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138 Cards in this Set
- Front
- Back
Most common complaint in people dissatisfied with their doc
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Chronic headaches
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Most important aspect of evaulation of pt with h/as
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History
(physical exam is usually unrevealing) |
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Pain sensitive structures (6)
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- Intracranial arteries (esp around meninges)
- Dura - Scalp vessels - Skin - Muscle - CN's |
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Classification of H/A (12)
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- 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 |
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Drugs that especially are associated with h/a
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Nitrates (vasodilators)
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____ helps with h/a's associated with systemic infection b/c it decs temp which decs CBF
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Tyelenol
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aka migraine with aura
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Classic migraine
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aka migrain without aura
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Common migraine
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H/a preceded by aura or accompanied by transient neuro or visual phenomenon
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Migraine with aura (classic)
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H/a not associated with neuro disturbances or aura
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Migraine without aura (common)
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Migraine that has florid or persistent neuro deficits
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Complicated migraine
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Of 28 million migraine sufferers, ____ million are F
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21 million
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F:M migraines
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3:1
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1/___ households has a migraine sufferer
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1/4
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Migraine prevalence peaks in age _____
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25-55
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Migraine is more common than ____ and ____ combined
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Asthma and Diabetes
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About ____ of migraine sufferers remain undx
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50%
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2 common mis-dx of actual migraine sufferers
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- Tension h/a
- Sinus h/a (only acute sinusitis causes h/a though) |
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Severe migraine is ranked highest (with psychosis, dementia and quadriplegia) in diability class by the
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WHO
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___% of migraine sufferers have a family hx
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60%
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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
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Prodromal sx's of migraine (4)
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- Mental and mood changes --> depression and euphoria
- Sluggish, fatigue - Anorexia - Food cravings |
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4 kinds of migraine auras
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- Scintillating scotoma
- Fortification spectra - Paresthesia - Vertigo |
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Migraine aura
- Dot covering vision expands --> obliterates vision - Usually unilateral |
Scintillating scotoma
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Migraine aura
- Zig zag pattern of scintillating scotoma |
Fortification spectra
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__% of migraines are unilateral
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60%
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H/A type
- Variable - Dull and steady - Pulsatile when severe |
Migraine
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3 kinds of phobia associated with migraine
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- Photophobia
- Phonophonia - Osmophobia |
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Associated with migraine
- strong odors make h/a worse |
Osmophobia
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Migraine is aggravated by any kind of ________
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Physical activity
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Heightened ensitivity to cutaneous stimuli on scalp
--> migraine sx |
Cephalic allodynia
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If migraine pt gets to the point where this develops, it becomes harder to tx
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Cephalic allyodynia
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Symptoms post migraine h/a (2)
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- Tender skull
- Fatigue / sluggish next day (may need to sleep it off) |
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International h/a society criteria for migraine --> need 2 of 4
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- Unilateral
- Throbbing - Worse with mvmt - Moderate or severe |
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International h/a society criteria for migraine --> need 1/2
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- N or V
- Photophobia or Phonophobia |
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Rapid screening for migraines: Y to 2/3 questions =
81% sensitivity 75% specificity |
- Nausea?
