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Headache & Pain

Headache & Pain Headache & Pain
Tension headache pathophysiology Abnormal myofacial nociception
HA -- bL pressure/tight, no change with exercise Tension HA
HA -- daily HA x3mo Chronic daily HA. Must be >15 days /month for >3 months
HA -- new-onset HA that recurrs daily without any hx New daily persistent HA
New daily persistent HA treatment TCAs are better than NSAIDs
Medication/opiod withdrawal HA timing Must be on daily opiods for >3 months. HA must occur <24hrs after last opiod dose
HA only with exercise/sex Primary exertional HA. Tx w/ indomethacin/propanolol before exercise
Primary exertional HA treatment Indomethacin/propanolol before exercise
Migraine gene association KCNK18. Hemipleic migraines a/w CACNA1A or ATP1A2 or SCN1A
Migraine criteria >5 attacks, each 1-72 hours, often uL, throbbing, worse w/ exercise, n/v, photo/phonophobia
Migraine vs Tension HA changes w/ activity Migraines worse w/ exercise. Tension HA better or no change w/ exercise
Migraine triggers Wine, MSG, cheese, sleep deprivation, stress
Migraine and stroke Migraines a/w stroke, but primarily in females <45yo who smoke or use OCPs
Migraine pathophysiology Trigger -> /\glutamate -> spreading depol -> meninges dilation -> vasoactive cGRP/PGE/substP
Menstrual migrane 1-4 days around menses, improves w/ estrogen OCP or pregnancy
Migraine -- acute treatments Fluids, antiemetics, diphenhydramine, NSAIDs, ketorlac, VPA, steroids, triptans, ergots
Migraine -- prophylactic treatments Propanolol, CCBs (verapamil), TCAs (amytriptyline), VPA, TPX, Emgality (galcanezumab)
Migraine -- when to start prophylactic treatments Approximately if 2 or more migraine attacks per week
Migraine -- Status migrainosus protocol Fluids+antiemetics+diphenhydramine -> NSAID/ketorlac -> VPA load -> steroid load -> DHE
Why is diphenhydramine part of migraine protocol? To prevent akathesia and acute dystonic reactions from the high-dose antiemetic
Migraine treatment in pregnancy Ropivocaine, occipital block. NO opiods, triptans or ergots
Which antiemetic to use in migraine treatment? Metoclopramide, chlorpromazine, procloperazine. Odansetron doesn't work
Who gets IIH? Female, fat, forty, fertile
IIH associated with which vitamin toxicity? Vitamin A toxicity. (Not deficiency - do not administer Vitamin A as treatment for IIH)
HA -- constant, throbbing, worse w/ valsalva/lying down High ICP headache. Consider tumors, mass lesions, IIH
IIH testing MUST get MRI and MRV to rule out cerebral venous sinus thrombus (frequent missed diagnosis)
IIH -- treatment Wt loss, acetazolamide, repeat LPs, shunt, CN2 fenestration
HA -- 70yo, transient blindness in one eye Amaurosis fugax. Diagnosis is giant cell arteritis
HA -- 70yo, temporal, unilateral, jaw claudication Giant cell arteritis. Can also present with amaurosis fugax
Giant cell arteritis treatment High dose steroids immediately (don't wait for biopsy confirmation), Tocelizumab (IL-6 antag)
Most senstive test for giant cell arteritis ESR. If ESR normal = very unlikely to be GCA
Tocelizumab -- mechanism IL-6 antagonism
Tocelizumab -- use Giant cell arteritis
Giant cell arteritis association A/w polymyalgia rheumatica
Post-LP HA timing Max 24-48 hrs post-LP
Post-LP HA treatment Fluids, NSAIDs, caffeine. If fails = epidural blood patch
Intracranial hypotension treatment Symptomatic, but if fails = epidural blood patch
Intracranial hypotension MRI finding Diffuse patchy thick enhancing dura (because brain sag = dilated dural veins leaking)
HA -- worse with standing up Intracranial hypotension. Consider CSF leak vs post-LP HA
HA -- uL, <1s, electric shock. Treatment? Primary stabbing headache. Tx = indomethacin, GBT, melatonin
uL face pain, <1s, electric shock Trigeminal neuralgia
Trigeminal neuralgia association Sjogren's syndrome. Multiple sclerosis. Scleroderma
Trigeminal neuralgia -- treatment CBZ / oCBZ. GBT, LTG, nerve blocks, rhizotomy. Microvascular decompression (MVD)
Glossopharyngeal neuralgia cause PICA obstruction
Sharp pain in tongue/mandible Glossopharyngeal neuralgia. Get MRA to r/o PICA pathology
Ramsey Hunt syndrome uL shock in ear. CN7 geniculate ganglion infection with HSV or VZV
Sharp pain in back of head Occipital neuralgia. Best tx is occipital nerve block of high cervical nerves (not trigeminal)
uL face pain, +dysautonomia, <5mins x200/day SUNCT/SUNHA (part of Trigeminal Autonomic Cephalgias TACs)
SUNCT/SUNHA treatment LTG 1st. GBT, TPX, IV lidocaine. No NSAIDS (no benefit)
uL face pain, +dysautonomia, 5-30mins x20-40/day Paroxysmal hemicrania (part of Trigeminal Autonomic Cephalgias TCAs)
Paroxysmal hemicrania treatment Indomethacin
Cluster headache pathophysiology Hypothalamic dysfunction
uL face pain, +dysautonomia, >30mins x1-8/day, cyclic Cluster headaches. Often occur in cycles at same periods throughout day
Cluster headache -- acute treatment 100% O2, triptans
Cluster headache -- prophylasix Verapamil, steroids, VPA
uL face pain, +dysautonomia, lasts for days Hemicrania continua
Hemicrania continua treatment Indomethacin
Post-herpetic neuralgia (shingles) virus Varicella Zoster in CN5 ganglia or dorsal root ganglia. Not herpes simplex
Painful dermatomal rash Post-herpetic neuralgia (shingles)
Post-herpetic neuralgia (shingles) treatment Steroids. Consider acyclovir/valcyclovir if within 72 hours. Chronic pain = gabapentin
VZV vaccine recommendation All adults >50. To prevent post-herpetic neuralgia (shingles)
Pain + fevers + bL foot erythema Erythomelagia
Pain+edema in one region, but not neuroanatomical Complex regional pain syndrome = aka reflex sympathetic dystrophy = aka casualgia
Complex regional pain syndrome pathophysiology Incomplete nerve injury from trauma/immoblization/other
Complex regional pain syndrome treatment Best = physical therapy. If fail = attempt sympathetic blocks or SC stimulators
Created by: amitchaudharimd
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