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Headache
Neurology
| Question | Answer |
|---|---|
| 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3 month of one or more acute meds; try bridge tx; initiate preventive agent as analgesic is withdrawn |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 |
| 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 |
| cluster HA | unilateral, orbital/temporal w/tearing; Tx O2, sumatriptan, prevent w/verapamil |
| HA prevalence | cluster M>F, parox hemicrania F>M |
| HA: serious sxs | meningits (fever, HA, stiff neck: LP/bld cx); SAH (sudden onset: CT); subdural |
Created by:
Abarnard
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