Neurology – Headaches: Tension and Migraine – PPT/Book – Flashcards
Unlock all answers in this set
Unlock answersquestion
A 29 year old female presents with complaints of recurring generalized headaches over the past couple of months that last for several hours to a day or 2 at a time. Her pain is described as a 3/10, no-pulsatile, pressure and is present shortly after waking up. She does have some pain and neck tightness, but no fever. She reports that she has been really stressed at work lately. What type of headache is this likely?
answer
Tension headache.
question
What is the pathophysiology of tension headaches?
answer
May be related to: 1. Emotional stress. 2. Sustained craniocervical muscle contraction.
question
Who gets tension headaches more often, males or females?
answer
Females.
question
Which age groups get tension headaches.
answer
*Mostly young adults. *But can be all ages.
question
It is unusual to have your first tension headache above the age of what?
answer
50.
question
Tension headaches associated with stressful events, moderate intensity, and self-limited with response to non-pharmacological treatment is most likely a [episodic/chronic] tension headache.
answer
Episodic.
question
Daily tension headaches that bilateral in the occipital-frontal regions and associated with contracted neck/scalp muscles are more likely [episodic/chronic] tension headaches.
answer
Chronic.
question
What is the International Headache Society's diagnostic criteria for tension headaches?
answer
2 or more of the following: 1. Non-pulsatile pressure or tightening. 2. Frontal-occipital. 3. Bilateral. 4. Mild to moderate. 5. Not aggravated by physical activity.
question
True or False: The pain of a tension headache is usually throbbing.
answer
False. It is usually steady and often described as a pressure feeling or viselike sensation.
question
Describe the location of tension headaches.
answer
*May be frontal, occipital, or generalized. *Often pain in neck area [differentiates from migraine]. *Usually bilateral.
question
What is the usual onset of a tension headache?
answer
*Often present upon waking up or shortly after. *Gradual onset.
question
Describe the duration of tension headaches.
answer
*Lasts for 30 minutes to days. *Does not rapidly appear and disappear.
question
Do tension headaches have an aura.
answer
No.
question
Do tension headaches have associated photophobia and/or phonophobia.
answer
Yes, they can, but these are not prominent symptoms.
question
Which of the following are tension headaches not associated with: a. Nausea and vomiting. b. Insomnia. c. Difficulty concentrating. d. Emotional distress or intense worry.
answer
a. Nausea and vomiting.
question
Which type of headache is commonly associated with muscular tightness in the head or neck?
answer
Tension headaches.
question
Physical exam findings of someone with a tension headache.
answer
1. Normal vital signs. 2. Normal neuro exam. 3. +/- Neck/scalp tenderness. 4. No pain over temporal arteries. 5. +/- Very tender cervical muscles. 6. Pain with neck flexion [distinguish from nuchal rigidity]. 7. Stress/anxiety/depression.
question
Should lab or imaging studies for tension headaches be ordered? If so, what?
answer
Order: 1. Specific labs only if indicated --> should be normal in tension headaches. 2. Head CT/MRI only if headaches have changed or neruo exam is abnormal.
question
What are non-pharmaceutical treatment options for tension headaches.
answer
1. Eliminate potential triggers [medications, drug dependency]. 2. Biofeedback Relaxation therapy. 3. Physiotherapy. 4. Acupuncture. 5. Electrical stimulation. 6. Life style modifications [exercise, diet, sleep]. 7. Massage, PT, posture training. 8. Cervical traction.
question
Per the book, what has been shown to be the most useful for prevention of tension-type headaches.
answer
Tricyclic antidepressants drugs in low doses. *Especially since many patients have concurrent anxiety/depression. *Amitriptyline is the most researched.
question
What drugs might be considered for symptomatic relief of a tension headache?
answer
1. NSAIDS. 2. Acetylsalicyclic acid [ASA]. 3. Barbituates [with ASA and caffeine]. 4. Acetominophen. 5. Analgesics/antiemetic or sedatives [phenergan, compazine]. 6. Ergot alkaloids [e.g. cafetrate].
question
Besides non-pharmaceutical options and oral medication treatments for tension headaches, what are 2 other injectable options to treat tension headaches?
answer
1. Injection of trigger points. 2. Botox.
question
You walk into the ER room of a 22 year old female who has turned off all of the lights and is wearing dark sunglasses. She is curled up in a ball, holding her stomach. She grabs the left side of her head and tells you that she has a throbbing headache and nausea that has been steadily building over the past several hours. What type of headache is this most likely?
answer
Migraine.
question
Migraine headaches are the [first/second/third] most common type of headache.
answer
Second.
question
What percent of the U.S. population has migraines?
answer
10-20%.
question
What is the female/male ratio for migraine prevalence?
answer
3 females: 1 male.
question
Migraines may begin at any age, but what are the peak ages of onset? By what age will 80% of people have their first migraine if they are going to have them?