- Light bother you? - Limits you from working, studying, etc? |
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If F, migraines often occur 1-2 days before menses when have dec _______
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Estrogen
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Migraine variant
- Vertigo, tinnitus, diplopia, ataxia |
Basilar Migraine
(has sx's assoc with vertebrobasilar system) |
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Migraine variant
-More common in kids - CN 3 paralysis |
Opthalmoplegic Migraine
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Migraine variant
- Autosomal dominant inheritance - Not a migraine until everything else is eliminated |
Hemiplegic Migraine
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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 |
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50% of F with migraine and aura have ___________
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Patent foramen ovale
(if fix it, migraine gets better) |
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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 |
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Do not trigger migraine as much anymore b/c have decreased estrogen content
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Oral Contraceptives
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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 |
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_____ and ____ sx's can accompany migraine attacks --> so often misdx as sinus dz
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Nasal and Ocular Sxs
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Vascular theory of migraine that has been discarded
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- Vasoconstriction --> ischemia --> aura
- Vasodilation --> inc CBF --> pain |
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Vascular theory of migraine discarded b/c
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Alterations in vascular flow are not necessary to produce pain sx's
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Leao's spreading depression theory of migraine that has been abandoned
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Slow moving wave of depressed electrical activity across cortex
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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
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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 |
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Current migraine theory
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Neurogenic theory
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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)
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______________ 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
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Trigeminal Nucleus Caudalis evetnds to dorsal corn for _____ --> causes neck and posterior head pain
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C2,C3,C4
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Cranial ______ activation in migraine can result in autonomic sx's
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Parasympathetic
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CN5 nucleus lies close to ______ nucleus --> supplies sinuses and lacrimal gland --> so may cause ANS sx's
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Superior salvitory nucleus
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Migraine tx: Drug A fails --> move on to Drug B --> C etc
- Not good b/c pt loses confidence in physician |
Step therapy
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Migraine tx: Find out about h/a --> depending on severity, prescribe A or B
(most pts have already done to self with OTC meds) |
Stratified Therapy
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If treat migraine early, pts end up using ____ meds overall
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Less
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Triptans that are rapid acting migraine tx (5)
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- Sumatriptan
- Rizatriptan - Zolmitriptan - Almotriptan - Eletriptan |
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Triptans that are delayed acting migraine tx (2)
- Good for migraines that last days |
- Naratriptan
- Frovatriptan |
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Most migraine drugs like triptans are vasoconstrictors so contraindicated with (3)
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- CAD
- CVD - PVD *Pt with high BP can use as long as BP is under control |
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Dr. Lubeck tends to use _____ for pts with migraine and vascular contraindications
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Butalbital
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_____ = used as rescue analgesic if triptan doesn't work
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Opioids
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Migraine phase that happens 24 hrs before
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Prodrome/Premonitory
(confusion, malaise, food cravings) |
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Migraine phase that happens 15-30 mins before
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Aura
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Prophlactic for migraines
- young people tolerate poorly b/c a lot of probs with exercise intolerance, fatigue, depression |
Beta blockers
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Prophlaxis
- Better for cluster h/a's than migraine |
Ca2+ blockers
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Migraine prophylaxis
- very effective - given at night --> causes sedation - can cause dry mouth and wt gain |
TCA's
- amitryptiline - nortriptyline |
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2 TCAs used as migraine prophlaxis
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Amitryptiline
Nortriptyline |
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Migraine prophylaxis
- Not effective unless pt has major mood change with migraine |
SSRIs
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Migraine prophylaxis
- 3 anticonvulsants |
- Depikote (Valproic Acid)
- Gapapentin - Topiramate |
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NSAIDs can be used as migraine _______
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Prophylaxis
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Migraine prophylaxis anticonvulsant
- Very effective but use w/ caution --> can cause fetal malform in prego (10% risk neural tube defect) - wt gain and tremor |
Depikote (Valproic Acid)
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Migraine prophylaxis anticonvulsant
- ADR = wt gain |
Gabapentin
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Migraine prophylaxis anticonvulsant
- ADR = wt loss, memory difficulty |
Topiramate
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- Approved by FDA in 2010 to prevent migraines occuring at least 15 days/month
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Botox
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- Injected into forehead, temporalis, trapezius, occipitalis, cervical paraspinals to prevent migraine
- $$$$$ |
Botox
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Almost daily h/a
- From overuse of meds - Sx's like migraine and tension h/a |
Rebound H/A
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Tension headache has 2/3
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- Pressure/tightening
- B/l - Not aggravated by routine PA |
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Tension headache has both of 2
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- No N/V
- No photo of phonophobia (or only 1 of) |
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Tension h/a has no evidence of _____ dz
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Organic
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Episodic Tension HA is less than _______
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15days/month
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Chronic tension H/a is more than
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15days/month
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#1 misdx of those with brain tumors is ______-
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Tension h/a
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H/a type
- Has no inc in scalp muscle EMG compared to migrain |
Tension h/a
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Tension h/a and migraine co-existing in the same pt
