Neurology
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| Migraine dx criteria | ≥2 of: (Unilateral; Pulsating; Mod/ severe intensity; fx: avoidance of routine physical activity); 1 of: (N/V; Photophobia and phonophobia)
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| 5 phases of migraine | Prodrome; aura; HA; termination; postdrome
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| Severe episodic HA with cerebellar sx = | basilar migraine
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| Menstrual migraine tx | triptans given acutely; NSAIDs; OCP
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| Chronic migraine: dx | CDH ≥3 months; >8 d/mo x 3 mo;
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| Sinus HA vs migraine | sinus usu continuous (not intermittent); TTP over sinuses; tx w/ Abx
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| Chronic Daily HA dx criteria | ≥ 15 d/mo; primary or secondary (usu considered primary); ≥1 migraine/wk = RF for dev CDH
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| CTTH: | CDH meeting TTH criteria
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| NDPH: | CDH dev within 3 days of sx onset, last ≥ 3 mo
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| Medication Overuse HA = | CDH assoc w/regular overuse for >3 month of one or more acute meds; try bridge tx; initiate preventive agent as analgesic is withdrawn
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| Med overuse indicators: | Simple analgesics: >3 d/wk; Triptans/ combo analgesics: >2 d/wk; Opioids/ergotamine: >2 d/wk
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| Hemicrania continua | Daily, continuous, strictly unilateral primary HA; assoc w/ cranial autonomic features (miosis, ptosis, eyelid edema, lacrimation, nasal congestion or rhinorrhea)
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| Hemicrania continua: dx & tx | dx: responds to indomethacin
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| Paroxysmal hemicrania | ≥ 20 frequent attacks (2-30 min); Pain severe & strictly unilateral, orbital, supraorbital, or temporal; Parasymp ipsilateral activation; Responds only to indomethacin
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| SUNCT | Short-lasting; Unilateral; Neuralgiform HA, with Conjunctival injection & Tearing; rare; M>F (>50 yo)
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| SUNCT sx | burning, stabbing, throbbing; seconds to 4 min; 5-6 per hr; SBP may rise
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| Trigeminal autonomic cephalgias include: | SUNCT; cluster; trigeminal neuralgia
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| Cluster HA epidemiology | M>F (older than migraine); 20-50 yo
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| HA red flags (SNOOP) | Systemic sx; secondary RF; neuro sx; onset sudden; older pt; Progression/prior HA hx; Pattern changes. Also AM (wakes from sleep); thunderclap HA, new onset in >50 yo
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| Neuroimaging not needed when: | No focal neuro findings; Pt has stable pattern of recurrent HA; No h/o seizures
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| Consider neuroimaging when: | Neuro exam abnormal; progressively worsening HA; new persistent HA; new, rapid onset HA (thunderclap headache); HA does not respond to standard tx
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| Thunderclap HA (non-SAH) | dx after exclude SAH; peaks in 1 min, lasts 1 hr-10 days
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| Migraine tx considerations | Pt age; current health status; coexistent illnesses; migraine type. ASA 900mg / Ibu 400mg / APAP 1000mg; triptans; +/- antiemetics
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| Use LP only after: | normal CT obtained & platelet count is normal
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| LP should be performed if: | Neuroimaging is normal or suggests dz that must be dx by measuring cerebrospinal fluid (CSF) pressure, cell count, and chem; CSF with bili & oxyHgb for thunderclap & normal CT
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| Pt needs preventive med (as well as abortive) if: | >8 HA / month
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| Definition of trigger | causes HA more than 50% of the time within 24 hr
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| HA imaging guidelines | Consider MRI if HA brought on (not just aggravated) by cough; SUNCT; cluster HA; pr paroxysmal hemicrania. MRI vs CT if abnormal neuro exam. CT within 12 hr of thunderclap HA
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| Cluster HA clinical features | Episodic: 1 wk to 1 yr w/remissions between clusters of at least 1 month; Chronic: clusters last >1 yr w/remissions <1 month
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| Cluster HA sx/sx | severe, unilateral, periorbital/temporal; nasal congestion, injected conjunctiva, ipsilateral sweating; at night (wakes pt), possible Horner syndrome
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| Cluster HA tx | Abortive tx: sumatriptan 6mg SQ and 6-10L O2. Preventive: verapamil 120mg TID x2 wks, prednisone & melatonin x2 wks
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| Migraine pathology | Not 2/2 vascular dilation/constriction. Primary neuronal dysfunction w/activation of trigeminovascular system reflex, cortical spreading depression, serotonin.
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| Migraine PPx med | BB: propranolol 80-240mg/day; alt: timolol, nadolol, atenolol, metoprolol. Possibly amitriptyline, venlafaxine; antiepileptics (Tapamax PG cat D)
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| Not to be used in acute migraine: | Ergotamine
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| Adolescent female w/ HA. +FHx. Severe HA, N/V, photphobia. +/- auras (usu contra to HA) | Migraine HA
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| Male, recurrent relapsing HA. Worsened w/ EtOH, Lacrimation, salivation, rhinorrhea | Cluster HA
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| Migraine dx criteria | ≥2 of: (Unilateral; Pulsating; Mod/ severe intensity; fx: avoidance of routine physical activity); 1 of: (N/V; Photophobia & phonophobia)
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| Severe episodic HA with cerebellar sx = | basilar migraine
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| Chronic migraine: dx | chronic daily HA ≥3 months; >8 d/mo x 3 mos
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| Sinus HA vs migraine | sinus usu continuous (not intermittent); TTP over sinuses; tx w/ Abx
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| chronic daily HA | ≥ 15 d/mo; primary or secondary (usu considered primary); ≥1 migraine/wk = RF for dev chronic daily HA
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| SUNCT = | Short-lasting; Unilateral; Neuralgiform HA, with Conjunctival injection & Tearing; rare; M>F (>50 yo)
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| SUNCT sx | burning, stabbing, throbbing; seconds to 4 min; 5-6 per hr; SBP may rise
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| Cluster HA = | M>F (older than migraine); severe, unilateral, nasal congestion, injected conjunctiva, ipsilateral sweating; at night (wakes pt)
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| HA red flags (SNOOP) | Systemic sx; secondary RF; neuro sx; onset sudden; older pt; Progression/prior HA hx; Pattern changes
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| Sumatriptan: indications | migraine (abortive tx); acute tx cluster HA; Fast onset, short duration; repeat dose in 1 hr if nec; Never give IV or IM
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| Ergotamine MOA | direct sm mx vasoconstrictor
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| Beta blockers: MOA: | central/serotonergic, beta-1 mediated
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| Migraine: prophylaxis | Beta (50-60% efficacy); TCA; SSRIs; bupropion; Valpro; verapamil; NSAIDs (ST for predictable)
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| Prophylactic tx: adequate trial of tx: | 6-8 weeks
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| Menstrual migraine: Tx | NSAIDs: begin 2-7 days prior to menses, continue through last day of flow; Hormonal therapy (OCP)
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| TCA MOA | antagonism of vascular or brainstem 5-HT2
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| Tension type HA | mild-mod intensity, bilateral, nonthrobbing HA w/o other assoc features; infreq <1/mo; freq 1-14 days/mo; chronic >15 days/mo; NSAIDs & TCAs
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| cluster HA | unilateral, orbital/temporal w/tearing; Tx O2, sumatriptan, prevent w/verapamil
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| HA prevalence | cluster M>F, parox hemicrania F>M
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| HA: serious sxs | meningits (fever, HA, stiff neck: LP/bld cx); SAH (sudden onset: CT); subdural
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