#1 Headaches.txt

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dohertys
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163909
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#1 Headaches.txt
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2012-07-25 09:58:08
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Family medicine
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Head aches headaches family medicine
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  1. #1 Headache
  2. CFPC Objectives of Headache
    • 1) For new-onset headaches differentiate benign from serious using
    • H & P
    • 2) If headache suggestive of serious pathology:
    • do appropriate work-up
    • make the diagnosis
    • timely appropriate treatment
    • do not assume relief of symptoms excludes serious pathology
    • 3) chronic and relapsing headache - treat appropriately, avoid narcotics and barbiturates
    • 4) If suspected SAH with negative CT scan - do an LP!
    • 5) Acute migraine headache - treat it and make ongoing treatment plan
  3. Approached to headaches
    • Classify as primary or secondary using red flags on
    • history and physical
  4. Primary headaches vs. Secondary
    • *benign, headaches are usually recurrent and have no organic disease as their cause
    • *secondary: caused by underlying organic disease ranging from sinusitis to SAH
  5. 3 common types of Acute Primary Headache Disorders
    • More common:
    • migraine with or without aura,
    • tension-type headache,
    • cluster headache
  6. 6 less common types of Acute Primary Headache Disorders
    • Less common:
    • paroxysmal hemicrania,
    • idiopathic stabbing headache,
    • cold-stimulus headache,
    • benign cough headache,
    • benign exertional headache,
    • headache associated with sexual activity
  7. Different types of Acute Secondary Headache Disorders
    • *2ndary to trauma
    • * vascular disorders: SAH, Acute Ischemic CVA, unruptured vasc malformation
    • arteritis, carotid or vertebral artery pain, venous thrombosis, arterial hypertension
    • *non-vascular intracranial disorders: benign intracranial HTN (pseudotumour), intracranial infection, low cerebrospinal fluid pressure
    • *substance abuse or withdrawal: acute or chronic
    • *noncephalic infection; viral or bacterial
    • *metabolic disorder: hypoO2, hyperCO2, mixed, hypoglycaemia, dialysis, other
    • *2ยบ to disorders of head and neck - ie. TMJ, cervical spine, etc.
    • *Cranial neuralgias
  8. QUESTIONS TO ASK ON HEADACHE HISTORY
    • 1) first or worst headache?
    • 2) pain on scale 1 to 10
    • 3) do you have regular headaches - are they just like this one?
    • 4) symptoms before the headache starts? symptoms during the headache? symptoms right now?
    • 5) onset and duration (gradual vs. sudden)?
    • 6) where is the pain? radiation?
    • 7) quality of pain? (throbbing, stabbing, dull)
    • 8) other medical problems? PMHx?
    • 9) medications?
    • 10) recent head injury or medical/dental procedure?
  9. Name the red flags in acute adult headaches
    • 1) new-onset headache after 50 years of age
    • 2) sudden onset of headache
    • 3) increasing frequency and severity
    • 4) new-onset in high risk for HIV or Cancer
    • 5) signs of systemic illness (fever, stiff neck, rash)
    • 6) focal neurologic signs besides aura
    • 7) papilledema
    • 8) subsequent to head trauma
  10. What does h/a beginning after age 50 suggest? work-up?
    • temporal arteritis, mass lesion
    • --> ESR, neuroimaging
  11. What does sudden onset of headache suggest? work-up?
    • SAH, pituitary apoplexy, hemorrhage into a mass lesion or AVM, mass lesions (especially posterior fossa)
    • neuroimaging, LP if CT is negative if suspicious for hemorrhage or malignancy
  12. What does new-onset h/a with high risk for HIV or Cancer suggested?
    • meningitis (chronic or carcinomatous), brain abscess (toxoplasmosis), metastasis
    • neuroimaging, LP if CT negative
  13. DDx of headache with signs of systemic illness? w/u?
    • meningitis, encephalitis, Lyme disease, systemic infection, collagen vascular disease
