Term
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Definition
- Regardless of the underlying etiology, current thinking holds that there is a common pathway for headache pain
• Distension or traction of intra- or extracranial arteries
• Traction on intracranial veins or the dura
• Irritation of cranial and spinal nerves
• Irritation of cranial and spinal muscles
• Meningeal irritation and raised intracranial pressure
• Disturbance of intracerebral serotonergic projections |
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Term
| after a headache is triggered, what happens? |
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Definition
• When the headache is triggered, the trigemino-vascular axons are stimulated, causing immediate pain and release of neurogenic peptidesà
- Stimulate endothelial cells, mast cells, and platelets (neurogenic inflammation) à
- Vasodilation, enhanced permeability of plasma proteins, and a perivascular reaction
• Neurogenic peptide release is modulated by serotonin (5HT) with the 5HT1 receptor believed to be the most important subtype |
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Term
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Definition
• Migraine
• Tension-type
• Cluster |
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Term
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Definition
| • Examples include head trauma, tumor, meningitis, giant cell (temporal) arteritis |
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Term
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Definition
¡ Location of the Pain § Diffuse
§ Unilateral § Band-like § Focal
¡ Characteristics of the Pain § Pulsating, Throbbing
§ Tight
§ Pressure
§ Dull, Steady
§ Sharp, Lancinating
- Temporal Pattern – Frequency, duration
- Precipitating Factors
• Foods
• Emotional Stress
• Alcohol
• Coughing
• Chewing or Eating
- Prodromal Symptoms (Aura) • Scintillations
- Relieving and Exacerbating Factors
- Associated Symptoms
• Weight loss
• Fever
• Nausea/Vomiting
• Photo/phonophobia
• Lacrimation/rhinorrhea • Autonomic dysfunction
- Past Medical History—cancer, immunocompromised, prior neurosurgery, polymyalgia rheumatica, psychiatric history, glaucoma
- Prior headaches—similar or different
- Medications—OCP/hormones, OTC pain relievers, recent
changes or discontinuation of medications
- Diet—caffeine |
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Term
| headache Signs and Symptoms - Red Flags |
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Definition
• Systemic symptoms (fever, wt. loss, malignancy...) • Neurologic symptoms
• Onset (“thunderclap”)
• Older
• Pattern, previous history |
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Term
Headache Red Flags:
Neurological Examination |
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Definition
• Pupil asymmetry: Examples: aneurysm contacting cranial nerve III, Horner’s Syndrome
• Temporal artery tenderness (Giant Cell Arteritis)
• Papilledema (increased intracranial pressure due to
mass, or “pseudotumor” cerebri).
• Drowsiness, impaired mentation
• Other focal neurological findings – cranial nerve deficits (such as facial droop, tongue deviation), unilateral motor deficits, unilateral non-dermatomal sensory deficits, aphasia, extensor toe response (Babinski) |
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Term
| Headaches you should worry about |
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Definition
• First
• Worst
• Cursed – disorientation, mental status change in association with HA |
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Term
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Definition
- Vital signs
• Temperature, BP
- Head and scalp
• Muscle tenderness or tension, tenderness to percussion of sinuses or temporal artery, signs of trauma
- Eyes
• Ptosis, visual field defects, EOMs, scleral injection, cloudy cornea, funduscopy for papilledema
- Mouth
• Thrush, tonsillitis
- Neck
• Is it supple?
- Neurological exam:
• Any new deficit demands imaging and/or lumbar puncture
- Skin
• Rash, needle marks
- Brudzinski’s and Kernig’s signs |
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Term
| headache Diagnostic Testing |
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Definition
- Majority of patients do not need tests
• CBC, electrolytes, EEG generally not helpful • ESR
• Carboxyhemoglobin
• Glucose
- Lumbar puncture is probably the most valuable lab test • May be therapeutic in addition to diagnostic
• ?CT or MRI prior to LP?
