Question 1

Tension HA:
Epidemiology

Accepted Answer

Most common – 70% of all H/A.
More women than men.

Question 2

Tension HA:
Characteristics

Accepted Answer

“Band-like”. 
Bilateral.
Generalized or back of head/upper neck, or front/temp.
HA lasting 30”–7d w/o N/V.
Pressing or tight.
Does not interfere w/ ADLs is not aggravated by physical activity.
Stress is common trigger.

Question 3

Tension HA:
Associated sx's

Accepted Answer

Neck muscle spasm/tension.

Question 4

Tension HA:
Diagnosis and W/U

Accepted Answer

No family history.
No labs needed unless underlying illness is suspected.
CT or MRI only if sudden onset of HA or if intracranial pathology is suspected.

Question 5

Tension HA:
International H/A Society

Accepted Answer

At least 10 HA episodes of HA lasting from 30” – 7 days, & 2 of the following (pressing or tightening – nonpulsating, mild to moderate, bilateral, no aggravation with activity);and no N/V, photophobia or phonophobia.

Question 6

Tension HA:
Non Pharmacological Tx

Accepted Answer

Relaxation techniques.
Cognitive behavioral tx if frequent H/A are an issue.
PT for muscle spasm and good body alignment.
Massage.
Ultrasound.
Exercise.
yoga. pilates.
Minimize caffeine use, smoking, and sudden w/d for possible causes.
Warm compre

Question 7

Tension HA:
Pharmacological Tx

Accepted Answer

Acute:  H/A can result from an imbalance of neurochemicals (ie: serotonin) so can use TCA, SSRIs (for severe cases – can cause sleep issues).

Question 8

Tension HA:
Pharmacological Tx cont'd

Accepted Answer

AVOID narcotics and OTC meds for < 1 H/A per week – OTCs may result in rebound HA once they are stopped (OTCs used > 4x/week).
Muscle relaxant (Skelaxin 400 – 800 mg) if muscle spasm is suspected.

Question 9

Tension HA:
Referral

Accepted Answer

PT.

Massage therapist.

Cognitive behavior therapist.

Question 10

Cluster HA:
Epidemiology

Accepted Answer

More men than women; age 20 - 40.

Question 11

Cluster HA:
Characteristics

Accepted Answer

Cluster, deep, continuous, severe.
Unilateral.
Behind or around the eye (supraorbital, orbital, temporal, or any combo).
Lasts 15 – 180 minutes.
May occur QOD – 8x QD.
Worse when lying down.

Question 12

Cluster HA:
Characteristics

Accepted Answer

Awakened during night with severe, unilateral, retrorbital pain.  Maximal pain in 15” and usually lasts 90” or longer (180”).

Question 13

Cluster HA:
Associated sx's

Accepted Answer

Ipsilateral conjunctival redness.
Tearing, congestion, ptosis, rhinorrhea.
Agitated or restless.
Pupil constriction.
Partial Horner’s sign.

Question 14

Cluster HA:
Dx and  work up

Accepted Answer

•	Good hx, FMH, PMH, presentation.
•	General head-to-toe PE.
•	Radiologic or lab testing is unnecessary unless underlying dx is suspected.

Question 15

Cluster HA:
International H/A Society:

Accepted Answer

At least 5 attacks: severe unilateral meeting characteristics and with at least 1 associated sx.

Question 16

Cluster HA:
Abortive Therapy

Accepted Answer

100% O2 for 15 minutes.
Triptans if given before a predictable episode (if they know what triggers the HA).
Narcotics DO NOT HELP; take longer to work than the actual attack.

Question 17

Cluster HA:
Prophylaxis Therapy

Accepted Answer

Valproic acid, Topiramate, Verapamil, Lithium

Question 18

Migraine :
Epidemiology

Accepted Answer

Common in women > men. < 40 y/o.

Question 19

Migraine:
Characteristics

Accepted Answer

Recurrent, unilateral/ipsilateral, pulsatile, pounding, moderate – severe, Aggrevated by physical activity.
Different types; w/ aura, w/o aura, or 
optical (variant atypical presentation).

Question 20

Migraine:
Associated sx's

Accepted Answer

Nausea, vomiting, photophobia, phonophobia.
Pt is quiet w/ light out and afraid to move
May be able to ID a trigger;  weather changes, foods, ETOH, altitude, delaying or skipping a meal, hormonal changes.

Question 21

Migraine:
Physical findings

Accepted Answer

Normal b/w episodes.

Question 22

Migraine:
Diagnosis

Accepted Answer

•	Lasts 4 – 72 hours

Question 23

Migraine:
Work Up

Accepted Answer

•	Good hx, FMH, PMH.
•	General head-to-toe PE.
•	Radiologic or lab testing is unnecessary unless underlying dx is suspected.
•	If don’t have sx in between H/A, then can dx as a migraine w/o further work-up.

Question 24

Migraine 
Non-Pharmacologic

Accepted Answer

•	Avoid daily stressors
•	Regular sleep, meals
•	Exercise
•	Relaxation training
•	Biofeedback

Question 25

Migraine:
Pharmacologic

Accepted Answer

•	Carry meds so can tx if come into contact w/ trigger.

