HEADACHE JEOPARDY

Clinic

100

The location of this type of  HA is Unilateral in 60-70%, bifrontal or global in 30%

Migraine

200

Are patient’s with a history of tension type likely to experience worsening or improvement during pregnancy?

In contrast to migraine, the frequency of tension-type headaches usually does not change during pregnancy since these headaches are not hormonally mediated. In two small studies, 56 and 67 percent of patients reported no change in tension headache frequency during pregnancy, 40 and 28 percent reported improvement, and 4 and 5 percent reported worsening

300

Migraines affect __ % of the general population

12-15 percent

400

Are patient’s with a history of migraines likely to experience worsening or improvement during pregnancy?

-The occurrence of migraine is modulated by fluctuations in estrogen levels 

-Most patients improvement over the course of pregnancy,

-5 % describe worsening

-The most common time for recurrence is postpartum. Those who breastfeed are less likely to experience migraine postpartum .

500

What are the risks with using NSAIDs in pregnancy?

• In the first trimester, a possible modest increase in early pregnancy loss and some congenital anomalies has been suggested, but available evidence is limited and weak.
• From 20 to approximately 30 weeks, fetal renal effects leading to oligohydramnios are a concern, generally after days to weeks of treatment; treatment <48 hours is generally safe.
• After 30 weeks, use should be avoided or limited to fewer than 48 hours due to concerns about prenatal constriction of the ductus arteriosus, persistent pulmonary hypertension of the newborn, oligohydramnios and its sequelae, necrotizing enterocolitis, renal dysfunction or failure, and intracranial hemorrhage

Triage

100

The headache is typically diffuse (holocephalic), constant, throbbing, and mild to severe in intensity. Blurred vision, photophobia, and confusion and alteration in the level of consciousness may occur.

PreE Headache

These symptoms are similar to those of migraine, except migraine pain is frequently unilateral. In patients with mildly increased blood pressure that may be due to pain, the diagnosis of preeclampsia-related headache is supported by the presence of other severe features of the disease: scotomata or other visual problems (eg, blurred vision, double vision, photophobia, amaurosis, hemianopsia), epigastric pain, or laboratory findings of thrombocytopenia, elevated liver chemistries, hemolysis, and/or elevated creatinine.

200

Ways to distinguish PreE HA from Migraine (Name 4)

Labs, PE, Associated symptoms, Pregnancy > 20w, relieved by meds

300

First line treatment for Migraine (Name 3)

First Line: Tylenol, Reglan, Fiorocet, Codiene

Second-line therapy: Aspirin or nonsteroidal anti-inflammatory drugs 

Third line: Opiods or Triptans

Refractory: Glucocorticoids, Peripheral Nerve block, MgSO4

400

Pathophysiology of Preeclampsia headache

The cause of headache in preeclampsia/eclampsia is not known, but may be related to increased cerebral perfusion pressure (eg, hypertensive encephalopathy), cerebral ischemia from vasoconstriction (reversible cerebral vasoconstriction syndrome [RCVS]), posterior reversible encephalopathy syndrome (PRES), cerebral edema, or microhemorrhages

500

Medication used for the treatment of HA that is contraindicated during pregnancy because it can cause hypertonic uterine contractions.

Ergotamine

In the ED, but also pregnant

100

Associated with Nausea, vomiting, photophobia, may have aura (usually visual, but can involve other senses or cause speech or motor deficits)

Migraine HA

200

Associated Symptoms include ipsilateral lacrimation and redness of the eye, stuffy nose, rhinorrhea, pallor, sweating, horner syndrome, focal neurological symptoms

Cluster HA

300

Unilateral HA , usually begins around the eye or temple.  Pain begins quickly, reaches a crescendo within minutes, pain is deep, continuous, excruciating, and explosive in quality

Cluster HA

400

First line treatments for Cluster Headache

-First- and second-line therapies: Oxygen, triptans, Topical lidocaine 

-Second-line therapies — After the first trimester, lithium and topiramate are options

-Third-line therapies — Third-line agents include pizotifen, gabapentin, intranasal application of capsaicin, oral melatonin, and greater occipital nerve block. 

