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What are the pain sensitive structures of the cranium?
- middle meningeal artery
- dural sinus
- falx cerebri
- proximal segment of the pial artery
What are some of the reasons headaches occur?
- distention, traction, dilation of intra/extracranial arteries
- traction/displacement of large intracranial veins
- compression, traction, inflammation of cranial and spinal nerve
- spasm, inflammation/trauma to cranial and cervical muscles
- meningeal irritation and raised ICP
- activation of brainstem structures
What are the general classifications of headaches?
Classification of headache that presents as new onset and demands prompt evaluation to rule out a serious pathology.
Class of headache that occurs over a period of weeks to months, and can be serious in elderly pts or pts with trauma.
Class of headache that occurs over a period of years, and are more likely to be due to a "benign" cause.
- Note: determine whether is it similar to previous HAs, if its different consider it acute and evaluate for a cause immediately
What conditions cause acute headache and facial pain symptoms?
- subarachnoid hemorrhage
- berry aneurysms
- hypertensive encephalopathy
- ocular disorders
What conditions cause subacute headache and facial pain symptoms?
- giant cell arteritis (temporal arteritis)
- brain tumor
- pseudotumor cerebri
- trigeminal neuralgia
- post-herpetic neuralgia
What conditions cause chronic headache and facial pain symptoms?
- migraine headache
- rebound/withdrawal headache
- cluster headache
- tension headache
- post-traumatic headache
- non-neurological disease
What should be included as part of the physical examination when evaluating a patient with headaches?
- vital signs
- palpate scalp, face, and head
- neurological exam
What is the most common cause of SAH?
What other conditions are berry aneurysms associated with?
- polycystic kidney disease & coarct of the aorta
- "mycotic" aneurysms (spread of systemic infection to the cerebral blood vessels)
Abnormal blood vessel communications typically in MCA distribution that is a cause of SAH.
AVMs (arteriovenous malformation)
What is the pathophysiology for an active bleeding SAH?
- increased ICP causes HA
- as ICP approaches systemic BP the cerebral blood flow decreases
- 50% of pts have LOC
- subhyaloid retinal hemorrages occur
- Note: blood is typically confined to the subarachnoid space
What are the clinical findings in a patient with SAH?
- "worst headache of my life" (severe pain)
- transient LOC in 50% of pts
- nuchal rigidity
- NEW and SUDDEN (key feature)
- elevated BP
- neurologic findings (typically not focal)
What is the gold standard test available to detect SAH?
What are the complications associated with SAH?
- recurrence of hemorrhage
- intraparenchymal extension
- arterial vasospasm
What is the treatment for SAH?
- bed rest
- elevate head 15-20 degrees
- mild sedation
- anlagesics for pain
- CCBs to avoid vasospasm (nimodipine)
What is the surgical treatment for SAH?
- clipping the neck of the aneurysm (definitive tx only used if pts are awake)
- removal of AVM (ambolization)
What is the prognosis for patients with SAH?
- 20% die before they reach the hospital
- 25% die from the bleeding
- 20% die from re-bleeding
Inflammation of the brain or its meningeal coverings caused by a viral, bacterial or other type of infection.
What is the quality of a headache with meningitis and what other symptoms accompany it?
- throbbing, bilateral (occipital/nuchal), worse with sitting upright
- mental status changes
What percentage of patients with a brain tumor have HA as their 1st symptom?
What percentage of patients with a brain tumor have a headache at the time of diagnosis?
What are the characteristics of a headache caused by a brain tumor?
- worse in the morning (WAKING FROM SLEEP!)
- worse with exertion or valsalva
- associated with nausea and vomiting
- altered mental status
What are the three syndromes a pt with a brain tumor present with?
- subacute progression of a focal neurologic deficit
- nonfocal neurologic disorder )HA, dementia, personality change)
What are some suspicious criteria of a brain tumor other than the typical signs and symptoms?
- cluster type HA
- abnormal neuro exam
- undefined mild/moderate headache
- headache with aura
- new onset of HA later in life
- know malignancy elsewhere (METS!)
What are the physical exam findings/studies done on a patient with a brain tumor?
- may be nonvocal
- may see papilledema
- diagnosis is suggested by contrast CT or MRI (biopsy to confirm)
- avoid lumbar puncture
What are the presenting signs and symptoms in patients with a primary brain tumor?
