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Headache Lecture

This document provides guidelines for evaluating and diagnosing headaches, including red flags that warrant further testing or indicate secondary causes. It also outlines criteria for diagnosing different types of headaches like migraines, with and without aura. Treatment options are discussed, including acute treatments like triptans or NSAIDs and preventative medications and lifestyle changes. Calcitonin gene-related peptide (CGRP) plays a role in migraines and new CGRP inhibitors are discussed as preventative treatment options.

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0% found this document useful (0 votes)
90 views3 pages

Headache Lecture

This document provides guidelines for evaluating and diagnosing headaches, including red flags that warrant further testing or indicate secondary causes. It also outlines criteria for diagnosing different types of headaches like migraines, with and without aura. Treatment options are discussed, including acute treatments like triptans or NSAIDs and preventative medications and lifestyle changes. Calcitonin gene-related peptide (CGRP) plays a role in migraines and new CGRP inhibitors are discussed as preventative treatment options.

Uploaded by

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HEADACHE LECTURE

Headache Eval: Red flags for secondary causes (SNOOP4)


 Systemic signs/symptoms: fever, blood work abnormal, wt loss, cancer hx
 Neuro exam abnormal
 Age of Onset < 5 yo or > 50 yo
 Acute Onset
 Pattern change/progressive
 Valsalva Precipitation
 Positional/postural
 Papilledema

Testing for 2ndary causes


 Imaging: MRI > CT except acute hemorrhage
o Suspect infxn or mass lesion  order WOW contrast
o Suspect vascular cause  vessel imaging
 LP
o Get opening pressure!
 Labs: CBC, ESR, CRP

Headache Dx: Migraine without Aura


 At least 5 attacks fulfilling criteria
 HA lacks 4-72 hrs (untreated or unscessfully treated)
 Has at least 2 of the following:
o Unilateral
o Pulsating
o Mod-severe pain
o Aggravation by or causing avoidance of routing physical activity (ex:
walking or climbing stairs)
 During HA at least 1 of the following
o N/V
o Photophobia and phonophobia

Headache Dx: Migraine without aura


 Atleast 2 attacks fulfilling criteria
 One or more of the following reversible aura symptoms
o Visual
o Sensory
o Speech/language
o Motor
o Brainstem
o Retinal
 At least 3 of the following
o At least 1 aura spreads gradually over 5 mins
o 2 or more aura symptoms in succession
o each individual aura lasts 5-60 mins
o at least 1 aura symptom is unilateral
o at least 1 aura symptom is positive
o the aura is accompanied or following within 60 mins by headache

Headache Dx: Phases of migraine attack


 Prodrome (few hrs to days)
o MC is fatigue
o Then problems w/ concentration
o Then yawning, irritability, depression
 Aura (5-60 mins)
 Migraine attack (4-72 hrs)
 Postdrome (24-48 hr)

Treatment: Acute
 Non-specific
o Acetylsalicyclic acid
o Tylenol, advil, aleve
o Diclofenac
o RISK FOR REBOUND  don’t use more than 14 days per month
 Triptans
o Almotriptan
o Eletriptan
o Frovatriptan
o Naratroptan
o Rizatriptan *sometimes insurance covered
o Sumatriptan (oral, nasal subq) **most often covered by insurance
o Zolmitriptan (oral, nasal) *sometimes insurance covered
o Only use about 9x/month
 Combination – Sumatriptan + Naproxen
 No triptans: Hx of MI, uncontrolled BP (>160), Hx of stroke  triptans cause
vasoconstriction
 Opioids/Barbituates are last resort  can covert to chronic migraine, response
decreases over time, can increase migraines due to up-regulation of CGRP
receptors  don’t use more than 1x week
 Make a stratified plan for diff levels of intensity - mild, mod-severe, rescue tx

Headache: Preventative
 Lifestyle mod (hydration, sleeping, skipping meals, exercise)
 Avoid triggers
 Consider adding preventative meds if
o 3+ HA per month causing functional impairment that don’t always respond
to acute tx
o > 6-8 HA per month
o contraindications to acute treatments
o severe presentation (hemiplegia)
o at risk of developing medication overuse

Headache Tx: Preventative


 anti-HTN
o metoprolol, propranolol, timolol, nadolol, atenolol
 anti-seizure meds
o topiramate
o Depakote
 Anti-depressant
o Amitriptyline
o Venlafaxine
 Nutra-ceuticals
o Magnesium citrate
o Riboflavin
o Feverfew
 Botulinum toxin injections (for chronic migraine only)
 Calcitonin-gene-related peptide inhibitors (CGRP)
o Erenumab
o Galcanezumab
o Fremanezumab

Hx of CGRP
 CGRP = potent dilator located in trigeminal system

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