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Various Types of Headaches


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Various Types of Headaches

Primary headaches.

Migraine without aura (common migraine). Must have at least 5 attacks that meet the following criteria:
Headache attacks last 4 to 72 hours.
Headache has at least 2 of the following:
Unilateral location
Pulsating quality
Moderate or severe intensity (inhibits daily activity)
Aggravation by routine physical activity
During the headache, at least 1 of the following:
Nausea or vomiting
Photophobia and phonophobia
No organic cause found by history, PE, neurologic exam.

Migraine with aura (classical migraine). Must have at least 2 attacks fulfilling the following criteria:
At least 3 of the following are present:
One of more fully reversible aura symptoms indicating focal cerebral cortical or brainstem dysfunction.
At least one aura symptom develops gradually over more than 4 minutes.
No aura symptom lasts more than 60 minutes (duration proportionally increases if >1 aura symptom present).
HA follows aura with free interval of less than 60 minutes (may begin before or with the aura). HA usually lasts 4 to 72 hours but may be absent.
No organic cause found by history, PE, neurologic exam.

Tension type.
Headache with at least 2 of the following:
Pressing or tightening quality
Mild or moderate intensity
Bilateral location
No aggravation by routine physical activity
No organic cause found by history, PE, neurologic exam.
Tension headache is separated into two subtypes based on frequency:
Headache lasting 30 minutes to 7 days
No nausea or vomiting with headache
Photophobia and phonophobia are absent, or one but not the other is present
At least 10 previous headaches as above, with number of headache days <180/year and <15/month
Headache averages 15 days/month (180 days/year), 6 months
No vomiting
No more than 1 of the following: nausea, photophobia, or phonophobia

Cluster (episodic or chronic).
Severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes untreated.
Headache is associated with at least 1 of the following on the pain side:
Conjunctival injection
Nasal congestion
Forehead and facial sweating
Eyelid edema
Frequency of attacks ranges from 1 to 8 daily.
At least 5 attacks occur as above.

Chronic paroxysmal hemicrania.
Severe unilateral orbital, supraorbital, or temporal pain always on the same side, lasting 2 to 45 minutes.
Attack frequency >5 a day for more than half the time (periods of lower frequency may occur).
Headache is associated with at least 1 of the following on the pain side:
Conjunctival injection
Nasal congestion
Eyelid edema
Absolute effectiveness of indomethacin (150 mg/day or less).
At least 50 attacks occur as above.
No organic cause found by history, PE, neurologic exam.

Secondary headaches.

Increased intracranial pressure (pseudotumor cerebri). Idiopathic, 19 of 100,000 in obese young females. Has been associated with tetracycline use. Often presents with chronic retrobulbar HA exacerbated by eye movements. Also visual changes, diplopia, meningeal signs, and paresthesias. Exam may reveal papilledema and cranial nerve VI palsy. CSF normal except for elevated opening pressure (250 to 450 mm H2O). Treatment: weight loss, serial LPs to remove 20 to 40 ml, diuretics, acetazolamide 500 to 1000 mg QD, prednisone 40 to 60 mg QD, and rarely a shunt.

Tumor. HA most common only complaint, though only 50% of tumors present with HA. 17% have 'typical' tumor HA (worse in morning, nausea, vomiting, worse bending over). Usually other neurologic signs or symptoms help localize tumor. Obtain head CT with contrast or MRI for patients with chronic HA presenting with new symptoms or abnormal neurologic signs. Treatment: neurosurgical consultation.

Arteritis (giant cell, temporal). Most common symptom is nonspecific headache often with scalp or temporal artery tenderness. Jaw claudication pathognomic. Elderly females at increased risk. Sedimentation rate elevated. Biopsy reveals arteritis. Treatment:

Acute effects of substance use. Occurs within a discrete period after substance use and disappears with elimination of use.

Substance withdrawal. Occurs after >3 months of high daily dose of substance. Occurs within hours after elimination and relieved by renewed intake. Disappears with withdrawal of substance. This includes caffeine use.

Meningitis and herpes encephalitis.

Drug-rebound headache. Aggravating factors: ergotamine induced, analgesic abuse (such as >50 g/month ASA or equivalent mild analgesic, >300 mg/month diazepam.) Treatment: stop drug.

