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32 Cards in this Set

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What are the major red flags associated with headache?
New onset after age 50

Rapid onset and severe intensity

Fever

Trauma

Vision Changes

HIV Infection

Current or PMH of HTN

Neurologic findings (mental status changes, motor or sensory deficits)
What are the guidelines of imaging for Headache?
Focal neurologic findings on PE

Headache after exertion, cough, sex or valsalva

Acute onset of severe headache

Headache that awakens a patient from sleep

Change in headache pattern

New onset headache in a patient over 35 years of age

New onset headache in a patient with HIV or cancer
These are the most prevalent type of headaches in the general population. There are two types of these headaches: Episodic and Chronic.
Tension-Type Headache
These occur randomly, range from <1 day per month up to 14 days per month, usually triggered by stress, anxiety, fatigue, the location is usually at the forehead, temples or back of the head and neck, symptoms include: soreness in the temples, tightening band like sensation around the head, tightness of the neck muscles.
Episodic Tension-Type Headache
These occur over 15 days per month. May be attributed to stress and fatigue but also physical and/or psychological problems or depression. Check SIGECAPS, higher incidence in women due to hormone levels, usually begin between the ages of 20-40.
Chronic Tension-Type Headache
A. At least 10 episodes fulfilling criteria B & D with number of headache days <180 per year or <15 per month
B. Headaches lasting from 30 minutes to 7 days
C. At least two of the following:
Pressing or tightening (nonpulsating) quality
Mild to moderate intensity
Bilateral location
No aggravation from walking stairs or similar routine activities
D. Both of the following
No nausea or vomiting
Photophobia & phonophobia absent, or only one is present
International Headache Society Criteria for Episodic Tension-Type Headache
Same as episodic except number of days ≥15 days per month, for at least six months
Chronic Tension-Type Headache
Abortive treatment-
Mild to Moderate
Simple Analgesics: Tylenol, Aspirin, NSAIDs
Moderate to Severe
Ketorolac (Toradol)
Muscle relaxants may alleviate spasms, if needed

Combination therapies with Barbiturates (Butalbital) or Opiods is NOT recommended for initial treatment due to associated risks of tolerance and dependency

Avoid overuse of medication
Treat underlying Depression
Treatment Tension-Type Headache
Prophylactic Medications
Amitriptyline (Elavil)
Selective Serotonin Inhibitors: Paroxetine (Paxil), Venlafaxine (Effexor), Fluoxetine (Prozac)

Relieve Stress
Smoking Reduction
Biofeedback, Relaxation Techniques
Acupuncture
Prophylactic and Other Treatments for Tension-Type Headache
a vascular type headache due to vasodilation of blood vessels innervated by the Trigeminal Nerve with release of neuropeptides from parasympathetic nerve fibers near the vessels
Migraine Headache
Wavy or jagged lines, dots or flashing lights, tunnel vision or blind spots

generally begins from five to thirty minutes before headache onset; usually fades as headache intensifies
Visual Aura
At least two of the following features:
Unilateral location
Throbbing character
Worsening pain with routine activity
Moderate to severe intensity
At least one of the following features:
Nausea and/or vomiting
Photophobia and phonophobia
International Headache Society Classification of Migraine Headache
Blindness or visual disturbances occur bilaterally which are accompanied or followed by dysarthria, disequilibrium, tinnitus, paresthesias, transient LOC or confusion

HA follows the visual disturbances and is usually occipital in location and associated with nausea and vomiting
Basilar Artery Migraine
Lateralized pain around the eye accompanied by nausea, vomiting and diplopia due to a transient Third Nerve palsy

The palsy may last longer than the orbital pain for several days or weeks
Ophthalmoplegic Migraine
Occurrence of Migraine with Aura and weakness in a person with at least one first- or second-degree relative with a similar disorder
FHMI: Mutation in the CACN1A gene on chromosome 19
FHM2: Mutation in the ATP1A2 gene on chromosome 1
Familial Hemiplegic Migraine
What is the basic TX for a migraine?
During acute attacks, patients may prefer quiet, darkened rooms
Simple Analgesics: Need to start immediately
Tylenol
Aspirin
NSAIDS
Naproxen (Anaprox), Ketorolac (Toradol)
Combination analgesics with caffeine
Acetaminophen, Aspirin & Caffeine (Excedrin Migraine)
TX for Migraines