- memory loss
- cognitive changes
- motor deficit
- language deficit
- personality change
- visual problems
- changes in consciousness
- nausea or vomiting
- sensory deficit
What are are risk factors to developing a brain tumor?
- exposure to radiation
What are the different types of brain tumors?
- pituitary adenomas
Characterized by a subacute granulomatous inflammation affecting the external carotid artery at the superficial temporal artery that is more common after age 50 with mean age of diagnosis being 70.
giant cell arteritis (aka temporal arteritis)
What are the signs and symptoms of giant cell arteritis?
- pain over scalp at temporal artery (headache)
- jaw pain/stiffness when chewing ("jaw or tongue claudication")
- inflammation of the ophthalmic artery leading to blindness (optic disc may appear pale)
- weight loss
How is giant cell arteritis diagnosed?
- biopsy of temporal artery (definitive)
- consider ESR (typically >50mm/hr)
- urgent tx with prednisone to avoid vision loss (burst with slow taper)
A diffuse increase in ICP causing HA, papilledema, pulsatile tinnitus, visual loss and diplopia.
idiopathic intracranial hypertension (aka pseudotumor cerebri)
What is the classical presentation of a patient with pseudo tumor cerebri (idiopathic intracranial hypertension)?
- middle aged
- Note: typically limited to a few months
What are the medications that can increase risk for developing pseudo tumor cerebri?
- birth control pills
- nalidixic acid
- steroids (starting/stopping)
- sulfa drugs
- vitamin A
A diffuse generalized headache made worse with straining, causing nausea (common), pulsatile tinnitus, transient visual disturbances (diplopia, diminished acuity), and papilledema (CN 6 palsy).
idiopathic intracranial hypertension (aka pseudotumor cerebri)
How is idiopathic intracranial hypertension (pseudotumor cerebri) diagnosed?
- MRI or CT to rule out mass (shows slit-like small ventricles)
- elevated CSF pressure tx with LP drainage (draining 20-40ml may treat the pain)
What medication helps pseudotumor cerebri by reducing production of CSF from the choroid plexuses?
What is the treatment for idiopathic intracranial hypertension?
- acetazolamine 1-2g/d
- furosemide (lasix) 40-60mg BID
- optic nerve sheath fenestration
- lumoperitoneal shunting
Microvascular compression of CN V causing excruciating "lancinating" pain over the lower 2/3 of ONE side of the face.
trigeminal neuralgia (aka tic douloureux)
What are the signs and tests for trigeminal neuralgia (tic douloureux)?
- normal neuro exam
- blood tests
- trigeminal reflex testing
What is the treatment for trigeminal neuralgia (tic douloureux)?
- antiseizure meds: carbamazepine, gabapentin, lamotrigine, phenytoin, valproate, pregabalin
- muscle relaxants: baclofen, clonazepam
- TCAs: amitriptyline, nortriptyline
- surgery: to relieve pressure on the nerve (stereotactic readiosurgery), or to remove a blood vessel or tumor compressing the trigeminal nerve
Similar to trigeminal neuralgia. Causes paroxysmal, burning/aching discomfort in the oropharynx/base of the tongue/tonsillar pillars, or auditory meatus.
How is the diagnosis of glossopharyngeal neuralgia made?
by history and reproduction of pain
How is glossopharyngeal neuralgia treated?
Most common cause of headache in the USA characterized as a recurring syndrome of headache, nausea/vomiting, and other neurology symptoms of varying degree.
Headaches that are more common in women with a lifetime prevalence of about 15% in women, has a pattern of familial clustering and onset is most common between age 20 and 30.
- Note: onset after age 50 is unusual and needs further eval
What are the triggers that help recognize a migraine headache?
- red wine
- lack of sleep
What are deactivators for migraine headaches?
A severe headache with no preceding symptoms, and is the most frequent type of vascular headache.
migraine without aura
A headache preceded by sensory, motor, or visual symptoms.
migraine with aura
A severe headache with dramatic neurologic deficit.
What is the quality of pain in a migraine headache and what are other symptoms typically associated with them?
- pounding, throbbing, typically unilateral pain that lasts for hours to days (if untreated)
What is the course of a migraine headache?