    • Neuroimaging, LP with pressure measure, blood work, serologies
  14. DDx of focal neurologic signs or symptoms (not aura)? W/u?
    • mass lesion, vascular malform'n, stroke, collagen vascular disease
    • neuroimaging, collagen vascular evaluation
  15. DDx of papilledema? w/u?
    • mass lesion, pseudotumour cerebri, meningitis
    • neuroimaging, lumbar puncture (with pressure measure)
  16. DDx of headache subsequent to head trauma?
    • intracranial hemorrhage, subdural hematoma, epidural hematoma, post-traumatic headache
    • Nueorimaging of brain, skull, possibly cervical spine
  17. Diagnositic criteria for cluster headaches
    • A) 5+ attacks
    • B) severe unilateral orbital/supraorbital or temporal pain lasting 15 min to 3 hours
    • C) at least one of:
    • conjunctival injection
    • lacrimation
    • nasal congestion
    • rhinorrhea
    • forehead and facial swelling
    • miosis
    • ptosis
    • eyelid edema
    • D) frequency - q2nd day up to 8/day
  18. Diagnostic criteria for episodic tension-type headache
    • A) 10+ previous headache episodes, <180 days/year
    • B) duration 30 minutes to 7 days
    • C) 2+ of:
    • pressing or tightening (nonpulsatile)
    • mild or moderate intensity
    • bilateral location
    • no aggravation with walking stairs or routine activity
    • D) Absence of:
    • -nausea or vomiting (can have loss of appetite)
    • -cannot have both photophobia and phonophobia (could have 1)
  19. Diagnostic criteria for migraine without aura
    • A) 5+ attacks meeting B-D
    • B) duration 4-72 hours (if untreated)
    • C) 2+ of:
    • unilateral
    • pulsating
    • moderate to severe
    • aggravation by walking stairs or similar physical activity
    • D) 1+ of:
    • nausea or vomiting
    • photophobia and phonophobia (both)
  20. Diagnositc criteria for migraine with aura
    • A) 2+ attacks with
    • B) 3+ of
    • i) fully reversible aura Sx indicating focal cerebral cortical or brain-stem dysfxn
    • ii) 1+ aura Sx develops gradually over >4 min, or 2 Sx in succession
    • iii) no aura Sx last > 1hr (increases with increasing # of Sx)
    • iv) headache follows aura - < 60 min between end of aura and start of h/a
  21. PHYSICAL EXAM for headache
    • vitals
    • palpation of head and face
    • CVS
    • fundoscopy
    • CN's
    • pupillary response
    • signs of meningeal irritation
    • sensation
    • force
    • reflexes
    • cerebellar
    • gait
  22. When to refer to specialist for headache
    • -inadequate level of comfort in diagnosis or treating
    • -Pt requests a referral
    • -initial diagnosis in question
    • -not responsive to treatment
    • -condition or disability worsesn/continues
    • -unable to classify headache
    • -habituation or rebound headaches limit treatment
    • -intractable or daily headaches
  23. Neuroimaging guidelines on headaches present > 4wks (HS Headache consortium)
    • - YES in nonacute headache with unexplained abN neuro exam (B)
    • - NO in migraine with normal neuro exam (B)
    • - no recommendations for neuroimaging based on neuro Sx
  24. Memory aid for Dx of migraine
    • POUND
    • P - pulsatile
    • O - one day duration (4h to 72 h)
    • U - unilateral location
    • N - nausea or vomiting
    • D - disabling intensity
    • 4+/5 = 92% probability
    • 3/5 = 64%
    • 2/5 = 17%
  25. Indications for migraine prophylaxis:
    • Contraindication or intolerance to abortive treatment
    • Headache symptoms > 2 days per week
    • headache severely limits Q of L despite treatment
    • Uncommon migraine conditions - hemiplegia, basilar, prolonged aura, migrainous infarct)
  26. 3 1st line abortive treatments for migraine:
    • Combination analgesics - tylenol, aspirin and caffeine conmbined
    • NSAIDs
    • TRIPTANS
  27. Dose for combination analgesics for migraine
    • acetaminophen 250mg/ ASA 250mg / caffeine 65mg
    • They are OTC
    • works as well as tritons
  28. Dose of NSAIDS for migraines
    • Ibuprofen 200-400mg PO
    • Ketorolac 10mg IV if in ED
  29. Dose of TRIPTANS for migraines
    • bind serotonergic Rc, 1st line if moderate to severe
    • many different ones, can switch between or increase dose
    • 4 with possible superiority:
    • Rizatriptan (maxalt) 10 mg PO
    • Eletriptan (relpax) 80 mg PO
    • Almotriptan 12.5mg PO
    • Sumatriptan 100mg PO

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