Lecture 17: Headaches

-Frequency: Days per month with headaches

• Have them Keep a headache diary

-Triggers: Is there anything that makes headaches more likely to occur.

-Frequency: Days per month with headaches

• Have them Keep a headache diary

-Triggers: Is there anything that makes headaches more likely to occur.

What are 2 important questions/things to know in the HPI regarding headaches and making your differential?

Triptans might be contraindicated in patients with cardiovascular disease.

Why is it important to know if your patient has a PMH of cardiovascular disease?

Primary Headaches

-Headaches in which the headache and its associated features are the disorder itself

-Ex → Migraines, tension headaches, and cluster headaches.

Secondary Headaches

-Headaches with an underlying pathology

• Ex → Head injury, brain tumors, systemic infections.

Tension-type HA ; Migraine HA

--------------- is the most common type of headache in the general population, but --------------- is the most common type of headache for which people seek treatment.

Aura

-Transient neurologic symptoms that Precede or occur with the onset of a migraine headache and persist for < 60mins.

1.) Prodrome (24-48 hours)

• Variable (mood changes, cravings, yawning constipation, ect…)

• Occurs in ~60%

2.) Aura (<60 minutes)

• Only 20-25% have this.

3.) Headache (4 hours-2 days)

• typically builds over a couple of hours

• Can start after or with the aura.

4.) Postdrome (<24 hours)

• Still have headache if moves head to around quickly

• Feel “drained” afterwards, Problems with concentration/irritability

What is the typical progression of a Migraine headache?

1.) A self-propagating wave of cortical neurons and glial cell depolarization (cortical spreading depression) leads to a period of time where neurons cant fire, leading to deficits.

2.) Activation of the spinal trigeminal nucleus which is believed to send information to the trigeminal ganglion.

3.) Calcitonin gene-related peptide (CGRP) and other mediators are released from first-order neurons in the trigeminal ganglion causing….

• Vasodilation of meningeal arteris

• Pathologic enhancement of pain transmission.

  • These two processes together are referred to as activation of the trigeminal vascular system.

What are the Hypothesized pathophysiology of Migraine headaches?

The enhanced pain transmission brought about by CGRP causes things that should not be painful to be painful.

What is thought to be the source of pain during a migraine?

Avoidance of any precipitating factors together with prophylactic or symptomatic pharmacologic treatment if needed.

What does management of Migraines consist of?

NSAIDS

Acetaminophen

Triptans

Antiemetics

Combination of sumatriptan and naproxen.

What medications have been shown to be effective for acute treatment of migraines?

Triptans

-serotonin 1b/1d agonists

-Inhibit the release of CGRP and other vasoactive peptides, promote vasoconstriction, and block pain pathways in the brainstem.

-In general, limit use to <10 days per month.

Migraine with brainstem aura or hemiplegic migraine

Known coronary artery disease

Peripheral vascular disease

History of stroke or TIA

uncontrolled hypertension

Pregnancy.

What are contraindications for Triptans.

Eletriptan at a 40mg dose

Among oral medications, which had the highest effectiveness?

True

T/F: Subcutaneous injection is more effective than oral medications

Chronic Migraines

Migraines that occur with a frequency of 15 or more days per month lasting 4 hours or more.

• Prophylactic treatment is key

• Acupuncture is as effective as prophylactic pharmacologic treatment.

Menstrual Migraines.

Occur up to 2-3 days before and 3 days after the start of menstruation

• Related to decreased levels of estrogen

• Acute treatment is the same as other migraines.

• Can only use Hormonal prophylaxis treatments if migraine does not have arua

Hemiplegic Migraine

Associated with acute onset of weakness as the aura. Often sometimes accompanied by confusion, fever, lethargy, coma, and seizures.

Migraines with brainstem aura

-Aura presents as brainstem dysfunction (balance problems)

-DO NOT use triptans, beta-blockers, or dihydroergotamine.

-USE NSAIDS or D2 blockers acutely

-Prophylaxis is usually with verapamil

Tension-type HA

-A most prevalent type of HA in the general population

• headache resulting from muscle involvement.

-Women twice as likely to get it than men

-Also called stress headaches.

-NSAIDs are the preferred treatment

-Prevention: Amitriptyline

• Triptans and ergotamines are not indicated.

Infrequent episodic

• Less than one per month

What is the most common type of Tension HA?

Cluster Headaches

-Affects males more than females (5:1)

-Triggers: none, but alcohol during headache triggers splitting headache

-Severity: Extremely severe pain

• Episodes typically happen at night and wake up the person

-1-2 episodes per year that last 4-8 weeks w/ 1-8 headaches per day.

• followed by pain-free interval that averages for a little less than a year.

-Treatment: 100% oxygen by a non-rebreather mask

• Prophylactic: Verapamil

-Pacing, jog in place, rocking aggression

-some sensitivity to light and nausea

-Restless

-Agitated.

-What are some common behaviors seen with cluster headaches?

-Typical signs and symptoms with normal neurologic exam

-MRI to rule out brain pathology or pituitary pathology

what are the diagnostic criteria for cluster headaches?

Giant Cell Arteritis

-Average onset age is 70

-Unilateral or bilateral frontotemporal headaches

-Absent pulse or tenderness in the temporal artery.

• associated with the rheumatologic disorder

• Risk of blindness due to blockage of posterior ciliary arteries

Diagnosis:

• Elevated ESR, CRP, and temporal artery biopsy

Treatment:

• Immunosuppression (high-does systemic steroids)

Cerebral venous Thrombosis

-Linked to pregnancy, post-partum period, infections, and malignancy

• Rare, but always think about it with pregnancy

-Papilledema, visual loss, seizures, focal neurological defects

-Diagnosis:

• CT venography or MR venography

-Treatment:

• Anticoagulate; if deteriorate consider thrombolysis

Idiopathic intracranial hypertension

-Most commonly found in overweight women aged 20-44

Major symptoms:

• Visual disturbances due to papilledema and abducens nerve dysfunction

• Examination reveals papilledema and some enlargement of blindspots

-Diagnosis:

• Lumbar puncture

-Treatment:

• Acetazolamide and topiramate reduce CSF formation

• If meds fail, shunt is needed.