Question 26

Migraine:
Acute Analgesic Tx:

Accepted Answer

1st line – acetaminophen, NSAIDs, combo (Excedrin migraine), caffeine. 
Antiemetic – ODT ondansetron. Mod-Severe Tx: Ergotamine (Ergo derivatives). ergotamine tartrate (Cafergot) dihydroergotamine.

Question 27

Migraine:
Poor 1st line choices for migraine acute analgesic

Accepted Answer

benzos, opioids, barbiturates (abuse/addiction)

Question 28

Migraine Treatment

Accepted Answer

1st line:  Highly effective w/o significant side effects.  May be given w/ prophylaxis and antiemetics.
•	Rizatriptan (Maxalt) 10 mg
•	Almotriptan (Axert) 12.5 mg
•	Eletriptan (Replax) 80 mg
•	Sumatriptan (Imitrix) – lower line on tx

Question 29

Migraine Prophylaxis:

Accepted Answer

For pts who experience >1 HA/week or if sx tx isn’t effective. 	Prophylaxis needs to be given a full 3 months before deeming ineffective & changing to another agent.

Question 30

Migraine Prophylaxis

Accepted Answer

Common tx: beta-blockers, propranolol, atenolol (for pts w/ palpations & MVP + migraine); depakote, gabaptentin topiramate (topamax)more side effects and monitoring needed, neuro consult; TCA, SSRIs if sleep is a problem.

Question 31

Migraine with Aura:
Characteristics

Accepted Answer

H/A preceded by focal neuro sx
Visual or sensory sx precede 5 – 20” before the H/A.

May be irritable, feelings of doom or fatigue, decreased energy, food cravings before headache.

Question 32

Migraine with Aura:
Physical Findings

Accepted Answer

Normal b/w episodes. Temporary focal or sensory abnormalities.

Question 33

Migraine with Aura, Aura Types:

Accepted Answer

Scintillating scotomato (spot of flickering light near center of visual fields; prevents vision w/in scomato; bright zig zags, wavy sparkly lights, homonymous (same side of both eyes) visual disturbance, or hemiparesis.

Question 34

Migraine with aura:
Diagnosis

Accepted Answer

Experience at least 2 attacks.
Aura which fully reverse and have no motor symptoms.

Question 35

Migraine with aura:
Diagnosis

Accepted Answer

Must have @ least 2 of  the following:  homonymous sx or unilateral hemiparesis (sensory sx), aura develops over 5” or 2 or more sx occurring in succession, or onset of H/A w/in 60” after aura.

Question 36

Migraine without Aura:
Characteristics

Accepted Answer

Independent.
Unilateral. Pulsating. Mod – severe pain. Causes avoidance of normal activity.

Question 37

Migraine without Aura:
Diagnosis

Accepted Answer

At least 5 attacks  fulfilling the criteria.
Lasts 4 – 72 hours.
Has at least 2 characteristics and at least 1 associated.

Question 38

Migraine HA's;
Referral

Accepted Answer

40% after 30 years are migraine free.
Referral to neurologist when 1st line therapies fail or pt is not responding to interventions or any uncertainty of the diagnosis.