- Preventative:  Verapamil and glucocorticoids

500

4 different phases of migraine

Prodrome - can occur in up to 77% of people, usually can be symptoms like yawning, depression, irritability, food cravings, neck stiffness, etc

Aura - 25% of people will experience an aura that is gradual, sometimes visual (bright lines), auditory (tinnitus, etc), somatosensory, motor, or even can be smell

Headache - usually unilateral, tends to be throbbing

Postdrome - sometimes can happen. Head movement may cause pain in location of the previous headache

OB pager

100

Are triptan's safe in pregnancy?

 Sumatriptan (50 to 100 mg orally, 4 to 6 mg subcutaneously, or 5 to 20 mg intranasal solution) and rizatriptan are two selective serotonin agonists that are highly effective in treating migraine headaches. They selectively vasoconstrict brain vessels, but there is a theoretic possibility of vasoconstriction of uteroplacental vessels and increased uterotonic activity 

-Human experience with triptan exposure during pregnancy primarily involves sumatriptan and has been generally reassuring [32,37,38].  manufacturer's pregnancy registry for sumatriptan exposure during pregnancy did not find an increased risk of congenital anomalies or early pregnancy loss in 600 exposed pregnant patients, including 514 first-trimester exposures . 

- In a 2015 systematic review of pregnancy outcome following prenatal exposure to triptans (6 studies, 4208 infants), triptan-exposed migraineurs had similar rates of major congenital anomalies, preterm birth, and early pregnancy loss as migraineurs not using triptans. When the triptan-exposed group was compared with the healthy controls, rates of major congenital anomalies and preterm birth were similar, but early pregnancy loss was increased.

200

Headache is usually positional (worse when upright, better when lying flat) and is often accompanied by neck stiffness, photophobia, nausea, or subjective hearing symptoms.

Spinal HA

300

How is a debilitating spinal HA treated?

Epidural blood patch

400

Etiology of a spinal headache

• The precise etiology of headache after dural puncture is unclear, but is thought to relate to leakage of cerebrospinal fluid (CSF) through the dural hole created by the needle. If CSF leaks at a rate greater than the rate of CSF production, low CSF pressure can result, accentuated at the level of the brain in the upright position. However, not all patients with PDPH have low CSF pressure, and not all patients with significant CSF leak develop a headache

500

How is an epidural blood patch performed and what is the MOA

• Epidural blood patch (EBP) is performed by injecting the patient's blood through an epidural needle into the epidural space
• It is thought that the injection of blood directly compresses the thecal sac, thereby increasing lumbar and intracranial cerebrospinal fluid (CSF) pressure. Once the injected blood clots, it may plug the CSF leak and/or initiate an inflammatory reaction that facilitates healing of the puncture site.

Home call

100

HA described as “pressure,” sometimes may feel like a band around the head (headband area)

Tension HA

200

Low risk features of Headache (Name 3)

• Age <50

• Features that are typical of primary headaches (see above) 

• History of similar headaches, no change in usual headache or new symptoms 

• No abnormal neurologic symptoms  

300

High risk features of a headache (Name 4)

• HA with AMS, seizures, papilledema, changes in vision, stiff neck, focal neurological signs/symptoms
• Sudden onset of severe headache
• New onset of migraine type HA
• HA in immunosuppressed individual
• Change in HA characteristics
• HA associated with fever, head trauma, drug use or toxin exposure, Valsalva, cough, exertion
• HA that awakens the patient from sleep
• HA unrelieved by pain medication
• Pregnancy

400

Preventative treatments for Migraines in pregnancy

BBlockers, Ca-channel blockers, SSRI, SNRI, GPN

Can also consider magnesium oxide

500

Usually moderate headaches with bilateral, non-throbbing quality. Precipitated usually by stress.

Tension HA