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Headache

Neurology

QuestionAnswer
Migraine dx criteria ≥2 of: (Unilateral; Pulsating; Mod/ severe intensity; fx: avoidance of routine physical activity); 1 of: (N/V; Photophobia and phonophobia)
5 phases of migraine Prodrome; aura; HA; termination; postdrome
Severe episodic HA with cerebellar sx = basilar migraine
Menstrual migraine tx triptans given acutely; NSAIDs; OCP
Chronic migraine: dx CDH ≥3 months; >8 d/mo x 3 mo;
Sinus HA vs migraine sinus usu continuous (not intermittent); TTP over sinuses; tx w/ Abx
Chronic Daily HA dx criteria ≥ 15 d/mo; primary or secondary (usu considered primary); ≥1 migraine/wk = RF for dev CDH
CTTH: CDH meeting TTH criteria
NDPH: CDH dev within 3 days of sx onset, last ≥ 3 mo
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3 month of one or more acute meds; try bridge tx; initiate preventive agent as analgesic is withdrawn
Med overuse indicators: Simple analgesics: >3 d/wk; Triptans/ combo analgesics: >2 d/wk; Opioids/ergotamine: >2 d/wk
Hemicrania continua Daily, continuous, strictly unilateral primary HA; assoc w/ cranial autonomic features (miosis, ptosis, eyelid edema, lacrimation, nasal congestion or rhinorrhea)
Hemicrania continua: dx & tx dx: responds to indomethacin
Paroxysmal hemicrania ≥ 20 frequent attacks (2-30 min); Pain severe & strictly unilateral, orbital, supraorbital, or temporal; Parasymp ipsilateral activation; Responds only to indomethacin
SUNCT Short-lasting; Unilateral; Neuralgiform HA, with Conjunctival injection & Tearing; rare; M>F (>50 yo)
SUNCT sx burning, stabbing, throbbing; seconds to 4 min; 5-6 per hr; SBP may rise
Trigeminal autonomic cephalgias include: SUNCT; cluster; trigeminal neuralgia
Cluster HA epidemiology M>F (older than migraine); 20-50 yo
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
Neuroimaging not needed when: No focal neuro findings; Pt has stable pattern of recurrent HA; No h/o seizures
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
Thunderclap HA (non-SAH) dx after exclude SAH; peaks in 1 min, lasts 1 hr-10 days
Migraine tx considerations Pt age; current health status; coexistent illnesses; migraine type. ASA 900mg / Ibu 400mg / APAP 1000mg; triptans; +/- antiemetics
Use LP only after: normal CT obtained & platelet count is normal
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
Pt needs preventive med (as well as abortive) if: >8 HA / month
Definition of trigger causes HA more than 50% of the time within 24 hr
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
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
Cluster HA sx/sx severe, unilateral, periorbital/temporal; nasal congestion, injected conjunctiva, ipsilateral sweating; at night (wakes pt), possible Horner syndrome
Cluster HA tx Abortive tx: sumatriptan 6mg SQ and 6-10L O2. Preventive: verapamil 120mg TID x2 wks, prednisone & melatonin x2 wks
Migraine pathology Not 2/2 vascular dilation/constriction. Primary neuronal dysfunction w/activation of trigeminovascular system reflex, cortical spreading depression, serotonin.
Migraine PPx med BB: propranolol 80-240mg/day; alt: timolol, nadolol, atenolol, metoprolol. Possibly amitriptyline, venlafaxine; antiepileptics (Tapamax PG cat D)
Not to be used in acute migraine: Ergotamine
Adolescent female w/ HA. +FHx. Severe HA, N/V, photphobia. +/- auras (usu contra to HA) Migraine HA
Male, recurrent relapsing HA. Worsened w/ EtOH, Lacrimation, salivation, rhinorrhea Cluster HA
Migraine dx criteria ≥2 of: (Unilateral; Pulsating; Mod/ severe intensity; fx: avoidance of routine physical activity); 1 of: (N/V; Photophobia & phonophobia)
Severe episodic HA with cerebellar sx = basilar migraine
Chronic migraine: dx chronic daily HA ≥3 months; >8 d/mo x 3 mos
Sinus HA vs migraine sinus usu continuous (not intermittent); TTP over sinuses; tx w/ Abx
chronic daily HA ≥ 15 d/mo; primary or secondary (usu considered primary); ≥1 migraine/wk = RF for dev chronic daily HA
SUNCT = Short-lasting; Unilateral; Neuralgiform HA, with Conjunctival injection & Tearing; rare; M>F (>50 yo)
SUNCT sx burning, stabbing, throbbing; seconds to 4 min; 5-6 per hr; SBP may rise
Cluster HA = M>F (older than migraine); severe, unilateral, nasal congestion, injected conjunctiva, ipsilateral sweating; at night (wakes pt)
HA red flags (SNOOP) Systemic sx; secondary RF; neuro sx; onset sudden; older pt; Progression/prior HA hx; Pattern changes
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
Ergotamine MOA direct sm mx vasoconstrictor
Beta blockers: MOA: central/serotonergic, beta-1 mediated
Migraine: prophylaxis Beta (50-60% efficacy); TCA; SSRIs; bupropion; Valpro; verapamil; NSAIDs (ST for predictable)
Prophylactic tx: adequate trial of tx: 6-8 weeks
Menstrual migraine: Tx NSAIDs: begin 2-7 days prior to menses, continue through last day of flow; Hormonal therapy (OCP)
TCA MOA antagonism of vascular or brainstem 5-HT2
Created by: Abarnard