Cause CNS depression of the central vasomotor and inflammatory centers; antagonizes serotonin
Ergotamine (Ergomar): Sublingual tabs
Dihydroergotamine mesylate (DHE) 1mg/ml: IM, IV, or Subcutaneous
Ergotamine tartrate & Caffeine (Cafergot): Tablets & suppositories
Nonselective Serotonin 5-H1 Agonists
Ergot Derivatives
Cause CNS depression of the central vasomotor and inflammatory centers; antagonizes serotonin
Ergotamine (Ergomar): Sublingual tabs
Dihydroergotamine mesylate (DHE) 1mg/ml: IM, IV, or Subcutaneous
Ergotamine tartrate & Caffeine (Cafergot): Tablets & suppositories
Ergot Derivitives for Migraine TX:

Overdose results in this: Significant Vasospasm and Encephalopathy
Vomiting, numbness, tingling, pain, cyanosis of the limbs, drowsiness, stupor or coma, convulsions
Limit to 14mg weekly
Should not be taken within 24 hours of using Triptans
Ergotism
If you give this and the headache goes away, it is diagnostic of migraines?
Sumatriptan (Imitrex)
TX for Migraines

Triptan Therapy
Affect receptors presents on cranial arteries, basilar artery & in vasculature of the dura mater mediating vasoconstriction
Selective Serotonin 5-HT1B/1D Receptor Agonists
Triptan Therapy
Affect receptors presents on cranial arteries, basilar artery & in vasculature of the dura mater mediating vasoconstriction
Sumatriptan (Imitrex): Subcutaneous Injection, Intranasal Spray, Tabs
Zolmitriptan (Zomig): Tablets and Intranasal Spray
Eletriptan (Relpax): Tabs
Rizatriptan (Maxalt): Tabs
Naratriptan (Amerge): Tabs
Almotriptan (Axert): Tabs
Frovatriptan (Frova): Tabs
contraindicated in patients with coronary, cerebrovascular or arterial disease as well as uncontrolled HTN
Triptan therapy
Avoid use with SSRIs or SNRIs as Serotonin Syndrome may occur
Triptan therapy
Migraine TX

may be needed in patients who are unable to tolerate triptans or NSAIDs
Opiods may be needed in patients who are unable to tolerate triptans or NSAIDs
Morphine
Meperidine (Demerol)
Migraine TX

Barbiturate based
Butalbital Combinations
Fiorinal: Aspirin, caffeine & butalbital
Fiorinal with Codeine
Fiorcet: Acetaminophen, caffeine & butalbital
Adjunctive Treatment for Migraines includes what?
Dopamine Antagonists
Added to NSAID, Triptan and Narcotic Regimens

Metoclopramide (Reglan)
Antiemetic and enhances gut motility
10mg PO or IV

Prochlorperazine (Compazine)
Antiemetic
10mg IM/IV or 25mg PR
Consider preventative treatment when migraines are occurring > ? times per month or are associated with significant disability
2
Headache is typically unilateral in presentation
Rarely switches sides
Pain usually starts around the eye & associated with increased tearing and eye injection
Also associated with ipsilateral nasal rhinitis
Radiation of pain to ipsilateral forehead, temple and cheek
Pain described as piercing, burning, throbbing, pulsating
Most commonly present in early morning or late at night.
Cluster Headache
A. At least 5 attacks meeting criteria B-D
B. Severe to very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated
C. At least one of the following
Ipsilateral conjunctival injection and or tearing
Ipsilateral nasal congestion and/or rhinorrhea
Ipsilateral eyelid edema
Ipsilateral forehead and facial swelling
Ipsilateral miosis and/or ptosis
Sense of restlessness or agitation
D. Attacks occur from one every other day to 8 per day
International Headache Society Classification of Cluster Headache
What are precipitating factors for cluster headaches?
ALCOHOL
Smoking
Sleep Apnea
What shows up in the physical exam of a patient with cluster headaches?
PE often WNL except for Horner Syndrome
Miosis
Ptosis
Anhidrosis
What is the TX for cluster headache?
100% Oxygen
12-15L/min for 15 minutes via non-rebreather mask
Sumatriptan (Imitrex)
SQ 6mg or Intranasal 20mg/spray
Z0lmitriptan (Zomig)
5 or 10mg Intranasal spray
Intranasal Dihydroergotamine (DHE)
0.5mg Intranasal spray
Intranasal Lidocaine
1 ml of 10% Lidocaine
What is the prophylactic management of cluster headache?
Verapamil
First line preventative medication
Obtain baseline EKG
Prednisone
60mg daily for 5 days then taper
Lithium Carbonate
Monitor plasma lithium level
Topiramate
100-400mg daily