Headache - Lubeck

Front 1

Most common complaint in people dissatisfied with their doc

Back 1

Chronic headaches

Front 2

Most important aspect of evaulation of pt with h/as

Back 2

History
(physical exam is usually unrevealing)

Front 3

Pain sensitive structures (6)

Back 3

- Intracranial arteries (esp around meninges)
- Dura
- Scalp vessels
- Skin
- Muscle
- CN's

Front 4

Classification of H/A (12)

Back 4

- Migraine
- Tension h/a
- Cluster h/a
- Misc h/a unassociated w/ structural lesion
- H/a with trauma
- H/a with vascular disorder
- H/a with nonvascular intracranial disorder
- H/a w/ drugs and drug withdraw
- H/a with systemic infection (flu)
- H/a with metabolic disorders
- H/a with cranium, neck, teeth, sinuses, eye disorders
- Cranial neuralgias

Front 5

Drugs that especially are associated with h/a

Back 5

Nitrates (vasodilators)

Front 6

____ helps with h/a's associated with systemic infection b/c it decs temp which decs CBF

Back 6

Tyelenol

Front 7

aka migraine with aura

Back 7

Classic migraine

Front 8

aka migrain without aura

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Common migraine

Front 9

H/a preceded by aura or accompanied by transient neuro or visual phenomenon

Back 9

Migraine with aura (classic)

Front 10

H/a not associated with neuro disturbances or aura

Back 10

Migraine without aura (common)

Front 11

Migraine that has florid or persistent neuro deficits

Back 11

Complicated migraine

Front 12

Of 28 million migraine sufferers, ____ million are F

Back 12

21 million

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F:M migraines

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3:1

Front 14

1/___ households has a migraine sufferer

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1/4

Front 15

Migraine prevalence peaks in age _____

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25-55

Front 16

Migraine is more common than ____ and ____ combined

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Asthma and Diabetes

Front 17

About ____ of migraine sufferers remain undx

Back 17

50%

Front 18

2 common mis-dx of actual migraine sufferers

Back 18

- Tension h/a
- Sinus h/a (only acute sinusitis causes h/a though)

Front 19

Severe migraine is ranked highest (with psychosis, dementia and quadriplegia) in diability class by the

Back 19

WHO

Front 20

___% of migraine sufferers have a family hx

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60%

Front 21

50% of migraine sufferers have onset by

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2nd decade

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20% of migraine sufferes have onset

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Under age 10

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10% of migraine sufferers have onset

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After age 40

Front 24

Prodromal sx's of migraine (4)

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- Mental and mood changes --> depression and euphoria
- Sluggish, fatigue
- Anorexia
- Food cravings

Front 25

4 kinds of migraine auras

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- Scintillating scotoma
- Fortification spectra
- Paresthesia
- Vertigo

Front 26

Migraine aura
- Dot covering vision expands --> obliterates vision
- Usually unilateral

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Scintillating scotoma

Front 27

Migraine aura
- Zig zag pattern of scintillating scotoma

Back 27

Fortification spectra

Front 28

__% of migraines are unilateral

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60%

Front 29

H/A type
- Variable
- Dull and steady
- Pulsatile when severe

Back 29

Migraine

Front 30

3 kinds of phobia associated with migraine

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- Photophobia
- Phonophonia
- Osmophobia

Front 31

Associated with migraine
- strong odors make h/a worse

Back 31

Osmophobia

Front 32

Migraine is aggravated by any kind of ________

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Physical activity

Front 33

Heightened ensitivity to cutaneous stimuli on scalp
--> migraine sx

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Cephalic allodynia

Front 34

If migraine pt gets to the point where this develops, it becomes harder to tx

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Cephalic allyodynia

Front 35

Symptoms post migraine h/a (2)

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- Tender skull
- Fatigue / sluggish next day
(may need to sleep it off)

Front 36

International h/a society criteria for migraine --> need 2 of 4

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- Unilateral
- Throbbing
- Worse with mvmt
- Moderate or severe

Front 37

International h/a society criteria for migraine --> need 1/2

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- N or V
- Photophobia or Phonophobia

Front 38

Rapid screening for migraines: Y to 2/3 questions =
81% sensitivity
75% specificity

Back 38

- Nausea?
- Light bother you?
- Limits you from working, studying, etc?

