rupture)

Question 24

Aneruysm

cause?

Answer 24

Congenital, HTN

Question 25

Sub-arachnoid Hemorrhage if Normal CT...

Answer 25

Can diffuse out over CSF w/ time *LP! Patient waits too long b/f coming in

Question 26

If suspect Sub-arach hemorrhage or Meningitis... CT +...

Answer 26

LP! * SAH = xanthochromia * Meningitis = up protein, down glucose

Question 27

Aneurysm treatment Clipping vs. coiling

Answer 27

Coiling = don't need to dig thru brain tissue to get at circle of willis But must have neck (not bell curve)

Question 28

2ndary HA common causes

Answer 28

``` Dehydration CO Sinusitis Otitis Acute Glaucoma Influenza Toxins Concussion ```

Question 29

* bilateral * non-throbbing * slow onset * NO N/V * NO Photo/phonophobia * NO focal neuro signs * wants rest * "stress"/"bad nerves" S/s

Answer 29

Tension HA

Question 30

Tension HA Prevention

Answer 30

* stress management | * healthy lifestyle

Question 31

Chronic Daily Headache Possible other path/causes

Answer 31

* Tumor * CSF leak * COPD * Thyroid conditions * HTN * Sleep apnea

Question 32

Migraine Initiation of Prophylaxis guidlines

Answer 32

6+ per month - DEFINITELY 2+ w/ severe impairment - CONSIDER (Others)

Question 33

Migraine Prophylaxis Rx

Answer 33

Level A = * BBlocker (Propranolol, Metoprolol) * Anti-convulsants (Divalproex sodium, Valproate, Topiramate) Level B = * ADD (amitriptyline, Venlafaxine) * BBlocker

Question 34

* Intermittent HA * Men * Unilateral * Unilateral rhinorrhea/lacrimation * maybe unilateral ptosis/myosis s/s?

Answer 34

Cluster HA *rare

Question 35

Cluster HA Path

Answer 35

* unknown * hypothalamic * trigeminal pain pathways

Question 36

* quick onset * eye/temple pain * unilateral w/ lacrimation/rhinorrhea * no other focal signs * restless, pacing patient S/s?

Answer 36

Cluster HA

Question 37

Cluster HA looks like what else?

Answer 37

Sub-Arachnoid Hemorrhage RULE OUT

Question 38

* "worst HA of life" * N/V * nuchal rigidity * Photophobia * "Sentinal bleed" = Hx of recent severe headache that resolved Present?

Answer 38

Sub-arachnoid hemorrhage

Question 39

Subarachnoid Hemorrhage CT

Answer 39

* Fresh blood | * NO common vascular distribution

Question 40

What if HA, then normal CT, but still S/s? *Motor weakness, aphasia, dysartria, droop?

Answer 40

Early ischemic stroke

Question 41

What if HA, then normal CT, but still S/s? *Acute onset HA, vomiting, photophobia, nuchal rigidity

Answer 41

SAH possible

Question 42

What if HA, then normal CT, but still S/s? *Fever, infx exposure, nuchal rigidity?

Answer 42

Meningitis possible

Question 43

Sub-Arach Hemorrhage Tx

Answer 43

* Neurosurgeon evaluation * Large bleeds - surgical decompression * Avoid UP ICP = anti-emetics * Manage HTN (rebleed) * Nimodipine = DOWN vasospasm

Question 44

Can we do LP for epidural or subdural hemorrhage?

Answer 44

NO *not in subarachnoid space

Question 45

AVM Tx

Answer 45

Excision | Cauterization

Question 46

Aneurysm Tx

Answer 46

* small = watch + wait | * clip/coil