Carbon monoxide poisoning.

Subarachnoid hemorrhage (SAH). Generally have acute onset of worst headache of life. May have nausea, vomiting, mental status changes, or loss of consciousness. Most (59%) have a 'warning leak' before severe event and may have antecedent headaches for weeks. Since mortality is 50% for each bleed, if one can pick up the warning leak, one can prevent death and illness.
May have mental status changes and meningeal signs but may not (39% initially free of CNS symptoms or signs).
Only 10% have initially focal exam.
May have fever and leukocytosis from meningeal irritation.
CT scan will find only about 90% of SAH (98% in third-generation scanners). All those who need a CT also need an LP. CT should be done on those with severe headache that is different from their usual headache or new onset of headache. In one study, 33% of those with new onset of severe headache and no CNS signs or symptoms and no other obvious cause of headache had SAH.
Response to nonnarcotic and narcotic analgesia does not rule out SAH.
Nimodipine reduces the risk of cerebral vasospasm, which may contribute to mortality. Dose is 60 mg Q4h for 21 days.

Physical examination. Vitals (BP and temperature), neurologic deficits, papilledema, retinal hemorrhage, cranial bruit, thickened tender temporal arteries, trigger point for fascial pain, ptosis, dilated pupils, and stiff neck.

Ancillary tests not necessary if physical exam is negative. Routine CT scanning has low yield except when headaches are severe - an indication that subarachnoid hemorrhage or a neurologic deficit may be present.
CT should be done to rule out mass lesion.
An LP should be done if CT negative and suspect SAH (CT will miss about 10%).
Be sure to rule out meningitis, temporal arteritis by the clinical setting. Obtaining a sedimentation rate in elderly patients with new-onset headaches is prudent.
Remember simple causes such as sinusitis, toothache, temporomandibular joint syndrome.

Treatment for Migraine Headache

General. Taper off analgesics to prevent rebound HA and start preventive medications. Depression (if identified) needs to be treated.

Nonpharmacologic prophylaxis for migraine.
Dietary changes.
Avoid monosodium glutamate, nitrates, and alcohol.
Spread out caffeine evenly.
Lifestyle changes. Regular eating, sleeping, and exercise patterns.
Behavioral therapies. Biofeedback, stress management, and self-help groups.

Acute therapy (outpatient).
Acetaminophen or ASA usually are not effective in severe headaches because of delayed gastric emptying. The uses of metoclopramide 10 mg PO may enhance the efficacy of oral medication.
NSAIDs. Such as ibuprofen 400 to 800 mg PO TID or QID or naproxen sodium 550 mg PO BID or TID with food.
Fiorinal 1 or 2 tablets Q4-6h up to 4 per day and twice per week. Avoid overuse.
Abortive therapy for migraines. Ergotamine derivatives contraindicated in peripheral or coronary artery disease. Do not use sumatriptan in those who have had an ergot preparation within the last 24 hours and vice versa.
Midrin 2 caps PO initially and then 1 capsule Q1h up to 5 in 12 hours.
Sumatriptan (Imitrex) 6 mg SQ; may repeat in 1 hour; maximum 12 mg/24 hours. Contraindicated if concomitant CAD or uncontrolled hypertension. Do not use if patient is given an ergot alkaloid in the last 24 hours. Many (up to 50%) will require rescue medicine because of sumatriptan's 2-hour halflife. Oral sumatriptan available but not so effective.
Cafergot 1 or 2 tablets PO; may repeat up to 4 tabs/attack or 10/week.
Ergotamine 2 mg PO or SL; may repeat in 30 minutes up to 6 mg/24 hours or 10 mg/week.
Prochlorperazine 25 mg PR BID PRN can be used to abort the migraine at home.

