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32 Cards in this Set
- Front
- Back
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What are the major red flags associated with headache?
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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) |
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What are the guidelines of imaging for Headache?
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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 |
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These are the most prevalent type of headaches in the general population. There are two types of these headaches: Episodic and Chronic.
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Tension-Type Headache
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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.
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Episodic Tension-Type Headache
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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.
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Chronic Tension-Type Headache
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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
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Same as episodic except number of days ≥15 days per month, for at least six months
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Chronic Tension-Type Headache
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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
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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
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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
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Migraine Headache
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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
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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
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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
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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
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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
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What is the basic TX for a migraine?
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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) |
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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 |
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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
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If you give this and the headache goes away, it is diagnostic of migraines?
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Sumatriptan (Imitrex)
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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 |
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contraindicated in patients with coronary, cerebrovascular or arterial disease as well as uncontrolled HTN
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Triptan therapy
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Avoid use with SSRIs or SNRIs as Serotonin Syndrome may occur
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Triptan therapy
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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) |
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Migraine TX
Barbiturate based |
Butalbital Combinations
Fiorinal: Aspirin, caffeine & butalbital Fiorinal with Codeine Fiorcet: Acetaminophen, caffeine & butalbital |
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Adjunctive Treatment for Migraines includes what?
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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 |
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Consider preventative treatment when migraines are occurring > ? times per month or are associated with significant disability
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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
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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
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What are precipitating factors for cluster headaches?
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ALCOHOL
Smoking Sleep Apnea |
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What shows up in the physical exam of a patient with cluster headaches?
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PE often WNL except for Horner Syndrome
Miosis Ptosis Anhidrosis |
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What is the TX for cluster headache?
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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 |
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What is the prophylactic management of cluster headache?
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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 |
