Headaches

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Author:
Mat
ID:
90345
Filename:
Headaches
Updated:
2011-08-17 15:12:05
Tags:
Neuro
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Description:
Migraines, etc.
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  1. What is paroxysmal hemicrania?
    one of the trigeminal autonomic cephalalgias, which are characterized by pain referred to the first division of the trigeminal nerve and by accompanying cranial autonomic symptoms, including lacrimation and rhinorrhea. An attack of paroxysmal hemicrania has an intermediate duration (mean, 15 minutes) and an intermediate episodic frequency (mean, 11 per day). Treatment with indomethacin can immediately and completely resolve the headache. Usually, the response occurs within the first 48 hours after treatment is initiated.
  2. How do you treat paroxysmal hemicrania?
    Indomethacin is the treatment of choice for paroxysmal hemicrania.
  3. What is the recommended treatment for migraine during pregnancy?
    Amitriptyline and verapamil are used for migraine prophylaxis. Both have an FDA rating of pregnancy category C (risk to the fetus cannot be ruled out) and are not contraindicated for pregnant women. However, prophylactic migraine therapy should be avoided whenever possibly during pregnancy, especially in the first trimester. Often, migraine improves during the second and third trimesters of pregnancy, so acute therapy during the first trimester is preferred. If migraine continues to be disabling and occurs frequently during the second and third trimesters, prophylactic therapy could be considered, especially if the health of the mother and/or the fetus is compromised.
  4. What is a thunderclap headache?
    A thunderclap headache is a severe and explosive headache that is maximal in intensity at or within 60 seconds of onset. Every thunderclap headache must be immediately evaluated to detect potentially catastrophic conditions, especially subarachnoid hemorrhage
  5. How do you manage a thunderclap headache?
    • CT angiography of the head and neck.
    • Magnetic resonance angiography. (MRA) would also be appropriate in this setting.
    • Both CT angiography and MRA can be performed with a venous phase to exclude cerebral venous sinus thrombosis.
  6. What is a cluster HA?
    Describe its classic presentation.
    What are the cardinal symptomsof a cluster HA?
    • Cluster headache lasts longest (mean duration, 1 hour), has relatively low episode frequency (one to three per day), and responds best to verapamil.
    • A cluster headache is an excruciating unilateral headache of extreme intensity, with a typical duration of 15 minutes to 3 hours.
    • Its pain is lancinating or boring in quality and is located behind the eye (periorbital) or in the temple, sometimes radiating to the neck or shoulder.
    • The cardinal symptoms of a cluster headache attack are ptosis (drooping eyelid), conjunctival injection (redness of the conjunctiva), lacrimation (tearing), rhinorrhea (a runny nose), and, less commonly, facial blushing, swelling, or sweating. These features are known as the autonomic symptoms. The neck is often stiff or tender in the aftermath of a headache, with jaw or tooth pain sometimes present.
  7. What is the recommended treatment for migraine during pregnancy?
    Amitriptyline and verapamil are used for migraine prophylaxis. Both have an FDA rating of pregnancy category C (risk to the fetus cannot be ruled out) and are not contraindicated for pregnant women. However, prophylactic migraine therapy should be avoided whenever possibly during pregnancy, especially in the first trimester. Often, migraine improves during the second and third trimesters of pregnancy, so acute therapy during the first trimester is preferred. If migraine continues to be disabling and occurs frequently during the second and third trimesters, prophylactic therapy could be considered, especially if the health of the mother and/or the fetus is compromised.
  8. What preventive medication for headache should be avoided in pregnant women?
    • Valproic acid is a known teratogen.
    • First-trimester exposure to this drug is associated with neural tube defects in approximately 17% of exposed fetuses. Its use should be avoided in women who are planning to become pregnant and during the first trimester of pregnancy.
  9. What is tension-type HA?
    • a dull, bilateral, or diffuse headache, often described as a pressure or squeezing sensation of mild to moderate intensity.
    • no accompanying migraine features (nausea, emesis, photophobia, phonophobia), and its pain is not worsened with movement and does not prohibit activity.
    • In patients with a new headache at presentation, especially patients older than 50 years, tension-type headache should be considered a diagnosis of exclusion because it is the type of headache most frequently mimicked by brain tumors and other organic causes.
  10. Clinical feature of chronic migraine?

    Recommended treatments?
    Migraine with or without aura on >15 days per month for >3 months

    Approved medications for episodic migraine (propranolol, topiramate, valproic acid)
  11. Clinical Features of chronic tension-type headache?

    Recommended Treatments?
    • Mild to moderate severity; no migraine symptoms; bilateral
    • Amitriptyline
  12. Clinical Features of new daily persistent headache?
    Recommended Treatments?
    Bilateral, persistent, moderately severe; may be preceded by viral infection; may resemble migraine or tension-type headache

    Amitriptyline
  13. Clinical Features of Hemicrania continua?

    Recommended Treatments?
    • Rare, unilaterally constant exacerbations of severe headache, cranial autonomic symptoms, and “ice-pick” pain
    • completely responsive to indomethacin
  14. Clinical Features of Cluster headache?

    Recommended Treatments?
    • Cluster periods of 4-8 weeks, 1-3 times per year; daily headaches, frequently nocturnal, occurring 1-8 times per day, each lasting about 1 hour on average; extremely severe, mostly periorbital/temporal, and associated with motor restlessness and autonomic symptoms (tearing, rhinorrhea)
    • Verapamil, prednisone, gabapentin; acute: sumatriptan by NS or SC injection; zolmitriptan by NS; 100% oxygen
  15. Clinical Features of Hypnic headache?

    Recommended Treatments?
    • Occurs daily but only during sleep; moderately severe; often bilateral; lasts about 1 hour; not associated with autonomic symptoms
    • Tx: Caffeine; lithium; indomethacin
  16. Clinical Features of Paroxysmal hemicrania?

    Recommended Treatments?
    • Headaches identical to cluster headache except that attacks occur more frequently (>5 and up to 24 per day) and are shorter in duration (8-25 min); usually completely responsive to indomethacin
    • Tx: Indomethacin
  17. Clinical Features of SUNCT (Short-lasting Unilateral Neuralgiform headache attackts with Conjunctival injection and Tearing) syndrome?

    Recommended Treatments?
    • Headaches resemble cluster and paroxysmal hemicranias except that attacks occur more frequently (30-100 per day) and are much shorter in duration (20-120 seconds). These headaches may be mistaken for trigeminal neuralgia except that patients have strictly periorbital (cranial nerve V1) pain and cranial autonomic symptoms.
    • Tx: Lamotrigine, gabapentin, topiramate, carbamazepine
  18. Treatment of Chronic Migraine and Medication Overuse Headache?
    • Education, support, and close follow-up for 8 to 12 weeks
    • Lifestyle modifications (quitting smoking, eliminating caffeine, exercising, eating regular meals, and establishing a regular sleep schedule)
    • Behavioral therapy (relaxation therapy, biofeedback, cognitive behavioral therapy)
    • Abrupt withdrawal of overused medications for acute headache, except barbiturates or opioids
    • Standard acute headache treatment (for moderate or severe headache; such therapy is generally not associated with medication overuse headache)
    • NSAIDs (such as naproxen sodium, 550 mg)
    • Dihydroergotamine (1 mg intranasally, subcutaneously, or intramuscularly)
    • Antiemetics (metoclopramide, 10-20 mg; prochlorperazine, 10 mg)
    • Preventive therapy:
    • Topiramate, 50-100 mg twice daily
    • Valproic acid, 250-500 mg twice daily
    • Amitriptyline, 50-100 mg at bedtime

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