Approach To The Patient With Headache

Front 1

What are the types of primary headaches (benign HA disorders)?

Back 1

Migraine (with or without aura)
Tension type
Cluster HA
Post-traumatic HA
Drug rebound HA

Front 2

What are secondary HA's?

Back 2

Headaches that are a sign of organic disease

Front 3

What should be asked in the headache history?

Back 3

How many types of HA's?
Frequency - previous, current, mode of increase (gradual or sudden)

Front 4

What should be asked of the headache pain?

Back 4

Intensity
Location
Duration
Impact of exertion

Front 5

What should be asked about the HA prodrome?

Back 5

Changes in energy levels, mood, appetite
Fatigue
Muscle aches
Aura

Front 6

What are some associated symptoms of HA?

Back 6

Nausea
Vomiting
Anorexia
Photophobia
Phonophobia
Diarrhea
Stuffy/runny nose
Watery eyes
Ptosis/miosis
Dizziness
Behavior - retreats to dark room, paces, rocks

Front 7

What are some triggers of HA?

Back 7

Hormones - menses, HRT, OC's
Diet - alcohol (beer/red wine), chocolate, aged cheese, MSG, aspartame, caffeine, nuts, nitrates, citrus
Stress
Environmental changes
Sensory stimuli - bright/flickering lights, odors

Front 8

What do you need to know about current and previous medications tried for HA?

Back 8

For both prophylactic and abortive therapy
Dosages
Effectiveness
Side effects

Front 9

What should be included in a good general exam for a HA patient?

Back 9

Vital signs - particularly BP/pulse (HTN can cause HA)
Cardiac status
Extracranial structures
ROM and presence of pain in C-spine

Front 10

What should be included in the neurological exam of a HA patient?

Back 10

Neck flexion
Presence of bruits over the head and neck
Optic fundi, pupils, visual fields
Thorough cranial nerve exam
Motor power in limbs
Muscle reflexes
Plantar responses
Sensory exam
Coordination
Gait

Front 11

What are signs that may indicate HA of pathological origin (secondary HA)?

Back 11

"Worst HA"
Onset of HA after age 50
Atypical HA for patient
HA with fever
Abrupt onset (max intensity in sec to min)
Subacute HA with progressive worsening over time
Drowsiness, confusion, memory impairment
Weakness, ataxia, loss of coordination
Paresthesias/sensory loss/paralysis
Abnormal medical or neurological exam

Front 12

What is included in the diagnostic evaluation for HA?

Back 12

Lab testing (appropriate for variant or atypical forms) - WSR, TSH, CBC, glucose
Neurodiagnostic tests - CT, MRI/MRA, EEG, LP, arteriogram
Other - dental, ENT, allergy evaluation

Front 13

T or F: Any patient with a worrisome history or abnormal examination needs an urgent imaging study and perhaps even an LP and possibly arteriogram.

Back 13

True

Front 14

What is the intensity, disability, age of onset, and gender ratio for a common migraine?

Back 14

Intensity: moderate to severe
Disability: inhibits or prohibits daily activities, pain aggravated by activity
Age of onset: late teens - early 20s, prevalence peaks between *35-40 years
*Gender ration: F:M = 3:1

Front 15

What is the frequency, duration, location, and description of common migraine?

Back 15

Frequency: 1-4 attack per month
Duration: 4-72 hrs, usually 12-24 hrs
Location: *unilateral or bilateral
*Description: throbbing/sharp/pressure

Front 16

What is the prodrome, postdrome, behavior, and aura for common migraine?

Back 16

Pro: Mood changes, myalgias, food cravings, sluggishness, excessive yawning
Post: fatigue, irritability, "fog"
*Behavior: retreat to dark, quiet room

Front 17

What are associated symptoms of common migraine?

Back 17

Most common: nausea, vomiting, photophobia, phonophobia
Least common: diarrhea, conjunctival injection, stuffy nose, lacrimation, miosis, ptosis

Front 18

What is classic migraine?

Back 18

Migraine with aura
Usually lasts 15-30 min, but sometimes longer
Commonly visual symptoms (eg scintillations, scotoma - often hemianopic) but can be anything neurological

Front 19

What is the intensity, disability, age of onset, and gender ratio for tension type HA?