ComPbms. HEENT

Headaches

Question	Answer
Tension HA: Epidemiology	Most common – 70% of all H/A. More women than men.
Tension HA: Characteristics	“Band-like”. Bilateral. Generalized or back of head/upper neck, or front/temp. HA lasting 30”–7d w/o N/V. Pressing or tight. Does not interfere w/ ADLs is not aggravated by physical activity. Stress is common trigger.
Tension HA: Associated sx's	Neck muscle spasm/tension.
Tension HA: Diagnosis and W/U	No family history. No labs needed unless underlying illness is suspected. CT or MRI only if sudden onset of HA or if intracranial pathology is suspected.
Tension HA: International H/A Society	At least 10 HA episodes of HA lasting from 30” – 7 days, & 2 of the following (pressing or tightening – nonpulsating, mild to moderate, bilateral, no aggravation with activity);and no N/V, photophobia or phonophobia.
Tension HA: Non Pharmacological Tx	Relaxation techniques. Cognitive behavioral tx if frequent H/A are an issue. PT for muscle spasm and good body alignment. Massage. Ultrasound. Exercise. yoga. pilates. Minimize caffeine use, smoking, and sudden w/d for possible causes. Warm compre
Tension HA: Pharmacological Tx	Acute: H/A can result from an imbalance of neurochemicals (ie: serotonin) so can use TCA, SSRIs (for severe cases – can cause sleep issues).
Tension HA: Pharmacological Tx cont'd	AVOID narcotics and OTC meds for < 1 H/A per week – OTCs may result in rebound HA once they are stopped (OTCs used > 4x/week). Muscle relaxant (Skelaxin 400 – 800 mg) if muscle spasm is suspected.
Tension HA: Referral	PT. Massage therapist. Cognitive behavior therapist.
Cluster HA: Epidemiology	More men than women; age 20 - 40.
Cluster HA: Characteristics	Cluster, deep, continuous, severe. Unilateral. Behind or around the eye (supraorbital, orbital, temporal, or any combo). Lasts 15 – 180 minutes. May occur QOD – 8x QD. Worse when lying down.
Cluster HA: Characteristics	Awakened during night with severe, unilateral, retrorbital pain. Maximal pain in 15” and usually lasts 90” or longer (180”).
Cluster HA: Associated sx's	Ipsilateral conjunctival redness. Tearing, congestion, ptosis, rhinorrhea. Agitated or restless. Pupil constriction. Partial Horner’s sign.
Cluster HA: Dx and work up	• Good hx, FMH, PMH, presentation. • General head-to-toe PE. • Radiologic or lab testing is unnecessary unless underlying dx is suspected.
Cluster HA: International H/A Society:	At least 5 attacks: severe unilateral meeting characteristics and with at least 1 associated sx.
Cluster HA: Abortive Therapy	100% O2 for 15 minutes. Triptans if given before a predictable episode (if they know what triggers the HA). Narcotics DO NOT HELP; take longer to work than the actual attack.
Cluster HA: Prophylaxis Therapy	Valproic acid, Topiramate, Verapamil, Lithium
Migraine : Epidemiology	Common in women > men. < 40 y/o.
Migraine: Characteristics	Recurrent, unilateral/ipsilateral, pulsatile, pounding, moderate – severe, Aggrevated by physical activity. Different types; w/ aura, w/o aura, or optical (variant atypical presentation).
Migraine: Associated sx's	Nausea, vomiting, photophobia, phonophobia. Pt is quiet w/ light out and afraid to move May be able to ID a trigger; weather changes, foods, ETOH, altitude, delaying or skipping a meal, hormonal changes.
Migraine: Physical findings	Normal b/w episodes.
Migraine: Diagnosis	• Lasts 4 – 72 hours
Migraine: Work Up	• Good hx, FMH, PMH. • General head-to-toe PE. • Radiologic or lab testing is unnecessary unless underlying dx is suspected. • If don’t have sx in between H/A, then can dx as a migraine w/o further work-up.
Migraine Non-Pharmacologic	• Avoid daily stressors • Regular sleep, meals • Exercise • Relaxation training • Biofeedback
Migraine: Pharmacologic	• Carry meds so can tx if come into contact w/ trigger.
Migraine: Acute Analgesic Tx:	1st line – acetaminophen, NSAIDs, combo (Excedrin migraine), caffeine. Antiemetic – ODT ondansetron. Mod-Severe Tx: Ergotamine (Ergo derivatives). ergotamine tartrate (Cafergot) dihydroergotamine.
Migraine: Poor 1st line choices for migraine acute analgesic	benzos, opioids, barbiturates (abuse/addiction)
Migraine Treatment	1st line: Highly effective w/o significant side effects. May be given w/ prophylaxis and antiemetics. • Rizatriptan (Maxalt) 10 mg • Almotriptan (Axert) 12.5 mg • Eletriptan (Replax) 80 mg • Sumatriptan (Imitrix) – lower line on tx
Migraine Prophylaxis:	For pts who experience >1 HA/week or if sx tx isn’t effective. Prophylaxis needs to be given a full 3 months before deeming ineffective & changing to another agent.
Migraine Prophylaxis	Common tx: beta-blockers, propranolol, atenolol (for pts w/ palpations & MVP + migraine); depakote, gabaptentin topiramate (topamax)more side effects and monitoring needed, neuro consult; TCA, SSRIs if sleep is a problem.
Migraine with Aura: Characteristics	H/A preceded by focal neuro sx Visual or sensory sx precede 5 – 20” before the H/A. May be irritable, feelings of doom or fatigue, decreased energy, food cravings before headache.
Migraine with Aura: Physical Findings	Normal b/w episodes. Temporary focal or sensory abnormalities.
Migraine with Aura, Aura Types:	Scintillating scotomato (spot of flickering light near center of visual fields; prevents vision w/in scomato; bright zig zags, wavy sparkly lights, homonymous (same side of both eyes) visual disturbance, or hemiparesis.
Migraine with aura: Diagnosis	Experience at least 2 attacks. Aura which fully reverse and have no motor symptoms.
Migraine with aura: Diagnosis	Must have @ least 2 of the following: homonymous sx or unilateral hemiparesis (sensory sx), aura develops over 5” or 2 or more sx occurring in succession, or onset of H/A w/in 60” after aura.
Migraine without Aura: Characteristics	Independent. Unilateral. Pulsating. Mod – severe pain. Causes avoidance of normal activity.
Migraine without Aura: Diagnosis	At least 5 attacks fulfilling the criteria. Lasts 4 – 72 hours. Has at least 2 characteristics and at least 1 associated.
Migraine HA's; Referral	40% after 30 years are migraine free. Referral to neurologist when 1st line therapies fail or pt is not responding to interventions or any uncertainty of the diagnosis.

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