- gradual at onset
- typically crescendo with complete resolution
- pain is dull, deep stead progressing to pulsatile when severe
- usually unilateral (60-70% of pts)
- pain is typically in the morning
What is the old theory for migraines?
vascular spasm followed by dilation with subsequent neurologic sequela
What is the new theory for migraines?
primary neuronal dysfunction leading to intra/extracranial symptoms (migrainous threshold)
What is the vascular theory for migraines?
- headache phase: extra cranial vasodilation
- neurologic symptoms: intracranial vasoconstriction
What is the neuronal theory for migraines?
wave of cortical spreading depression terminating on cerebral arteries
What are the characteristics of the migrainous threshold?
- genetically determined
- similar to a seizure threshold
- set off by triggers
What is the trigeminovascular system migraine theory?
- activation of cells in the trigeminal nucleus cudalis
- release of substance P and calcitonin gene related peptide
- sterile inflammation
- serotonin, dopamine
What is the POUND mnemonic for migraines?
- Onset/duration (4-72 hrs)
- Unilateral in location
- Nausea and vomiting
- Disabling in intensity (headache is severe)
- (phono/photophobia, scotomata common, with or without aura)
What are the findings on physical exam for a pt with a migraine?
- normal exam outside of the attack
- pt often appears very ill during attack but usually has no focal neuro signs
- imaging is not necessary with typical migraine symptoms
What are the first line agents used as acute management for migraines?
- combination (tylenol, aspirin, and caffeine=excedrine)
What are the second line agents used as acute management for migraines?
What are the third line agents used as acute management for migraines?
- antiementics, dopamine blockers-->
- prochlorperzine 0.1mg/kg/dose (IV/IM/PR)
- metoclopromide 10mg/dose (IV) often combined with diphenhydramine to prevent akinetic response and induce fatigue
What are the general rules for migraine management?
- non pharmologic management for everyone (ID triggers, manage environmental shifts)
- medicate at the beginning of pain (not during aura)
- start with OTC meds first
- avoid narcotics
What are the simple analgesics (NSAIDs) typically effective for mild to moderate migraines?
- ibuprofen (motrin)
- naproxen (naprosyn)
- ketorolac IM
What are the simple analgesics (combination pills) typically effective for mild to moderate migraines?
- excedrin migraine: tylenol/ASA/caffeine
- midrin: tylenol/dichloralphenazone/isometheptene
- fiorcet: tylenol/butalbital/caffeine (not controlled)
- fiornal: tylenol/butalbital/caffeine/ASA (controlled)
What are the triptans used as abortive therapy for migraines?
- sumatriptan (imitrex) (oral, intranasal, SQ best for pts with nausea, vomiting)
- zolmitriptan (zomig): most efficacious
- naratriptan (amerge)
- rizatriptan (maxalt): most efficacious
- almotriptan (axert)
- eletriptan (relpax)
- Note: give at onset of pain not at onset of aura, SE are seen in 89% of patients, recurrence in 40-78%, may repeat dose after 1-2 hours only once
What are the contraindications for using 5HT1 agonists (triptans)?
Nonselective 5HT1 agonist, is an old school vasoconstrictors, and is available in oral forms in combination with caffeine.
- Note: most common side effect is NAUSEA, contraindicated in CAD, and pregnancy
Dopamine antagonists used as adjunctive therapy for migraines that improve gastric motility, relieve nausea and offer significant acute relief and may be used in combo with triptans.
- metoclopramide (reglan)
- compazine, reglan (IV)
Medications that offer acute and effective pain relief but do not address underlying disease processes and can create a craving which can lead to recurrent migraines.
- IV narcotics
- Stadol (nasal butorphanol)-restrictive use
What are the antihypertensives used as prophylaxis for recurrent episodes of migraine?
- propranolol 40mg po BID
What are the antidepressants used as prophylaxis for recurrent episodes of migraine?
- amitriptyline 50mg po qhs
- NOT SSRIs or SNRIs
What are the anticonvulsants used as prophylaxis for recurrent episodes of migraine?
- valproic acid 250mg po BID
- topiramate 25-100mg BID
- gabapentin at various doses
What are the medications other than antihypertensives, antidepressants, and anticonvulsants?
- botox injections q3mos
How are prophylactic medications for migraines picked?
- consider co-morbid conditions
- start at a low dose and increase gradually
- keep pt on a 4 week trial/longer
- avoid overuse of analgesics (rebound HA)
- education is key!