answer
Peak = Adolescence and early adulthood. Most by age 30.
question
New onset of migraines past age _____ is rare.
answer
Past age 50.
question
A positive family history of migraine headaches is reported in what percent of cases?
answer
65-91%.
question
A migraine attack is the end result of the interaction of a number of factors of varying importance in different individuals. What are 4 factors discussed in the book?
answer
1. Genetic predisposition. 2. Susceptibility of CNS to certain stimuli. 3. Hormonal factors. 4. Sequence of neurovascular event.
question
The pathophysiology of migraines involves many factors is not well understood. However, what is one of the key structures in the mechanism of pain in a migraine? Describe this pathophysiology?
answer
Trigeminal Vascular System: 1. Stimulation of trigeminal nucleus caudalis activates serotonin receptors and nerve endings on nearby dural arteries. 2. Vasodilation and neurogenic inflammation results. 3. Consequently, perivascular nerve endings are stimulated, leading to referred pain along the trigeminal nerve.
question
Which 2 neurogenic peptides have been linking to the pathophysiology of migraines?
answer
1. Serotonin. 2. Dopamine.
question
Which neuropeptide receptor is the most important in the migraine headache pathway?
answer
Serotonin receptor 5-HT. *note, Triptans target this.
question
True or False: Neuropeptides are vasoactive.
answer
True.
question
What is the migrainous aura likely caused by and what does it correspond to?
answer
"Cortical spreading depression," corresponds to: *Wave of neuronal depolarization. *Spreads over cortex posterior to anterior.
question
What are some triggers for migraines that were discussed in class?
answer
1. Emotional or physical stress. 2. Lack or excess of sleep. 3. Missed meals. 4. Specific foods [chocolate, alcohol]. 5. Menstruation. 6. Oral contraceptives.
question
Where is the usual location of a migraine headache?
answer
1. Frontotemporal distribution. 2. Usually unilateral, but can be bilateral.
question
Describe the character/quality of migraine pain.
answer
1. Pulsating. 2. Dull, throbbing. 3. Severe, disabling pain.
question
Describe the onset and duration of a migraine.
answer
1. Builds gradually. 2. May last hours or more.
question
What is the usual severity level of a migraine?
answer
Severe, disabling.
question
Is a migraine headache worse with activity?
answer
Yes.
question
Besides an aura, what are some symptoms that are often present during a migraine?
answer
1. Photo-/phono-phobia. 2. Anorexia. 3. Nausea. 4. Occasionally vomiting.
question
Especially in the absence of GI symptoms, the diagnosis of migraine requires the presence of at least one of which features/symptoms?
answer
1. Photophobia. 2. Phonophobia. 3. Osmophobia.
question
In children, migraine is often associated with what types of symptoms?
answer
Episodic: 1. Abdominal pain. 2. Motion sickness. 3. Vertigo. 4. Sleep disturbances.
question
Which type of migraine is more common, one with or without an aura?
answer
Migraine without aura is more common = 70% - 80%
question
What is a migraine aura?
answer
Focal neurological symptoms that precede accompany, or rarely, follow an attack.
question
Describe the onset/timing/duration of a migraine aura.
answer
Usually: 1. Develops over 5-20 minutes. 2. Lasts less than 60 minutes.
question
What types of symptoms can an aura involve?
answer
1. Visual. 2. Sensorimotor. 3. Language. 4. Brainstem disturbances.
question
What is the most common type of migraine aura?
answer
Positive visual disturbances.
question
What are some visual disturbances that often precede a headache?
answer
1. Scotoma. 2. Scintilla.
question
A migraine aura can include symptoms like unilateral paresthesia/weakness, diplopia, visual field abnormalities, dysarthria, etc. What are 2 things from the history that indicate that a migraine is more likely than a TIA?
answer
1. Symptoms of a migraine evolve, where as they do not in a TIA. 2. Symptoms are typically "negative" in TIA, vs "positive in migraine. *i.e. positive = presence of abnormal sensation, vs. negative = absence of normal sensory.
question
Migraines with auras were formerly called what? Without auras?
answer
With auras = classic. Without auras = common.
question
In primary care especially, migraines are commonly mis-diagnosed as what?
answer
Sinus headaches.
question
What are rare, variants of migraines?
answer
1. Hemiplegic migraine. 2. Basilar migraine. 3. Ophthalmoplegic migraine. 4. Vestibular migraine.
question
What types of symptoms are associated with a basilar migraine?
answer
Bilateral occipital lobe, brainstem, or cerebellar dysfuction, including: 1. Diplopia. 2. Ataxia. 3. Aphasia. 4. Syncope. 7. Other balance problems.
question
Basilar migraines primarily occur in which age group?
answer
Children.
question
What are vestibular migraines?
answer
Symptoms of vertigo with or without the other typical migraine symptoms.
