Headaches [Cephalgia]

- 2 Naproxen w/ Caffeine and Headache went away.

- Caffeine can be palliative or exacerbate

Types of headache [Paul Winter- PEDS]

- PRIMARY HEADACHES
1. Migraine
2. Cluster
3. Tension

**TO JUSTIFY MRI cant just have a headache!***

DDx:
H/a- freq
- Know Number of Migraine days per month
o Note migraine can last 72h; IF MIGRAINE FREE FOR 24H
- Unsuccessfully treated migraines
o Triptan only get it a specific time
o Topimax (preventative) if Increased migraines missing work, life,school
- Headache Diary
- Know their meds can get med overuse h/a

- Migraine w/o aura

o @least 5 attacks
o Lasts >4 h
o @least 2 sx:
Unilateral
Pulsating
Moderate severe pain
Aggravated by or causing avoiding physical activity
o During h/a @ least 1:
n/v/photophobia and phonophobia
- Migraine w/ aura
o 30% of the time
Should not be on OCPs / Triptans at same time risk of stroke goes up
o Aura
Vvisual / sensory/dysphasic speech disturbance
Homonoymous visual sx/unilateral sensory sx
>1 aura sx over >5 min, and or different aura sx
5-60min
o Listen to the heart patent foramen ovales

- SNOOP Worrisome h/a red flags

o Systemic sx (fever, wt loss) or secondary risk factors(HIV, systemic cancer)
o Neurologic sx (confusion, impaired alertness,
o Onset: sudden abrupt split second
o Older: new onset and progressive h/a; >50 years old (giant cell arteritis)
 o Prev h/a hx: first/different h/a ((change in attack frequency, severity or clinical features)
- Migraine Trigger
o #1 Stress
o #2 Hormones
o #3 Not eating
o #4 Weather changes in barometric pressure.
- Migraine Pathophys
o Massive vasodilation causing pulsating pain
o Activation and peripheral sensitization of the trigeminal vascular systesm
o If DO NOT BREAK THE MIGRAINE.. brain statys in lower state excitability. Pt is never h/a
free. Nerve blocks etc. Treat early and repeatedly.
o Tx: Triptans- Sertonergic
- Cortical neuronal hyperexcitability multiple mechanisms.
- Low brain Mg2+
o 1-2g of MgSO4 IV can break the headache

Hyperalgesia
Heig

Allodyna pain resulting from a painless stimulus

Acute Migraine
Nonspecific
NSAIDS
Perchlorperazine treats h/a and n
Corticosteroids
Opiods
Specific
Ergotamine/DHE
Triptans: FIRST LINE!! Want rapid onset.
Sumatirptan (Tablet, orally,nasal spray, injectable
If fail triptans do DHE.
Rizatriptan/almotriptan
HEMIPLEGIC MIGRANES/CARDIAC ISSUES DO NOT USE TRIPTANS.

Migraine Prevention
- Topiramate 25 mg
T1/2= 24h
S/E: paresthesia, cognitive dysfunction, wt loss, renal stones, glaucoma
Must stay on the drug for 3 months at the therapeutic dose
o OFF LABEL
ZONESIMIDE
TCA
ELEVILLE
NORTYPTILLINE SOME WT GAIN
o 10mg bump to 30
- Nonpharm
o COQ10 150-300 /day STUDIES SHOW THAT PEOPLE W/ MIGRAINES HAVE LOW COQ10
(MITO DEFECT)
 o B2 400/DAY
o YOGA-TAI CHI
o OMT
- Candesarten 8mg daily for 1-2 weeks then increase to BID dosing
- Other
o Nerve block
Occipital nerve block
Neuralgia
o Depomedrol (steroid)
Only for CLUSTER unles do not respond to nerve block lidocaine.
GREATER OCCIPITALUSED FOR CLUSTER HEADACHE
- CHRONIC MIGRAINE > 15 mg days/month
o Fail 3 preventive and 3 aboortive
- Botox 200 u

Tension Headache
- <15 days per month
- Pressing/tightening (NON PULSATING)
- Bilateral location
- Not aggravated by routhine physical activity
- No n/v/
- No photophobia and sonophobia or only 1 present
- Fewer than 1 days per month w/ headache
- ANTIDEPRESSANTS can worsen headache
o Zorolto/ PPI / TRAZDONE /zoloftCAN TRIGGER IT
- Triggers: muscle spasm / stress
- TX: PT/EXERCISE/TREAT ASSOCIATED SX ALONG WITH IT B/C CAN EVOLVE INTO AN ANALGESIC
REBOUND H/A SO YOU WANT MONITOR THE OTC USE.
- TCA- preventative therapy
- Meds can use: ANTIDEPRESSANTS/NSAIDS/MUSCLE RELAXANTS/

CLUSTER
- RAPID ONSET (5-15min)short duration (45-90min)
- Pacing/restless pt
- Unilateral orbital/temporal severe pain intensity
- O2 IS INDICATED !!! ONLY ONE
- Sx:
o AUTONOMIC SX
o CONJUNCTIVAL INJECITON
o NASAL CONGESTION/RHINNORHEA
o + HORNERS
-TX- SUMATRIPTAN SUBQ 6 MG IV + 100% O2 7-10l/MIN FOR 15 MIN W/ LOOSE FACE MASK
Preventative: verapamil 480mg/d w/ ekg monitoring
High doose prednisone/dexamethasone over 10-14d 80-100mg w/ 14 d taper.
Bridge w/ Compazine on preventing agent and best treatment is prevention.
- Keep headache diary

Explain GOAL and outcome of treatment.