What does patient education for migraine prophylaxis consist of?
avoid triggers (caffeine, chocolate, red wine, cheese)
Headaches due to overuse of analgesics and/or caffeine causing pt to take increasing amounts for relief, when levels drop HA ensues. Daily headache may overlie migraine or other headache symptoms.
drug rebound headache
What is the treatment for drug rebound headache?
- abrupt withdrawal of meds and caffeine-containing sources
- consider sumatriptan or dihydroergotamine IV/IM during transition
Unilateral headache that may start as a burning sensation over the lateral aspect of the nose or pressure behind the eye. HAs commonly occur at night, may awaken the pt from sleep and start as clusters of brief, SEVERE, constant, non throbbing attacks that remit for months at a time.
- cluster headaches
- Note: last a few seconds to less than 2 hrs
What are the physical findings on a patient with cluster headaches?
lacrimation & tearing on the same side as the headache
Men are more likely than women to get this headache which is rarely associated with family history, and tend to begin around 25 years of age. Headaches may be due to activation in hypothalamus, or vasculitis disrupting sympathetic fibers in the cavernous sinus.
What is the treatment for acute relief of a cluster headache?
- 100% oxygen (8-10 L/min x 10-15 min)
- sumatriptan 4-6mg SC (2doses in 24 hrs)
- dihydroergotamine 1mg IV (CAD warning)
- prednisone may stop a cluster attack
What are the medications used as prophylaxis for cluster headaches?
Chronic headaches of unapparent cause that lack features of migraine or cluster HA. Underlying pathophysiology is unknown but it causes contraction of the neck and scalp muscles, typically occurs after age 20 and has a prevalence of being daily and chronic.
- tension headache
- Note: episodic attacks affect up to 80% of adults, women are affected more than men
Headache that is non throbbing typically felt bilaterally on the forehead, temples and occiput with NO photophobia, nausea, vomiting, visual changes.
The physical exam on patients with this type of headache is normal between attacks, and during attacks appear uncomfortable but present with a non-focal exam (normal fundoscopy).
- tension headache
- Note: no studies necessarily needed if history is typical
What causes tension headaches to occur?
- neck and scalp muscles become tense/contract
- may be response to stress, depression, head injury or anxiety
What are some triggers of tension headaches?
- caffeine use (withdrawal)
- colds, flu, sinus infection
- dental problems (jaw clenching/teeth grinding)
- eye strain
- excessive smoking
- fatigue or overexertion
How are tension headaches treated?
- simple analgesics
- ergots (cafergot, DHE)
- avoid rebound headache
What is the prophylaxis for tension headaches?
- TCAs (amitriptyline): reduce duration & frequency
- psychotherapy: cognitive behavioral therapy may be as good as TCA
- lifestyle modification: exercise
- reassure patient: syndrome is real and treatable
What are the disqualifying criteria with headaches described by AR 40-501?
- history of recurrent headaches including but not limited to...
- tension headaches that interfere with normal function in the past 3 years or severe enough for prescription medications
Headache with nonspecific symptoms that follow closed head injury with symptoms that do not necessarily correlate with severity of injury, and warrants ruling out subdural hematoma.
- post-traumatic headache
- Note: syndrome of HA, impaired concentration, and altered mood
What are the signs, symptoms and diagnostic findings of a post-traumatic headache?
- within 24 hrs of injury
- constant, dull ace, worse with head movement
- may worsen over few weeks with gradual improvement
- nausea, vomiting common
- exam non-focal
- CT/MRI have typically normal results
How are post-traumatic headaches treated?
- simple analgesics
- ergot derivatives for pain refractory to analgesics
What are non-neurological diseases that can cause headache?
- sinusitis: consider with history of URI/fever with sinus tenderness
- dental: TMJ dysfunction, tooth abscess
- glaucoma: pain typically localized to periorbital region
What are the general rules for imaging recommendations on a patient with a headache?
- nonacute HA an unexplained abnormal neuro finding
- HA worsened by valsalva
- HA that awaken pt from sleep
- new onset HA in older person
- HA with exertion
- progressively worsening HA
- NOT necessary for pts with classical migraine and normal neuro exam, or tension type HAs with normal exam
- MRI has greater resolution compared to CT