• Measure opening pressure
- Neuroimaging
• CT:
• Non-contrast is preferred study for acute head trauma and subarachnoid hemorrhage
• Contrast CT is used for space occupying lesions, complications of HIV, subacute subdural hemorrhage
• CT is generally able to demonstrate any neurosurgical emergency or contraindications for LP
• MRI: • More sensitive than CT for some lesions
• MRA in selected cases |
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Term
| Scan head in the presence of “red flags”: |
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Definition
• Worst headache of patient’s life
• First headache
• New headache pattern or change in old pattern
• Progressively worsening
• Onset after age 50 years
• Worse in early morning, especially if it awakens pt • Marked exacerbation with straining/Valsalva
• Focal neurological findings, including papilledema • Nuchal rigidity
• Fever
• Altered LOC
• History of malignancy and/or HIV |
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Term
| pneumonic to remember when to scan head |
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Definition
• S (Systemic signs- fever, muscle pain, weight loss) • N (Neurological signs)
• O (Onset- speed, severity, or activity)
• O (Older age of onset)
• P (Prior headache history- is this a change) |
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Term
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Definition
• History of similar headaches
• Normal vital signs and exam
• Normal alertness and cognition
• Supple neck
• Normal neurological exam
• Improvement in headache without treatment
• All must apply for a scan not to be indicated
• This list is not exclusive as there may be cases where neuroimaging is indicated |
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Term
Headache Red Flags:
Workup
• Head CT without contrast |
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Definition
• Can be obtained quickly
• Blood will show up bright – subarachnoid hemorrhage, subdural hematoma, epidural hematoma
• Look for mass effect or midline shift – worrisome for increased intracranial pressure
• May miss more subtle mass lesions or posterior fossa lesions – MRI better for these |
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Term
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Definition
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Term
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Definition
| brain tumor, mass effecxt, midline shift |
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Term
Headache Red Flags
• Some indications for lumbar puncture |
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Definition
• Thunderclap headache
• Subacute progressive headache
• Headache associated with fever, meningismus, confusion, or seizure
• High or low intracranial pressure
!!! Obtain head CT prior to LP to rule out increased ICP/herniation. |
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Term
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Definition
• 18% of females, 6% of males, 5% of children
• Frequency may range from once in lifetime to almost daily
• Risk factors: hormones, chronobiologic changes, vasodilators, sensory input, diet, drugs, trauma, stress
• Protective factors: regular meals, regular sleep , regular exercise, biofeedback, healthy lifestyles |
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Term
| International Headache Society Criteria: MigraineWITHOUTAura |
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Definition
- 5 attacks lasting 4–72 hours (30 minutes–7 days)
- 2 of the following
• Unilateral
• Pulsating
• Moderate or severe intensity
• Aggravation by routine physical activity
- 1 of the following
• Nausea and/or vomiting
• Photophobia and phonophobia
- No evidence on history or examination of disease that might cause headaches |
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Term
| IHSCriteria: MigraineWITHAura |
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Definition
At least two attacks fulfilling the following:
• Fully reversible visual, sensory, or aphasic symptoms, but no motor
weakness
• At least 2 of the following:
- Homonymous positive features and/or unilateral sensory sxs - Symptom(s) develop gradually over > 5 minutes
- Each symptom lasts 5-60 minutes
• Headache must occur within 60 minutes of aura (or may be before/simultaneous with aura)
• Not attributed to another disorder |
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Term
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Definition
| prodrome, aura, headache w associated features, postdrome |
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Term
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Definition
- Vascular Theory
• Aura/headache a result of vasodilation
• Leads to irritation of trigeminal nerve fibers to the vessels
- Trigeminovascular system theory
• Migraine is a “brain” event
• Increased responsiveness (sensitization) of central pain (trigeminal) neurons innervating intracranial/extracranial structures |
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Term
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Definition
• Non-Pharmacologic
• Pharmacologic
- Acute Therapy – taken IMMEDIATELY at outset of headache, on PRN basis, goal is to treat current headache.
- Preventive Therapy – taken DAILY, goal is to decrease frequency/severity of headaches. |
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Term
| Migraine Treatment: Non-Pharmacologic |
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Definition
• Patient Education
- Make a diagnosis and give them reassurance
- Reinforce neurobiologic basis
- Discuss expectations
- Engage in management
• Avoidance of triggers
• Stress Relaxation Therapy
• Avoid Medication Overuse |
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Term
| early treatment for migraine |
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Definition
• Early treatment when the headache is mild is more effective than later treatment
• Narcotics and sedatives should be avoided
• Chronic analgesic use should be avoided (rebound headache) |
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Term
| acute treatment options for migraine |
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Definition
• OTCs: acetaminophen, aspirin, NSAIDs
• Ketorolac (Torodol®)
• Isometheptene muscate, dichloralphenazone, and acetaminophen (Midrin®) |
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Term
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Definition
for migraine:
• Vasoconstrictors
• Nausea is side effect: give metoclopramide (Reglan®) or prochloperazine (Compazine®)
• Should not use ergotamines more than twice per week and total weekly dose should not exceed 10mg |
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Term
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Definition
for migraine:
• Promethazine (Phenergan®), droperidol |
|
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Term
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Definition
for migraine:
haloperidol (Haldol®), chlorpromazine (Thorazine®) |
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Term
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Definition
for migraine:
Butlbital, Fiorinal, Fioricet
Addictive and high incidence of rebound headaches |
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Term
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Definition
for migraine:
butorphanol nasal spray (Stadol®), acetaminophen plus hydrocodone or oxycodone or codeine or propoxyphene, meperidine (Demerol®) |
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Term
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Definition
for migraines:
The “triptans”
Sumatriptan (Imitrex®) and others
Selective5-hydroxytryptamine(5HT1B/1D) receptor agonists |
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Term
| Serotonin Agonists—The “triptans” |
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Definition
for migraines:
- Have 3 potential mechanisms of action
• Cranial vasoconstriction
• Peripheral neuronal inhibition
• Inhibition of neuronal transmission in the trigeminocervical complex
- Associated with high rate of rebound • 37%-45% of patients
- May result in vasoconstriction of coronary arteries
• “Small but not negligible” chance of MI
• Patients at risk include men >40 yo, women >50 yo, and those with cardiac risk factors and uncontrolled hypertension
- Do not use with ergotamines |
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Term
| when to take triptan for migraines |
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Definition
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Term
| Preventative Treatment for migraines |
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Definition
- Prophylaxis may be indicated if 2 or more severe headaches occur per month or if quality of life is impaired
- General principles
• Start low and increase slowly
• Each medication should be given a trial of at least 2-3 months
• Discontinue or taper drugs that may be leading to rebound headaches
• Encourage a headache diary
• Educate the patient about treatment, side effects, expectations for cure |
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Term
| Preventive Medication Groups for migraines |
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Definition
- Anticonvulsants
• Valproate
• Gabapentin
• Topiramate
- Antidepressants
• Tricyclics
- ß-adrenergic blockers
• Propranolol
- Botulinum toxin
- Calcium channel antagonists
Verapamil
- Others
Riboflavin Magnesium |
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