Term
|
Definition
an inherit predisposition to have recurrent headaches independent of other disease processes
-migraine
-tension
-cluster |
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Term
|
Definition
a headache associated with an underlying systemic or neurologic disorder
more worrisome, always want to try and rule-out
-infection
-tumor
-HTN
... |
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Term
|
Definition
visual - most common
unilateral numbness or weakness
dysphasia
"basilar" - vertigo, diplopia, ataxia |
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Term
diagnostic criteria
migraine (without aura) |
|
Definition
at least 5 attacks that:
-last 4 to 72 hours untreated
-HA has at least 2: unilateral, pulsting, moderate or severe, aggravated y routine physical activity
-at least 1 during HA: nausea/vom, photo-/phonophobia |
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Term
pathophysiology
intracranial pain-sensitive structures |
|
Definition
NO NOCICEPTORS IN BRAIN PARENCHYMA
arteries
-circle of Willis and 1st few cm of branches
-dural
large veins and dural venous sinuses
portions of dura near blood vessels
-->areas lining the brain, not the brain itself |
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Term
pathophysiology
pain-sensitive structures outside the skull cavity |
|
Definition
external carotid and its branckhes
skin
scalp
fascia
muscles
teeth
sinus mucosa
cutaneous nerves
cervical nerves and nerve roots
-trigeminal nerve innervates many of above
-C2 dermatome borders trig nerve |
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Term
|
Definition
orthodromic pain signal leads to referred pain to scalp, neck, etc
pain signal also causes neurogenic inflammation --> loop of amplified orthodromic pain signal
descending pain-modulating pathways DISinhibited; get UNinhibition of pain pathways
cortical hyperexcitability contributes to disinhibiton of trigeminal nucleus/descending pain-modulators |
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Term
pathogenesis of migraine
aura |
|
Definition
theory of "spreading depression" (also stim by cortical hyperexcitability)
aura is the clinical manifestation of spreading depression |
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Term
spreading depression
precipitated by |
|
Definition
mechanical deformation
electrical stimulation
glutamate or KCl or Na-K ATPase inhibitor
--trigger by many things, cortical hyperexcitability, possibly the orthodromic pain signal of the migraine itself |
|
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Term
spreading depression
characteristics of depressed zone |
|
Definition
marked depolarization of neurons
marked increase extracellular K
marked decrease extracellular Ca and Na |
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Term
spreading depression
after depressed zone |
|
Definition
wave of markedly increased blood flow
...2-3 min...
wave of moderately reduced blood flow for 60-90 minutes |
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Term
|
Definition
endogenous:
-hormones
-stress
...
exogenous:
-wine
-chocolate
... |
|
|
Term
migraine pathogenesis
*role of serotonin* |
|
Definition
migrainers have low plasma serotonin between attachs but levels rise during attacks
serotonin is released by mast cells and platelets during neurogenic inflammation
serotonergic neurons may be implicated in the contraction and relaxation of cerebral and meningeal blood vessels
serotonin is the main NT used by raphe nuclei cells in the RVM pathways that inhibits trigeminal pain transmission |
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Term
| migraine vs. tension headache |
|
Definition
not so different?
many patients have features of both or headaches that are intermediate
same meds work for both |
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Term
| diagnosis of primary headaches |
|
Definition
RECOGNIZING THE SYNDROME
Dx's:
migraine/tension
cluster
trigeminal neuralgia
chronic paroxysmal hemicrania
atypical facial pain |
|
|
Term
cluster headache
properties of the cluster |
|
Definition
distinctive feature = TIME COURSE
last 4-8 weeks; once or twice a year
one or more HA a day with at least one of the HA at teh same time each day
M>W 6:1 |
|
|
Term
cluster headache
properties of the headache |
|
Definition
explosive - patients try to move around, may hit head
unilateral, almost always same side
ipsilateral lacrimation, injection, nasal congestion, rhinorrhea, sometimes Horner's
last 30-120 minutes |
|
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Term
|
Definition
characterized by paroxysmal, "electric-shock-like" pain
lasts about a second or less, often in volleys
trigger zones are common
superimposed dull ache may occur
onset usually after age 50
can be precipitated by dental disease or MS |
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|
Term
| signs that a HA could represent an emergency |
|
Definition
"worst HA of life" - QUALITATIVELY different from previous
fever, meningeal signs, focal neuro deficits
these are clues to either SAH or bacterial meningitivs |
|
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Term
| what to if suspect SAH or meningitis |
|
Definition
CT of brain is available stat
LP - unless CT shows SAH, herniation |
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Term
|
Definition
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|
Term
| LP findings in bacterial meningitis |
|
Definition
WBC > 1000
glucose < 1/3 serum glucose
elevated protein |
|
|
Term
potential danger signs of HA
but NOT emergent |
|
Definition
major change
-recent onset
-recent change in charater
exam findings
-focal neuro exam
-papilledema (swelling of optic nerve disk)
atyp symptoms
-strongly postitional
-prominent systemic symptoms |
|
|
Term
giant cell arteritis
(temporal arteritis) |
|
Definition
emergency HA situation
inflammatory condition affecting medium sized blood-vessels
patients usually >60 |
|
|
Term
giant cell arteritis
presentation |
|
Definition
non-specific headache
temoral artery tenderness
jaw claudication
labs: elevated sed rate and CRP |
|
|
Term
giant cell arteritis
management |
|
Definition
urgent treatment necessary to prevent visual loss from stroke of optic nerve
treatment with steroid |
|
|
Term
idiopathic intracranial HTN (IIH)
(pseudotumor cerebri) |
|
Definition
| causes incresased intracranial pressure for unknown reason |
|
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Term
|
Definition
diffuse headache
often with transient visual symptoms
worse with getting up from lying or sitting position
NO mass |
|
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Term
|
Definition
*papilledema is hallmark
typically obese
6th nerve palsy - diplopia |
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Term
| spontaneous intracranial hpotension |
|
Definition
post-LP headache without the LP
resolves when lying flat, aggravated by siting up or standing
may be associated with: dizziness, nas/vom, diplopia, blurred vision/visual field defects, hyperacusis/tinnutus, mental status changes
tx with blood patch into spinal canal |
|
|
Term
| cerebral venous thrombosis |
|
Definition
features may be similar to stroke
headaches
focal neruo symptoms
seizures
usually in patients with coagulopathy or severe dehydration
give heparin/warfarin |
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Term
|
Definition
neck pain
headache
focal neuro symptoms
may have history of neck trauma or manipulation
tx with warfarin until recanalization is demonstrated |
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|
Term
| general principles of headache treatment |
|
Definition
eliminate triggers when possible
use abortives early in headache and repeat is necessary
patients requiring large quantities of abortives should be put on prophylactic medication
choice of meds should be based on patient's other medical problems, side-effect profile |
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Term
general principles of headache treatment
prophylactics |
|
Definition
with prophylactic medications, start at a low dose and increase as necessary (and tolerated)
once on effective prophylaxis, previously ineffective abortives may work
after adequate control for 6-12 months, try tapering the prophylactic |
|
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Term
| migraine/tension HA abortives |
|
Definition
apirin
acetaminophen
NSAIDs
acetaminophen/isometheptene/dichlorphenazone
triptans
ergots
chlorpromazine |
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