Back 19

Intensity: mild to moderate
Disability: may inhibit but does not prohibit daily activities
Age of onset: variable, peak incidence 20-40 yrs
Gender ration: F:M = 3:2

Front 20

What is the frequency, duration, location, and description of tension-type HA?

Back 20

Frequency: episodic type (<15 days/mo) or chronic (>15 days/mo)
Duration: episodic (several hrs) or chronic (all day, waxing and waning)
Location: *bifrontal, *bioccipital, neck, shoulders, band-like
*Description: dull, aching, squeezing, pressure, no prodrome or aura

Front 21

What are analgesic rebound HAs?

Back 21

Taking analgesics every day can train the body that it is going to receive medicine so it makes more pain receptors

Front 22

What is the intensity, disability, age of onset, and gender ratio for cluster HA?

Back 22

*Intensity: severe, excruciating
Disability: prohibits daily activities
Age of onset: 20s to 50s
*Gender ratio: F:M = 1:6 (recent association with obstructive sleep apnea)

Front 23

What is the frequency, duration, location, and description of cluster HA?

Back 23

Monthly frequency: episodic (1 or more attacks/day for 6-8 wk) or chronic (several attacks/wk w/o remission)
Duration: 30 min - 2 hrs
*Location: 100% unilateral, generally orbitotemporal
Description: nonthrobbing, excruciating, sharp, boring, penetrating

Front 24

What is the prodrome, aura, behavior, and associated symptoms of cluster HA?

Back 24

Prodrome: may include brief mild burning in ipsilateral inner canthus or internal nares
Aura: none
*Behavior: frenetic, pacing, rocking
*Associated symptoms: ipsilateral ptosis, miosis, conjunctival injection, lacrimation, stuffed/runny nose

Front 25

What is used for acute treatment of migraine?

Back 25

OTC analgesics
NSAIDs
Isometheptene
Butalbital
Opioids
DHE nasal spray
Triptans (5HT1 agonists) - specific for migraine, not just pain

Front 26

What are contraindications to triptan use?

Back 26

*Documented or strong risk factors for ischemic heart disease, other CV, cerebrovascular, or peripheral vascular disease, Raynaud's syndrome, uncontrolled HTN, hemiplegic or basilar migraine, use within 24 hr of tx with ergotamines, MAOI's, or other 5HT1 agonists

Front 27

What is DHE protocol?

Back 27

Metoclopromide or prochloperazine 10 mg IV over 60 sec
Wait 5 min to allow distribution
Give DHE .5 mg IV over 60 sec, wait 3-5 min
May repear .5 mg IV if no relief, may repeat every 8 hr for short-term use
*Same contraindications as triptans
Side effects: chest pressure, anxiety, speeding or dissociation of thoughts, nausea

Front 28

What are adjunctive agents for migraines?

Back 28

Antiemetic if nausea vomiting major feature (before analgesic meds)
Sedative/hypnotic or major tranquilizer if insomnia major feature
Prednisone taper sometimes used to break cycle of prolonged migraine or several wks of frequent migraines

Front 29

What is used for preventative treatment of migraine?

Back 29

Antidepressants: TCA's, SSRI's, MAOI's
Beta-blockers
CCBs
Anticonvulsants: *valproic acid and *topiramate
Ergot alkaloids
NSAID's
Muscle relaxants
Methysergide
BOTOX injections

Front 30

What are nonprescription treatments of migraine?

Back 30

Exercise
Stop smoking
HA education
Riboflavin
Magnesurm
Biofeedback/relaxation/stress management

Front 31

What is used for acute treatment of tension HA?

Back 31

OTC analgesics
NSAID's
Opioids
Midrin

Front 32

What is preventive treatment for tension HA?

Back 32

Antidepressants: TCA's, SSRI's, MAOI's
Muscle relaxants
Anticonvulsants
BOTOX injections
Ergot alkaloids

Front 33

What is acute treatment for cluster HA?

Back 33

DHE 1 mg IM or Ergotamine 2 mg SL
Lidocaine 4% - 1ml intranasal
Narcotics
Oxygen 100% 8L/min by mask
Sumatriptan 6 mg SQ

Front 34

What is preventive treatment for cluster HA?

Back 34

CCB
Anticonvulsant
Lithium
Indomethacin
Prednisone x 10-14 days
Capsaicin .025% intranasal tid x 1 wk
Ergotamine Tartrate