Headache

Question 1

Which trimesters are headaches most common?

Answer 1

1st and 3rd

Question 2

Etiology of headache

Answer 2

• 1st trimester:
  
  • Hormonal changes
  • Increase in blood volume
• 3rd trimester:
  
  • Tension headaches
  • Postural changes and related muscle strain
  • Development of preeclampsia during the third trimester.

Question 3

Tension headache

Answer 3

• Most common HA type in pregnacy and non-pregnancy
• Mild-moderate intensity
• Usually bilateral
• Minimal or no associated symptoms (ie N/V, photophobia)
• Late 30 min - 7 days
• Tension behind head extending into neck, can be related to posture
• Pain usually responds to rest, massage, application of heat or ice, antiinflammatory medications, or mild tranquilizers
• Manage chronic tension HA

Question 4

2 major classification of headaches

Answer 4

• Primary
  
  • Migraine
  • Tension
  • Cluster
• Secondary: symptom of another condition
  
  • Trauma or injury
  • Cranial or cervical vascular disorder
  • Nonvascular intracranial disorder
  • Substance abuse or withdrawl
  • Infection
  • Preeclampsia

Question 5

Migraine headache

Answer 5

• Unilateral, or front of head/temple, throbbing
• N/V or photophobia
• Moderate to severe
  
  • often decrease in frequency/intensity during pregnancy, especially 2nd+3rd tri
• Lasts 4 - 72 hours
• Aggrivated by position changes, sensitive to light/sound
• May have higher risk for PEC
• 3 categories:
  • with aura - can happen 1st time in pregnancy
  • without aura
  • chronic - at least 15 days/month x 3 months
• Minority of people will have first migraine in pregnancy, usually 1st tri

*

Question 6

Migraine pathophysiology

Answer 6

Exact patho unclear

Neuronal dysfunction → decreased cortical blood flow, activation of vascular and meningeal nociceptors, and stimulation of trigeminal sensory neurons

Question 7

MIgraine pharmacologic treatment

Answer 7

• Acetaminophen
• Acetaminophen + Metoclopramide 10mg
• Acetaminophen + Codeine 30mg
• Fioricet
• Antiemetics
• Triptans
• Opioids - for severe
• Preventative therapy
  
  • Betablockers (Propranolol and Metoprolol)
• IV hydration and antiemetics
• Multitarget drug therapy is necessary in most cases for migraine relief

Question 8

Cluster Headache

Answer 8

• Less common < 1%, women < men
• Usually dx before you see them
• Repetitive HA
• Always unilateral around eye or temple, pain comes on suddenly and hits peak quickly within minutes and then gradually comes back down
• Pain deep, continuous, excruiciateing/explosive
  
  • pregnancy does not affect severity
• Can still move around tho some may be confined to bed
• 15 min – 3 hours
• Associated: red, watery eyes, stuffy nose, restless, aggitated

Question 9

Cluster headache treatment

Answer 9

• Oxygen therapy
• Sumatriptan
• Topical lidocaine – inside nostril on affected side
• Preventative therapy
  
  • Verapmil (Ca channel blocker)
  • Glucocorticoids

Question 10

Tension headache treatment

Answer 10

• Acetaminophen
• Acetaminophen 500mg + Caffeine 100mg
• Acetaminophen +Codeine 30mg
• Fioricet

Question 11

Non-pharmacologic headache treatment

Answer 11

• Regular and adequate sleep patterns
• Life style changes, relaxation techniques, CBT
• Dietary modifications
• Headache diary
• Avoiding triggers
• Massage therapy
• Acupuncture
• Magnesium supplementation
• Chiropractic
• Oxygen therapy

Question 12

HA symptomatology that requires consultation and/or immediate referral

Answer 12

S Systemic symptoms: illness or condition

• Fever

N Neurologic symptoms or abnormal signs

• Altered mental status
• Change in vision
• Seizures

O Onset is new or sudden or severe

• “worst headache of my life”

O Other associated conditions or features

• Trauma
• Illicit drug use
• Awakens from sleep

P Previous HA history with change in symptoms

• Change in characteristics, severity or features

Question 13

Preeclampsia headache

Answer 13

• Any patient after 20 weeks → always consider
• If pt have never had a HA before → 1/3 have PEC
• Diffuse, constant, throbbing, can be mild (varies, wide range of intensity)
• Associated: blurred vision, epigastric pain, edema
• Protein/cr ratio or 24 hr urine. Lab work to r/o HELLP

Question 14

Headache management

Answer 14

• VITAL SIGNS - r/o PEC
  
  • Normal with hx of HA with similar sx of the past → no need for further workup
• Non Pharmacologic treatment
• Pharmacologic treatment - tylenol surprisingly helpful especially if taken immediately after sx onset
• Educate
• Preeclamptic workup
• Consult
• Triage evaluation

Question 15

Lifestyle changes

Answer 15

• Sleep
• Exercise
• Dietary modifications (triggers: aged cheeses, saltier processed foods)
• Keep HA diary to figure out triggers
• Massage therapy effective for migraines
• Mg supplementation (400 mg q day per neuro) daily is more effective than just with sx

Question 16

Foods containing tyramine (potential HA trigger)

Answer 16

• Aged cheeses
• Canned or processed meats
• Olives
• Pickles
• Canned soups