What a Long, Strange Triptan Its Been Headaches as long as the RITEWorst headache of l
Grunwald, Drew, Host has reference to this Academic Journal, PHwiki organized this Journal What a Long, Strange Triptan Its Been Headaches as long as the RITEWorst headache of life, artists depictionRyan JacobsonThis Lecture: Why & WhatIdentified as an area of deficiency in many yearsMany questions pertain to headache pathophysiology in addition to management each yearCase-based scenarios in addition to review based on data from the last 4ish years Case 1 A 29-year-old baker has been busy tasting pies. Eventually he develops symptoms of flushing, palpitations, tingling in his extremities, in addition to a severe headache. He is hallucinating. He does not have a history of migraine. Which ingredient has he over-indulged in
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Case 1Nutmeg. Mediated by a chemical in nutmeg myristicin, which acts as a hallucinogenSymptoms improve over several hours. Benzodiazepines can be used as long as agitationTested multiple times Case 2A 29-year-old woman with no previous history presents with a left-sided headache. Photophobia in addition to vomiting are present. She endorses seeing flashing lights in her vision, a symptom that began just be as long as e the headache. She notes poor sleep over the previous 3 days. Family history notable as long as sister with migraine.Exam: afebrile. no papilledema. No nuchal rigidity. What is your next stepLumbar puncturePET scanIV phenytoin loadTriptan
Case 2MigraineCan treat as long as migraine with triptan. Triptans work at 5HT1 receptors, 1b 1d subtypes.Remember triptans are contraindicated with known CAD Note: if they give you a scenario where a woman is being abused in addition to has migraines, address the abuse first. Tested 2013. This patient’s symptoms are most compatible with migraine. There are no features of her history or examination to suggest a more serious underlying disorder such as meningitis, subarachnoid hemorrhage, or a space occupying lesion. Parenteral symptomatic therapy is warranted of which sumatriptan would likely be most effective.Case 3A 43 year old man presents with head pain that wakes him up in the early morning hours. He describes pain behind his right eye that occurs in severe attacks. He has noticed tears coming out of the right eye during the attacks. He cannot provoke episodes by touching the right side of his face. He denies trauma. Case 3 Cluster HeadacheThere is an association with smoking.Oxygen should abort headache. DHE less effective. Prednisone can potentially prevent recurrence of headache.What can prevent the next headacheWe will re-visit some details of cluster headache in a few slides
Case 4A 33-year-old woman presents as long as evaluation of episodes of head pain. She has not seen a doctor as long as these, because the attacks of pain only last about 5-8 minutes. The pain is located over her left eye in addition to temple. During the attacks, she has noticed some discharge from her left eye in addition to nose on some occasions. Which treatment should be offeredCase 4The diagnosis is paroxysmal hemicrania. Some autonomic features.The headaches are Indomethacin responsive.Side-lockedMinutes long, several times a day.More common in women. Tested multiple times, essentially every year
Contrast with Hemicrania ContinuaConstant unilateral headache, temporal or periorbital Also more common in women Can have exacerbations that sound migrainous or cluster-like Child with hemicrania continua was on 2011 exam. Adult in 2012. Child in 2015 (why!)Also indomethacin responsive (by definition)A continuous, unilateral headache is most likely hemicrania continua, one of the trigeminal cephalgias. It is very responsive to indomethacin, in addition to this can be used as both a treatment in addition to diagnostic trial.Contrast with Cluster HeadacheMore common in menAssociated with smoking (appears to have been tested in 2012) Remember, oxygen is useful. This was tested in 2012 in addition to 2013. Time duration between that of paroxysmal hemicrania in addition to hemicrania continua Case 4-AA 33-year-old man presents with unusual head pains. He says that he gets sudden bouts of brief of right eye in addition to temple pain. They are so short, that they last as long as one commercial on TV. Nothing provokes them. His wife notes that he has no pain tolerance, since tears are always coming out of his right eye during the episodes of pain. What is the best diagnosis, in addition to what are the next steps
