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Headache & Pain
@NeuroFOD | @NeuroFOD |
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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 |