Front 39

If F, migraines often occur 1-2 days before menses when have dec _______

Back 39

Estrogen

Front 40

Migraine variant
- Vertigo, tinnitus, diplopia, ataxia

Back 40

Basilar Migraine
(has sx's assoc with vertebrobasilar system)

Front 41

Migraine variant
-More common in kids
- CN 3 paralysis

Back 41

Opthalmoplegic Migraine

Front 42

Migraine variant
- Autosomal dominant inheritance
- Not a migraine until everything else is eliminated

Back 42

Hemiplegic Migraine

Front 43

More common migraine triggers (10)

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- Stress
- Menstruation
- Glare, dazzle
- Physical activity
- Sleep excess OR deprivation
- Hunger
- Head trauma
- Certain foods
- Barometric changes (snow/rain)
- Pungent odors

Front 44

50% of F with migraine and aura have ___________

Back 44

Patent foramen ovale
(if fix it, migraine gets better)

Front 45

Less common migraine triggers (8)

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- High altitude
- High humidity
- Excessive vit A
- Anemia
- Drugs (vasodilators)
- Oral contraceptives
- Reading, refractive errors
- Allergies

Front 46

Do not trigger migraine as much anymore b/c have decreased estrogen content

Back 46

Oral Contraceptives

Front 47

Foods that trigger migraine (11)

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- Cheese
- Alcohol and wine - esp darker
- Caffeine, chocolate
- Dairy
- Fermented and pickled foods
- Citrus fruits, figs, raisins
- Nitrates, Monosodium glutamate
- Artifical sweeteners
- Sulfites
- Nuts, legumes, pea pods
- Yeast products

Front 48

_____ and ____ sx's can accompany migraine attacks --> so often misdx as sinus dz

Back 48

Nasal and Ocular Sxs

Front 49

Vascular theory of migraine that has been discarded

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- Vasoconstriction --> ischemia --> aura
- Vasodilation --> inc CBF --> pain

Front 50

Vascular theory of migraine discarded b/c

Back 50

Alterations in vascular flow are not necessary to produce pain sx's

Front 51

Leao's spreading depression theory of migraine that has been abandoned

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Slow moving wave of depressed electrical activity across cortex

Front 52

Spreading oligemia theory of migraine that has been abandoned

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Spreading wave of dec CBF occurs across cortex during migraine --> indepedent of topography of cerebral arteries

Front 53

Serotonergic transmission of migraine theory

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- Platelet serotonin falls during migraine attacks
- unstable serotonergic transmission --> inc activity of raphe cells --> spreading oligemia

Front 54

Current migraine theory

Back 54

Neurogenic theory

Front 55

Neurogenic Theory of Migrain

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Primary disturbance of brain fx --> disturbance in serotonergic transmission causes change in CBF (doesn't necessarily cause pain)--> Inflm in walls of meningeal vessels --> Innervated by CN5 (most pain referred to V1)

Front 56

______________ receives afferent messages and acts as sensory relay center in brain --> get referral of pain to various areas in face

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Trigeminal nucleus caudalis

Front 57

Trigeminal Nucleus Caudalis evetnds to dorsal corn for _____ --> causes neck and posterior head pain

Back 57

C2,C3,C4

Front 58

Cranial ______ activation in migraine can result in autonomic sx's

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Parasympathetic

Front 59

CN5 nucleus lies close to ______ nucleus --> supplies sinuses and lacrimal gland --> so may cause ANS sx's

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Superior salvitory nucleus

Front 60

Migraine tx: Drug A fails --> move on to Drug B --> C etc
- Not good b/c pt loses confidence in physician

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Step therapy

Front 61

Migraine tx: Find out about h/a --> depending on severity, prescribe A or B
(most pts have already done to self with OTC meds)

Back 61

Stratified Therapy

Front 62

If treat migraine early, pts end up using ____ meds overall

Back 62

Less

Front 63

Triptans that are rapid acting migraine tx (5)

Back 63

- Sumatriptan
- Rizatriptan
- Zolmitriptan
- Almotriptan
- Eletriptan

Front 64

Triptans that are delayed acting migraine tx (2)
- Good for migraines that last days

Back 64

- Naratriptan
- Frovatriptan

Front 65

Most migraine drugs like triptans are vasoconstrictors so contraindicated with (3)

Back 65

- CAD
- CVD
- PVD
*Pt with high BP can use as long as BP is under control

Front 66

Dr. Lubeck tends to use _____ for pts with migraine and vascular contraindications