Case 4A SUNCT short-lasting unilateral neuralgi as long as m headache with conjunctival injection in addition to hearingThink BUNCT – these are the briefest of the TACs – 5-240 seconds Conjunctival injection in addition to tearing prominent in storySUNCT (5-240 seconds) < Paroxysmal Hemicrania (women!) < Cluster < Hemicrania ContinuaCase 4A, continued In SUNCT, consider imaging to rule out skull base lesion.Some role as long as IV Lidocaine Does patient have HA Just a Headache Not Just a HeadacheMELAS INFECTION CADASIL SAHMIGRAINOUS POSITIONAL/MENINGEAL ENHANCEMENT PAPILLEDEMA/OBESE AUTONOMIC/TACCSF HYPOTENSION. RECOMMEND BLOOD PATCH. PSEUDOTUMOR. Consider if on Vitamin A derivatives. PROPHYLACTIC NEEDED ABORTIVE NEEDED MEDICATION OVERUSE-CONSIDER TOPIRAMATE. -TRIPTAN IF NO C/I -DISCONTINUE OFFENDING AGENT -NO VPA IF WOMAN. -AVOID BB IN ASTHMA MAN/MANY MINUTES MAN/FEW SECONDS WOMAN/SECONDS-MINUTES WOMAN/CONTINUOUS CLUSTER SUNCT PAROXYSMAL HEMICRANIA HEMICRANIA CONTINUA OXYGEN INDOMETHACIN DID I MISS SOMETHING IS IT A TACNO YESConsider lidocaine Case 5A 76-year-old retired horticulturist presents as long as evaluation of headaches. She is distraught, as she has never had headaches be as long as e. She has pain over the right temple. The pain has been worsening over time. She has lost weight in the past 10 days, because her jaw in addition to tongue hurt with chewing. Review of Systems notable as long as fatigue in addition to shoulder achesWhat are your next steps, in addition to in which order Case 5The diagnosis is temporal arteritis.Next steps:Check ESRGive steroids urgentlyTemporal artery biopsy to follow as soon as possible2014: steroids be as long as e biopsy may result in scar tissue rather than inflammation in biopsy specimenCase 6A 38-year-old migraineur has been relatively headache free as long as the last 6 months. She slips on an icy sidewalk, striking her neck. She now has a new type of headache, described as severe, diffuse head pain. Associated features include nausea in addition to tinnitus. She notes that the pain is 10/10 when upright, in addition to 1/10 when supine. Her MRI is shown. Case 6Answer: intracranial hypotension. They have given a traumatic precipitant. Imaging shows diffuse dural enhancement. (HOPEFULLY they give you an image with smooth, diffuse enhancement to steer you away from cancer) If no image is given, they want you to identify it with MR imaging or CT myelogram. Do not go as long as LP or cytology.
Case 6 continued The patient wishes as long as a medication that will be safe with breast feeding. Which of the following is the safest option1. Aspirin2. Heavy duty barbituates3. Sumatriptan4. Amitriptyline 5. Hydrocodone-AcetaminophenCase 6 continued They want you to say that narcotics are safest. While the amount of most drugs excreted in breast milk is 1% to 2% of the maternal dose, there is some variability depending on both the drug’s characteristics in addition to breast milk’s characteristics. Barbiturates may cause sedation; aspirin is considered less safe than acetaminophen; triptans in addition to tricyclic antidepressants are of unknown risk to the infant; while narcotics are safe.
Case 7 In peds clinic you see 2 patients – Patient 1 Savannah is a 9 year old girl with frequent headaches as long as the past 2 months. They are located over the temple, in addition to occasional cause vomiting. They are getting no better. Exam is normal. Patient 2 Dylan is a 10 year old boy with headaches as long as the past 2 months. They are gradually worsening. When the headache is most severe, he loses vision. Examination is notable as long as right hemibody ataxia.Which one needs imagingCase 7The second patient (obviously) The majority of children with recurrent headaches, with complete clearing between episodes, do not need neuroimaging. The following would m in addition to ate neuroimaging in a child presenting with headaches: auras lasting more than an hour, persistent neurologic findings, abnormal neurologic exam between headaches, predominantly occipital headaches, loss of vision at headache peak, or recent significant change in headache pattern. Case 7 continued Which treatment is best as long as Patient 1Dietary Modification Sumatriptan Valproate Stress Management Topiramate
CGRP Calcitonin gene-related peptide (CGRP) is derived, with calcitonin, from the CT/CGRP gene located on chromosome 11. It is primarily produced in nervous tissue; however, its receptors are expressed throughout the body. It is found in every location described in migraine genesis in addition to processing, including meninges, trigeminal ganglion, trigeminocervical complex, brainstem nuclei, in addition to cortex. It is released in animal models following stimulation of the CNS similar to that seen in migraine, in addition to triptans inhibit this release. Injection of CGRP into migraineurs results in delayed headache similar to migraine. Elevation of CGRP occurs during migraine, resolving following migraine- specific treatment. Finally, in addition to most importantly, CGRP receptor antagonists terminate migraine with efficacy similar to triptans.Migraine PathophysiologyUnclear what they were asking about here. Buzzwords: trigeminovascular reflex, peripheral sensitization The pathophysiology of migraine is complex. The first phase of a migraine attack involves activation of the trigeminovascular reflex, resulting in release of vasoactive peptides (calcitonin gene-related peptide, neurokinin A, substance P) from trigeminal afferents supplying dural blood vessels. This produces vasodilation in addition to sterile inflammation in dural vessels, leading to activation of first-order trigeminal afferents (peripheral sensitization) in addition to manifested clinically by throbbing head ( in addition to neck) pain. As the attack progresses, second- in addition to third-order trigeminothalamic in addition to thalamocortical neurons become activated, mediated primarily by nitric oxide in addition to glutamate transmission, resulting in central sensitization. This is clinically reflected by cutaneous allodynia.
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