Headache

The Migraine And Headache Program

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Primary headache syndromes

• Tension: associated with muscle contraction in neck or lower head

• Cluster, periodic, paroxysmal, brief, sharp, orbital headache that may awaken from sleep

• lacrimation. rhinorrhea. conjunctival injection, or unilateral Horner's syndrome Secondary causes of headaches

• Vascular, stroke, intracerebral hemorrhage. SAH. subdural hematoma

AVM. unruptured aneurysm, arterial hypertension, venous thrombosis

• Infection: meningitis. encephalitis, abscess

• Trigeminal neuralgia

• Extracranial: sinusitis. TMJ syndrome, temporal arteritis Clinical evaluation (jama 2006:296 1274)

• History: quality, severity, location, duration, time of onset, précipitants relieving factors

• Associated symptoms (visual As. nausea, vomiting, photophobia)

• Focal neurologic symptoms

• Head or neck trauma, constitutional symptoms

• Medications, substance abuse

• General and neurologic examination

• Warning signs that should prompt neuroimaging:

worst ever, worsening over days, wakes from sleep vomiting, aggravated by exertion or Valsalva fever, abnl neurologic exam. aura, duster-type headache

Migraine

Epidemiology

• Affects 15% of women and 6% of men; onset usually by 30 y Clinical manifestations (lone« 2004:363 381; jama 2006:296:1274)

• Unilateral or bilateral, retro-orbital, throbbing or pulsatile headache; lasts 4-72 h

• Often accompanied by nausea, vomiting, photophobia

• "POUNDing": Pulsatile: duration 4-72 hOurs; Unilateral; Nausea & vomiting; Disabling I

LR 3.5 if 3 criteria are met. LR 24 if a4 criteria are met

• Classic (18%) visual aura (scotomata with jagged or colored edge) precede headache

• Common (64%) headache without aura

• Complicated = accompanied by stereotypical neurologic deficit that may last hrs

• Précipitants: stress, hunger, foods (cheese, chocolate) and food additives (MSG), fatigue.

alcohol, menstruation, exercise Treatment (nejm 2002:346 257) '

• Eliminate précipitants

• Prophylaxis: TCA. pB. CCB. valproic acid, topiramate {jama 2004.291:965)

• Abortive therapy

ASA. acetaminophen, caffeine, high-dose NSAIDs metodopramide IV. prochlorperazine IM or IV

5-HTi agonists ("triptans"); contraindic in Pts w/ complicated migraine. CAD. prior stroke combination of triptan < NSAID more efficacious than either single agent alone (jama 2007:297:1443)

ergotamine. dihydroergotamine; use with caution in Pts with CAD

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The Prevention and Treatment of Headaches

The Prevention and Treatment of Headaches

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