question
True or False: Tension headaches are associated with the presence of a patent foramen ovale.
answer
False. Migraine headaches are associated with a patent foramen ovale. Some hypothesize that this might contribute to the increased stroke risk in those with migraines.
question
One prospective study of women younger than 45 found that active migraine with aura was associated with significantly increased risk of what serious conditions?
answer
1. CVD. 2. MI. 3. Ischemic stroke. 4. Death due to ischemic CVD.
question
3 treatment goals of migraine treatment.
answer
1. Making an accurate and confident diagnosis, and reassuring the patient that there is not a more sinister cause. 2. Relieving acute attacks. 3. Preventing pain and associated symptoms of recurrent headaches.
question
Women who have migraine with aura already have an increased risk of stroke, but this risk is about doubled if they also take what medication?
answer
Oral contraceptives. ***Copper IUD is an option, but avoid hormonals.
question
The patient should be involved in their treatment plan for migraines. What is the most important way they can do this and what 3 purposes of this?
answer
Keep a headache diary: 1. Identify triggers. 2. Monitor headache frequency. 3. Monitor treatment response.
question
When are migraines treated prophylactically?
answer
Frequency of migraines >2-3/month.
question
For a preventative drug to be considered effective, it should decrease headache frequency rate by how much?
answer
50% decrease.
question
In general, what are 5 drug classes that can be used to prevent migraines?
answer
1. Beta-adrenoceptor blockers. 2. Antiepileptic drugs. 3. Antidepressants. 4. Calcium channel blockers. 5. Other.
question
What are the top 3 migraine prophylaxis drugs?
answer
1. Topiramate. 2. Amitriptyline. 3. Propranolol.
question
4 important things to know about topiramate.
answer
1. Contraindicated if kidney stone history. 2. Can cause forgetfulness and cloudy thinking. 3. Significant weight loss. 4. Teratrogenic, so contraceptives a must [causes cleft palate].
question
3 things to know about amitriptyline.
answer
1. Black box for suicide risk. 2. Urinary retention [in elderly]. 3. Good for chronic pain.
question
What drug class is propranolol in? Who is it contraindicated in?
answer
Class = Beta Blocker. Contraindicated in = Asthma patients.
question
What are 6 general treatments/things you can do to treat a symptomatic migraine?
answer
1. Dark, quiet room. 2. Simple analgesic immediately will often help. 3. Extracranial vasoconstrictors [e.g. cafergot]. 4. Triptans. 5. Treat nausea/vomiting. 6. Hydration.
question
What is the MOA of triptans in migraine therapy?
answer
5-HT1 serotonin receptor agnoists that: 1. Stimulate 5-HT1 receptors to produce a direct vasoconstrictive effect. 2. Suppress inflammation.
question
When are triptans contraindicated?
answer
1. Vasospastic vascular disorders. 2. Ischemic vascular disorders. 3. Uncontrolled HTN. *e.g. Vasocontrictive angina.
question
Women who take oral contraceptives are at increased risk of what if they take triptans?
answer
Strokes. *2-4 fold rate increase.
question
What is the MOA of ergotamines in migraine therapy?
answer
1. Direct vasoconstrictors of smooth muscle in cranial blood vessels. 2. Alpha-adrenergic antagonist and serotonin antagonists effects.
question
What is the main ergotamine used to treat migraines?
answer
Ertotamine tartrate. *[Brands = Cafergot, Cafatine, Cafertrate, which also contain caffeine].
question
True or False: By definition, migraines are not responsive to simple analgesics, such as acetaminophen, aspirin or NSAIDS.
answer
False. Many attacks will respond to this, especially if only a mild to moderate attack.
question
Opiods and barbituates should not be used in routine migraine management. However, if used, what things do barbituates help with?
answer
1. Induces sleep. 2. Provides analgesia.
question
What other medications are barbituates usually given with for migraine?
answer
1. ASA or acetaminophen. 2. Caffeine.
question
Why is caffeine given with barbituates is there is a migraine?
answer
Increases GI absorption.
question
Which combination barbituate is most commonly used to treat acute migraines? What is in it?
answer
Fioricet: 1. Acetaminophen. 2. Butalbital. 3. Caffeine.
question
What are 4 antiemetics commonly prescribed for nausea and vomiting with migraines?
answer
1 Odansetron [Zofran]. 2. Promethazine [Phenergan]. 3. Prochlorperazine [Compazine]. 4. Droperidol [Inapsine]. *Note, they will also help the headache. *Connelly prefers Odansetron.
question
What is it called when a severe migraine lasts longer than 72 hours?
answer
Status migrainosus.
question
How is status migrainosus treated?
answer
Consider admission and give: 1. IV diphenhydramine [antihistamine]. 2. Ketorolac [no longer than 5 days]. 3. IV dihydroergotamine. 4. IV dexamethasone.