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Butalbital

Front 67

_____ = used as rescue analgesic if triptan doesn't work

Back 67

Opioids

Front 68

Migraine phase that happens 24 hrs before

Back 68

Prodrome/Premonitory
(confusion, malaise, food cravings)

Front 69

Migraine phase that happens 15-30 mins before

Back 69

Aura

Front 70

Prophlactic for migraines
- young people tolerate poorly b/c a lot of probs with exercise intolerance, fatigue, depression

Back 70

Beta blockers

Front 71

Prophlaxis
- Better for cluster h/a's than migraine

Back 71

Ca2+ blockers

Front 72

Migraine prophylaxis
- very effective
- given at night --> causes sedation
- can cause dry mouth and wt gain

Back 72

TCA's
- amitryptiline
- nortriptyline

Front 73

2 TCAs used as migraine prophlaxis

Back 73

Amitryptiline
Nortriptyline

Front 74

Migraine prophylaxis
- Not effective unless pt has major mood change with migraine

Back 74

SSRIs

Front 75

Migraine prophylaxis
- 3 anticonvulsants

Back 75

- Depikote (Valproic Acid)
- Gapapentin
- Topiramate

Front 76

NSAIDs can be used as migraine _______

Back 76

Prophylaxis

Front 77

Migraine prophylaxis anticonvulsant
- Very effective but use w/ caution --> can cause fetal malform in prego (10% risk neural tube defect)
- wt gain and tremor

Back 77

Depikote (Valproic Acid)

Front 78

Migraine prophylaxis anticonvulsant
- ADR = wt gain

Back 78

Gabapentin

Front 79

Migraine prophylaxis anticonvulsant
- ADR = wt loss, memory difficulty

Back 79

Topiramate

Front 80

- Approved by FDA in 2010 to prevent migraines occuring at least 15 days/month

Back 80

Botox

Front 81

- Injected into forehead, temporalis, trapezius, occipitalis, cervical paraspinals to prevent migraine
- $$$$$

Back 81

Botox

Front 82

Almost daily h/a
- From overuse of meds
- Sx's like migraine and tension h/a

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Rebound H/A

Front 83

Tension headache has 2/3

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- Pressure/tightening
- B/l
- Not aggravated by routine PA

Front 84

Tension headache has both of 2

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- No N/V
- No photo of phonophobia (or only 1 of)

Front 85

Tension h/a has no evidence of _____ dz

Back 85

Organic

Front 86

Episodic Tension HA is less than _______

Back 86

15days/month

Front 87

Chronic tension H/a is more than

Back 87

15days/month

Front 88

#1 misdx of those with brain tumors is ______-

Back 88

Tension h/a

Front 89

H/a type
- Has no inc in scalp muscle EMG compared to migrain

Back 89

Tension h/a

Front 90

Tension h/a and migraine co-existing in the same pt

Back 90

Mixed h/a
(probably just tension h/a is a milder migraine)

Front 91

Symptomatic Pharm tx of tension h/a

Back 91

- Similar to migraine
- Avoid daily analgesia use

Front 92

Prophylactic pharm tx of tension h/a

Back 92

Similar to migraine

Front 93

PT tx of tension headache (3)

Back 93

- OMT
- Massage
- Biofeedback

Front 94

Psychological tx is used for this only if there is an emotional problem underlying the cause of the h/a

Back 94

Tension h/a

Front 95

Trigger in a h/a prone individual can cause these 4 kinds of h/a

Back 95

- Migraine w/ aura
- Migraine w/o aura
- Tension-vascular
- Tension type

Front 96

Ex: throbbing h/a w/o vomitting but with photophobia

Back 96

Tension-vascular h/a

Front 97

M:F of Cluster h/a

Back 97

9:1

Front 98

Boring, excrutiating, throbbing unilateral pain
- Frequently around orbit

Back 98

Cluster H/A

Front 99

Cluster h/a is often assoc with (3)

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- Horner's syndrome
- Rhinorrhea
- Nasal Congestion

Front 100

Characterized by extreme restlessness during h/a

Back 100

Cluster h/a

(this distinguishes it from migraine)

Front 101

H/a triggered by alcohol

Back 101

Cluster h/a

Front 102

- 1-6 attacks/day --> frequently at night
- Duration 30-90 mins

Back 102

Cluster h/a

Front 103

Attacks occuring during certain wks to months and then remit

Back 103

Cluster h/a

Front 104

Increased levels of ______ are present in cluster h/a's

Back 104

Histamine

Front 105

Biological timeclock = in ____ of thalamus --> controls circadian rhythm --> disturbance in this may cause cluster h/a's during certain time of yr, day, etc

