What are “red flag signs” that warrant more thorough evaluation of headache?
- first / WORST headache
- SUDDEN ONSET
- CHANGE in pattern or intensity of headache
- hx of cancer or HIV
- associated neuro symptoms (seizure, syncope, etc)
When would a CT/MRI scan be warranted for a patient who has chronic migraine headaches?
- Change in headache pattern of onset
- new onset seizures
- focal neurologic symptoms
If a patient gets a supraorbital unilateral headache every week that last for an hour or two with associated watering of the eyes, what classification is that?
- Cluster Headache
What are the general characteristics of a cluster headache?
- Short lasting 15-180minutes
- unilateral (temporal, supraorbital, orbital)
+ Associated Parasympathetic Symptoms
– lacrimation, rhinorrhea, miosis, ptosis, etc
What can sometimes be associated with a cluster headache?
Horner Syndrome – loss of sympathetic input
- ptosis
- miosis
- lacrimation
What are the criteria for Migraine without an aura?
Must have at least 5x episodes with these characteristics
- lasting 4-72 hours
- unilateral location - pulsating
- intensity prohibits daily activities
- aggravated by movement
+++ Associated with: (at least one)
– Nausea / Vomiting / Photophobia / Phonophobia
What are the best predictors of migraine headaches?
- Nauea
- Disability
- Photophobia
- if 2/3, then there is a 96% chance of migraine diagnosis
How do you diagnosis a tension headache?
15 days per month x 3 months - fluctuating length of time - nonpulsating - mild/moderate intensity - bilateral location - doesn't change with movement \+++ Associated with: Only 1 -- Photophobia/Phonophobia -- Mild Nausea (not severe)
What are other manifestations of tension headache?
- Neck pain
- Back pain
What is a common reason believe they have a “sinus headache” (doesn’t exist)
- location
- weather as trigger
- improves with sinus medication
(that’s only because ephedrin causes constriction of vessels, which can improve headaches)
What are risk factors for chronic daily headaches that are modifiable?
- obesity
- medication overuse
- stressful life
- snoring
What are risk identifiers for daily headaches, nonmodifiable?
- Females
- Low education
- Low socioeconomic status
- Hx Head injuries
What the general pathology that causes headaches?
- Enhanced release of excritatory neurotransmitters
- Reduced amount of inhibition
- Low Mg+2
- Altered energy metabolism in brain
What are the timeline of events that lead to a headache?
- Wave of intense cortical activity
- Followed by a wave of neuronal suppression
- Wave of activity moves 2-3mm/min
- if begins in a occiptial silent area, then no aura, if working area, then aura develops first.
What are physiology associated with a development of a headache?
- influx of excitatory neurotransmitters - Glutamate
- migratory activity, followed by an increased Archadonic Acid and NO for increased blood flow due to activation of the trigeminovascular system
- Decreased descending inhibition of pain during migrate
What amino acid is required to produce Serotonin?
Tryptophan
What breaks down Serotonin and what deactivates it from the clefts?
SERT – deactivates from cleft w/ reuptake
MAO - breaks down
Where are the serotonnergic neurons located in the brain?
- Raphe Nucleus
What are the major class of drugs used to abort migraine headaches?
- Triptans
- Serotonin Receptor 1B/1D Agonists
- Promotes Vasoconstriction
What are the major mechanisms of how Triptans work?
- Inhibit release of vasoactive peptides
- Promote vasoconstriction
- Block brainstem pain pathways
- Inhibits the trigeminal nucleus caudalis
(responsible for the vasodilation)
How is the HT1B receptor responsible for the action of the Triptan?
- G-protein coupled
- Induces these changes by activating in the neuron
What are common side effects of Triptans?
- peripheral vasoconstriction
- Angina
- Dizziness/Flushing
Who should Triptans NOT be given to?
- Recent Stroke or MI
- Uncontrolled HTN
What is a 2nd line therapy for abortive migraine therapy?
Ergots – 1A Receptor Agonist