Acute therapy (emergency room): migraine.
Antiemetics may in themselves abort the headache.
Prochlorperazine (Compazine) 10 mg IV or chlorpromazine 25 to 75 mg IV. Chlorpromazine has fallen out of favor because of hypotension, which can be treated with IV NS.
Metoclopramide 5 to 10 mg IV Q8h. Often given with dihydroergotamine (DHE) to prevent DHE-induced nausea. May be combined orally with ASA.
NSAIDs (ketorolac [Toradol] 60 mg IM, indomethacin [Indocin] 50 mg PR BID or TID). Not so effective in migraines.
Dihydroergotamine (DHE) 0.75 mg IV over a few minutes preceded by prochlorperazine or metoclopramide 10 mg IV. Another 0.5 mg of DHE may be given in 30 minutes. Contraindicated in peripheral or coronary artery disease or those who are >60 years of age or those who have had sumatriptan.
Meperidine (Demerol) 50 to 100 mg IM Q3h PRN.
Dexamethasone 4 mg IM or a short course of prednisone (40 to 60 mg PO QD), combined with analgesics above, if migraine continues >24 hours.
Sumatriptan (Imitrex); see above for dose. Oral sumatriptan also available but less effective.
Lidocaine 100 mg IV once for intractable headache. Patient should not drive after treatment. Risk for seizures, arrhythmia, confusion.
Transnasal butorphanol 1 mg (1 spray in 1 nostril) repeated if necessary in 60 to 90 minutes.

Amitriptyline 10 to 200 mg PO QHS. Other tricyclic antidepressants (TCAs) also effective.
Propranolol 20 to 60 mg PO BID to QID. Long-acting form can be used. Consider switching to a second beta-blocker if first one fails after adequate trial period (6 to 8 weeks). Contraindicated in asthma, heart failure, and diabetes.
Verapamil 40 to 80 mg PO TID (80 to 240 mg/day). Diltiazem and nifedipine are less effective. More beneficial in migraine with aura or cluster headache. Trial should be .2 months. Contraindicated in heart failure and heart block. Constipation is a common side effect.
NSAIDs, especially useful for menstrual migraine.
Cyproheptadine 2 to 4 mg PO QID. Less effective than methysergide but safe.
Methysergide (Sansert) 1 to 2 mg PO QID. Should not use longer than 6 months without a 1-month drug holiday to avoid fibrosis. Contraindicated in peripheral or coronary artery disease.
Ergotamine (low dose) 1 mg PO BID, not to exceed 10 mg/week (2 days/week skipped), contraindicated in ischemic diseases.
Carbamazepine 200 to 800 mg PO daily dose divided BID to QID.
Phenytoin 300 to 800 mg PO daily dose divided QD to TID. Efficacy not shown for migraine with aura.
Valproic acid 250 to 1500 mg PO daily dose divided BID to QID titrated up to effective blood levels (50 to 100 mg/L).
Fluoxetine 10-30 mg PO Qa.m. Other SSRIs are also effective.

Treatment for Severe Tension Headache
Symptomatic treatment. Simple analgesics, NSAIDs, or TCAs as above.
Preventive treatment. TCAs, beta-blockers, or calcium-channel blockers as above.

Treatment for Cluster Headache
Acute treatment is by any of the following:
Oxygen inhalation through a nonrebreathing mask at a flow rate of 6 to 8 L/min for 15 minutes is 70% effective.
Nasal lidocaine 4% solution (15 drops) or 5% ointment (3 swabs) intranasally on ipsilateral side may be abortive.
Sumatriptan is especially effective for cluster headache because by definition they last <3 hours. However, this is not an approved usage.
Parenteral therapy as above.
Prophylactic treatment. Low-dose oral ergotamine, methy-sergide, prednisone (60 mg QD for 1 week with a rapid tapering off), verapamil (80 to 160 mg TID), lithium carbonate 300 mg BID or TID, with or without valproate 250 to 1500 mg total daily dose divided BID to QID.

Rates of successfuln pregnancy following 3 spontaneous losses(habitual abortions) are
a. very poor
b. slightly worse than those in the baseline population
c. No different from those in the baseline population
d. just under 50%
e. good unless cervical incompetenence is diagonosed
Give explanation


The data applies to cases of rec abortion without identifiable causes.
if 3 preg lost- 70-80% success
if 4/5 preg lost- 65-70% success.
Hope this helps.




Pregnancy MAY accelerate the growth of CA Breast- inflammatory CA is infact most common in lactating mothers.
Prepregnancy mammography is advised in women>35 expecting

No effect of cyclic hormones during this period
lactation decreases breast cancer risk
Have more kids to reduce your risk of breast & uterine Cancer
Nulliparous women more risk of having cancer

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