Back 105

Suprachiasmatic nucleus

Front 106

Cluster h/a symptomatic tx (3)

Back 106

- Ergotamine
- Injectable sumatriptan
- 100% O2

Front 107

Cluster h/a tx
- aka Imatrex
- Works really well but $$$

Back 107

Injectable sumatriptan

Front 108

Used to tx cluster h/a's
- But most insurance companies will only reimburse it for respiratory conditions

Back 108

100% O2

Front 109

Cluster h/a Prophylaxis (5)

Back 109

- Prednisone
- Valproic Acid
- Methysergide
- Lithium
- Verapamil

Front 110

Very effective for cluster h/a prophylaxis, but as taper off, h/a's return

Back 110

Prednisone

Front 111

Giant Cell Arteritis M:F

Back 111

2:1

Front 112

H/a that is rare under age 55

Back 112

Giant Cell Arteritis

Front 113

Unilateral, intense, boring pain
- Tender, non-pulsatile temporal artery

Back 113

Giant Cell Arteritis

Front 114

H/a with systemic sx's
- wt loss
- fever

Back 114

Giant Cell Arteritis

Front 115

Lab results assoc with giant cell arteritis

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Elevated ESR

Front 116

Jaw claudication is assoc with this type of h/a

Back 116

Jaw claudication

Front 117

50% with giant cell arteritis also have ______________

Back 117

Polymyalgia Rheumatica

Front 118

Giant cell arteritis - conside if 50-50 rule applies

Back 118

- Age 50+
- ESR > 50

Front 119

Need 3/5 to dx giant cell arteritis

Back 119

- Age>50
- ESR>50
- New onset localized h/a
- Non-pulsatile or tender artery
- + bx

Front 120

1/3 to 1/2 of pts with this h/a will develop blidness of untx'ed (from ischemia)

Back 120

Giant Cell Arteritis

Front 121

Pathology of giant cell arteritis = inflm of ___________

Back 121

Medium sized arteries

Front 122

Tx for giant cell arteritis (2)

Back 122

- Prednisone before bx results
- Temporal artery bx

Front 123

Sharp, shooting, lancinating pain lasting seconds to mins in distribution of CN5

Back 123

Trigeminal Neuralgia

Front 124

- Almost always unilateral
- Trigger points on face and inside mouth

Back 124

Trigeminal Neuralgia

Front 125

If under 50 and expect trigeminal neuralgia, need to r/o ____ 1st

Back 125

MS

Front 126

Trigeminal Neuralgia tx

Back 126

Carbamazepine
Surgery

Front 127

Sudden onset of worst headache ever + nucal rigidity

Back 127

Subarachnoid Hemorrhage

Front 128

With subarachnoid hemorrhage, will have CN3 palsy if it is in ___________
(dilated pupil + ptosis)

Back 128

Posterior Communicating Artery

Front 129

Dx of Subrachnoid Hemorrhage that has 90% sensitivity

Back 129

CT scan w/o contrast

Front 130

Subarachnoid Hemorrhage: If CT is (-), need to do ______

Back 130

Lumbar puncture to check for blood

Front 131

If recent blood in CSF, RBCs will not have had time to lyse and therefore will be at ______ after centrifuge

Back 131

Bottom

Front 132

If blood resided in CSF for 4hrs+ ___________

Back 132

Will get small red pellet + red supernatant = Hb in plasma (b/c RBCs have been lysed)

Front 133

Cause normal neuro exam except for signs of inc ICP
- papilledema
- H/A
- rarely CN 6 palsy

Back 133

Pseudotumor Cerebri

Front 134

Nerve with longest intracranial course so when tehre is inc ICP, it is the most likely affected as it is pressed against tentorium

Back 134

CN6

Front 135

Dx:
- Normal CT
- Lumbar puncture w/ elevated opening pressure

Back 135

Pseduotumor Cerebri

(lumbar puncture okay to do b/c there is no mass --> will not cause herniation)

Front 136

Drug etiology of pseudotumor cerebri (3)

Back 136

- Tetracycline
- Vit A
- Steroid withdraw

Front 137

Drug that causes pseudotumor cerebri --> happens In F using this to tx acne

Back 137

Tetracycline

Front 138

Endocrine abnormalities can cause pseudotumor cerebri --> most likely in ________

Back 138

Obese F with menstraul irregularities