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Mixed h/a
(probably just tension h/a is a milder migraine) |
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Symptomatic Pharm tx of tension h/a
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- Similar to migraine
- Avoid daily analgesia use |
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Prophylactic pharm tx of tension h/a
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Similar to migraine
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PT tx of tension headache (3)
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- OMT
- Massage - Biofeedback |
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Psychological tx is used for this only if there is an emotional problem underlying the cause of the h/a
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Tension h/a
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Trigger in a h/a prone individual can cause these 4 kinds of h/a
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- Migraine w/ aura
- Migraine w/o aura - Tension-vascular - Tension type |
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Ex: throbbing h/a w/o vomitting but with photophobia
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Tension-vascular h/a
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M:F of Cluster h/a
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9:1
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Boring, excrutiating, throbbing unilateral pain
- Frequently around orbit |
Cluster H/A
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Cluster h/a is often assoc with (3)
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- Horner's syndrome
- Rhinorrhea - Nasal Congestion |
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Characterized by extreme restlessness during h/a
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Cluster h/a
(this distinguishes it from migraine) |
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H/a triggered by alcohol
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Cluster h/a
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- 1-6 attacks/day --> frequently at night
- Duration 30-90 mins |
Cluster h/a
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Attacks occuring during certain wks to months and then remit
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Cluster h/a
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Increased levels of ______ are present in cluster h/a's
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Histamine
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Biological timeclock = in ____ of thalamus --> controls circadian rhythm --> disturbance in this may cause cluster h/a's during certain time of yr, day, etc
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Suprachiasmatic nucleus
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Cluster h/a symptomatic tx (3)
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- Ergotamine
- Injectable sumatriptan - 100% O2 |
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Cluster h/a tx
- aka Imatrex - Works really well but $$$ |
Injectable sumatriptan
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Used to tx cluster h/a's
- But most insurance companies will only reimburse it for respiratory conditions |
100% O2
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Cluster h/a Prophylaxis (5)
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- Prednisone
- Valproic Acid - Methysergide - Lithium - Verapamil |
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Very effective for cluster h/a prophylaxis, but as taper off, h/a's return
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Prednisone
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Giant Cell Arteritis M:F
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2:1
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H/a that is rare under age 55
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Giant Cell Arteritis
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Unilateral, intense, boring pain
- Tender, non-pulsatile temporal artery |
Giant Cell Arteritis
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H/a with systemic sx's
- wt loss - fever |
Giant Cell Arteritis
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Lab results assoc with giant cell arteritis
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Elevated ESR
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Jaw claudication is assoc with this type of h/a
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Jaw claudication
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50% with giant cell arteritis also have ______________
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Polymyalgia Rheumatica
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Giant cell arteritis - conside if 50-50 rule applies
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- Age 50+
- ESR > 50 |
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Need 3/5 to dx giant cell arteritis
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- Age>50
- ESR>50 - New onset localized h/a - Non-pulsatile or tender artery - + bx |
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1/3 to 1/2 of pts with this h/a will develop blidness of untx'ed (from ischemia)
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Giant Cell Arteritis
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Pathology of giant cell arteritis = inflm of ___________
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Medium sized arteries
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Tx for giant cell arteritis (2)
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- Prednisone before bx results
- Temporal artery bx |
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Sharp, shooting, lancinating pain lasting seconds to mins in distribution of CN5
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Trigeminal Neuralgia
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- Almost always unilateral
- Trigger points on face and inside mouth |
Trigeminal Neuralgia
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If under 50 and expect trigeminal neuralgia, need to r/o ____ 1st
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MS
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Trigeminal Neuralgia tx
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Carbamazepine
Surgery |
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Sudden onset of worst headache ever + nucal rigidity
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Subarachnoid Hemorrhage
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With subarachnoid hemorrhage, will have CN3 palsy if it is in ___________
(dilated pupil + ptosis) |
Posterior Communicating Artery
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Dx of Subrachnoid Hemorrhage that has 90% sensitivity
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CT scan w/o contrast
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Subarachnoid Hemorrhage: If CT is (-), need to do ______
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Lumbar puncture to check for blood
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If recent blood in CSF, RBCs will not have had time to lyse and therefore will be at ______ after centrifuge
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Bottom
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If blood resided in CSF for 4hrs+ ___________
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Will get small red pellet + red supernatant = Hb in plasma (b/c RBCs have been lysed)
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Cause normal neuro exam except for signs of inc ICP
- papilledema - H/A - rarely CN 6 palsy |
Pseudotumor Cerebri
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Nerve with longest intracranial course so when tehre is inc ICP, it is the most likely affected as it is pressed against tentorium
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CN6
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Dx:
- Normal CT - Lumbar puncture w/ elevated opening pressure |
Pseduotumor Cerebri
(lumbar puncture okay to do b/c there is no mass --> will not cause herniation) |
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Drug etiology of pseudotumor cerebri (3)
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- Tetracycline
- Vit A - Steroid withdraw |
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Drug that causes pseudotumor cerebri --> happens In F using this to tx acne
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Tetracycline
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Endocrine abnormalities can cause pseudotumor cerebri --> most likely in ________
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Obese F with menstraul irregularities
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