Su 12 Ambulatory Medicine 1-4

Front 1

109. Cause of Tension Headaches?

Back 1

a. Unknown; may be similar to that of migraines.

Front 2

2. General characteristics of tension HAs?

Back 2

a. Usually worsens throughout the day

Front 3

3. Precipitants of Tension HA?

Back 3

1. Anxiety
2. Depression
3. Stress

Front 4

4. Characteristics of pain associated w/Tension HA (THA)?

Back 4

a. Steady, aching, “viselike”
b. Encircles entire head (tight band-like pain)
c. Usually generalized, but may be most intense around neck or back of head.
d. Can be accompanied by tender muscles (posterior cervical, temporal, frontal).
e. Tightness in posterior neck muscles.

Front 5

5. Approach to tx of tension HA?

Back 5

a. Attempt to find the causal factor.
b. Evaluate the pt for possible depression or anxiety. Stress reduction is important.

Front 6

6. Tx of mild to moderate tension HA?

Back 6

a. For mild to moderate:
1. NSAIDs
2. Acetaminophen
3. Aspirin

Front 7

7. Tx of severe Tension Has?

Back 7

a. Meds that are used for migraines may be appropriate, given the difficulty in distinguishing between these two entities.

Front 8

8. Emergency evaluation of HA?

Back 8

1. Obtain a noncontrast CT scan to first R/o any type of intracranial bleed.
2. However, small bleeds (subarachnoid haemorrhage) may be missed by CT scan, so a lumbar puncture may be necessary.

Front 9

9. Cluster Headaches?

Back 9

a. Very rare.
b. Usually occurs in middle-aged men

Front 10

10. 2 Subtypes of Cluster Headaches?

Back 10

a. Episodic cluster HA (90% of all cases)- lasts 2-3 months, w/remissions of months to years.
b. Chronic cluster HA (10% of all cases)- Lasts 1-2 yrs. Has do not remit.

Front 11

11. Presentation of Cluster Headaches?

Back 11

a. Excruciating periorbital pain (“behind the eye”)- almost always unilateral.
b. Described as a “deep, burning, searing, or stabbing pain.” Pain may be so severe that the pt may even become suicidal.
c. Accompanied by ipsilateral lacrimation, facial flushing, nasal stuffiness/discharge.
d. Usually begins a few hours after pt goes to bed and lasts for 30-90 minutes; awakens pt from sleep (but daytime cluster HAs also occur).
e. Attacks occur nightly for 2-3 months and then disappear.

Front 12

12. What makes Cluster Headaches worse?

Back 12

a. Alcohol and sleep.

Front 13

13. Tx of acute attacks of cluster headaches?

Back 13

a. Sumatriptan (Imitrex) is the DOC.
b. O2 Inhalation!
c. The combination of Sumatriptan and O2 therapy is very effective and narcotics are usually not necessary.

Front 14

14. Prophylaxis against Cluster HA?

Back 14

a. Of all HA types, cluster HAs are most responsive to prophylactic tx.
b. Offer all pts prophylactic meds.
c. Verapamil taken daily is the DOC.

Front 15

15. Alternative agents for Cluster HAs?

Back 15

a. Ergotamine
b. Methysergide
c. Lithium
d. Steroids

Front 16

16. How long do the prophylactic meds take to go into effect?

Back 16

a. 1 week- They cause resolution (or marked reduction) of the number of HAs.

Front 17

17. Migraine etiology?

Back 17

a. Inherited disorder (probably autosomal dominant w/incomplete penetrance).
b. FM>M
c. Usually 1-2/month.

Front 18

18. Pathophys of Migraines?

Back 18

a. Not clearly defined by serotonin depletion plays a major role.

Front 19

19. 4 types of migraine?

Back 19

1. Classic migraine (15%)
2. Common migraine (85%)
3. Menstrual migraine
4. Status migrainous

Front 20

20. Classic migraine?

Back 20

a. Aura is usually visual (flashing lights, scotoma, visual distortions) but can be neurologic (sensory disturbances, hemiparesis, dysphasia).

Front 21

21. Menstrual migraine?

Back 21

a. Occurs between 2 days before menstruation and the last day of menses
b. Linked to oestrogen withdrawal!

Front 22

22. Tx of Menstrual migraines?

Back 22

a. Similar to non-menstrual migraines except that oestrogen supplementation is sometimes added.

Front 23

23. Status Migrainous?

Back 23

a. Lasts over 72 hours and does not resolve spontaneously.

Front 24

24. Factors that can provoke a migraine?

Back 24

a. Hormonal alteration (menstruation)
b. Stress, anxiety
c. Lack of sleep
d. Certain foods/drugs: chocolate, cheese, alcohol, smoking, oral contraceptive pills.
e. Weather changes and other environmental factors.

Front 25

25. Prodromal phase of migraine (occurs in 30% of pts)?

Back 25

a. Consists of sx of excitation of CNS:
1. Elation
2. Excitability
3. Increased appetite and craving of certain foods (esp. sweets)
b. Alternatively, depression, irritability, sleepiness, and fatigue may be manifested.
c. May precede the actual migraine attack by up to 24 hours.

Front 26

26. Presentation of Migraine?

Back 26

a. Severe, throbbing, unilateral HA (not always on the same side).
b. Lasts 4-72 hours
c. At times, it may be generalized over the entire head and may last for days if not treated.
d. Pain is aggravated by coughing, physical activity, or bending down.
e. Variable pain quality: “throbbing” or “dull and achy”.
f. Other sx:
i. N/V (in as many as 90% of cases)
ii. Photophobia
iii. Increased sensitivity to smell.

Front 27

27. Tx of mild migraine acute attacks?

Back 27

a. NSAIDs or acetaminophen.
b. If they are not effective, try either dihydroergotamine (DHE) or a triptan).

Front 28

28. MOA of Dihydroergotamine (DHE)?

Back 28

a. 5HT-1 receptor agonist.
b. It is highly effective in terminating the pain of migraines.
c. Available for SC, IM, IV, or nasal administration.

Front 29

29. Contraindications to Dihydroergotamine (DHE)?!?!?

Back 29

a. CAD
b. Pregnancy
c. TIAs
d. PVD
e. Sepsis

Front 30

30. Sumatriptan MOA?

Back 30

a. A more selective 5-HT1 receptor agonist than DHE or other triptans.
b. Acts rapidly (w/I 1 hour) and is highly effective
c. Should not be used more than once or twice per week.