Презентация на тему: Approach to Headaches

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Approach to Headaches
mechanisms of headache
Origins of Pain in the Head
Classification of Headaches
HISTORY
RED Flags
Physical Exam
MIGRAINE Headaches
MIGRAINE Headaches
MIGRAINE Headaches
Visual Auras: Patient drawings
MIGRAINE: Acute Treatment
MIGRAINE: Acute Treatment
MIGRAINE: Prophylaxis
TENSION Headaches
CLUSTER Headaches
Medication Induced Headaches
Giant Cell Arteritis
Giant Cell Arteritis
Giant Cell Arteritis
Giant Cell Arteritis
Case 1
Case 2
Case 3
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Первый слайд презентации: Approach to Headaches

AIMGP Seminar April 2004 Gloria Rambaldini

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Слайд 2: mechanisms of headache

1. Traction or dilatation of intracranial or extracranial arteries. 2. Traction of large extracranial veins 3. Compression, traction or inflammation of cranial and spinal nerves 4. Spasm and trauma to cranial and cervical muscles. 5. Meningeal irritation and raised intracranial pressure 6. Disturbance of intracerebral serotonergic projections

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Слайд 3: Origins of Pain in the Head

Extra-cranial pain sensitive structures: Sinuses Eyes/orbits Ears Teeth TMJ Blood vessels Intra-cranial pain sensitive structures: Arteries Veins Meninges Dura

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Слайд 4: Classification of Headaches

PRIMARY - NO structural or metabolic abnormality: Tension Migraine Cluster SECONDARY – structural or metabolic abnormality: Extracranial: sinusitis, otitis media, glaucoma, TMJ ds Inracranial: SAH, vasculitis, dissection, central vein thrombosis, tumor, abscess, meningitis Metabolic disorders: CO2 retention, CO poisoing

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Слайд 5: HISTORY

Headache Characteristics: Temporal profile: acute vs chronic, frequency Location and radiation Quality Alleviating and exacerbating factors Associated symptoms Constitutional symptoms PMH: HTN, DM, hyperlipidemia, smoking

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Слайд 6: RED Flags

New onset headache in a patient >50 y.o. Sudden, worst headache of one’s life Morning headache associated with N/V Fever, weight loss Worsens with valsalva maneuvers Focal neurologic deficits, jaw claudication Altered LOC Hx of trauma, cancer or HIV

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Слайд 7: Physical Exam

Blood pressure Fundoscopy Auscultation for bruits in H/N Temporal artery inspection and palpation Meningismus Neurologic exam: motor, sensory, coordination and gait

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Слайд 8: MIGRAINE Headaches

Affects 15% of the general population Female > Males Family History present in 70% Pathophysiology: vascular vs neurologic Precipitants: caffeine, chocolate, alcohol, cheese, BCP/HRT, menses, stress

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Слайд 9: MIGRAINE Headaches

Diagnostic criteria: 1. 5 attacks in 6 months 2. Headaches lasting 4-72 h with >/= 2: - unilateral - pulsatile - moderate to severe in intensity - aggravated by activity 3. Associated with >/= 1: - nausea/vomiting - photophobia/phonophobia

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Слайд 10: MIGRAINE Headaches

Subtypes: Auras – visual or sensory Scintillating scotoma Fortification spectra Ophthalmoplegic CN III palsy Vertbrobasilar hemiplegic

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Слайд 11: Visual Auras: Patient drawings

Scintillating Scotomas Progression of a typical aura over 30 minutes BMJ 2002; 325:881-6

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Слайд 12: MIGRAINE: Acute Treatment

Mild attacks: NSAIDS +/- dopamine antagonists eg. ASA 650-1300 mg q4h + metoclopromide 10 mg PO/IV Moderate attacks: NSAIDS (ibuprofen 400-800 mg PO q2-6h) 5-HT1 receptor agonists Selective – sumatriptan 50-100 mg PO Nonselective – ergot 1-2 mg PO q1h x 3 CMAJ 1997; 156: 1273-87

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Слайд 13: MIGRAINE: Acute Treatment

Severe & Ultra-severe attacks: First line: DHE 0.5-1 mg q1h IM/SC/IV sumatriptan 50-100 mg PO or 6 mg SC Second line: chlorpromazine 50 mg IM Prochlorperazine 5-10 mg IV/IM dexamethasone 12-20 mg IV CMAJ 1997; 156: 1273-87

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Слайд 14: MIGRAINE: Prophylaxis

Consider if >/3 attacks/month, impaired quality of life: B-blockers Calcium channel blockers TCA (amitriptyline) NSAIDS Valproic acid 5HT2 Antagonists (methysergide, pizotyline) CMAJ 1997; 156: 1273-87

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Слайд 15: TENSION Headaches

Most common type, typically brought on by stress, lasting 30 min to 7 d Diagnostic Criteria >/= 2: Pressing/tightening, non-pulsating Mild-moderate Bilateral Not worsened by ADLs Photo or phonophobia (not coincident) Not associated with N/V Treatment: reassurance, NSAIDS

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Слайд 16: CLUSTER Headaches

Age of onset 25-50 y.o., M>F Features: Attacks clustered in time (>5) Severe unilateral, orbital or temporal pain Lasting 15 min – 3 h Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead/facial swelling, miosis, ptosis Treatment: Acute: O2, 5HT1 antagonists, DHE Prophylaxis: Calcium Channel Blockers, ergots, Li

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Слайд 17: Medication Induced Headaches

Rebound headaches due to overuse of analgesics or prophylactic meds 25% of patients referred to neurologists for ‘intractable’ headaches have medication-overuse or medication-induced headaches

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Слайд 18: Giant Cell Arteritis

Chronic granulomatous vasculitis affecting the arteries originating from the aortic arch 18/100 000 persons >50 y.o. Features: Headache 2/3 of patients Fever, weight loss, malaise Scalp tenderness Jaw claudication Diplopia PMR related Sx (50% of GCA patients have PMR)

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Слайд 19: Giant Cell Arteritis

Physical Exam: BP and pulse deficits in arms Fundoscopy Temporal Artery: beaded, prominent, tender H/N and subclavian bruits MSK exam Investigations: Normocytic normochromic anemia ESR (typically > 50) TA biopsy JAMA 2002; 287(1): 92-101

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Слайд 20: Giant Cell Arteritis

Diagnostic Criteria – 3/5 (Sn 94%, Sp 91%) Age > 50 y.o. New onset headache TA tender +/- decreased pulse ESR > 50 Bx: necrotizing granulomatous arteritis

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Слайд 21: Giant Cell Arteritis

Treatment: Prednisone 40-80 mg PO od until symptoms resolve and ESR normalizes Once in remission decrease dose by 10% q1-2w Osteoporosis prevention: vitamin D and calcium +/- bisphosphonate AIM 2003; 139:505-515

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Слайд 22: Case 1

A 28 y.o. woman is referred to you for management of her headaches Headaches are described as right-sided pounding, with associated nausea and photophobia Aggravated by activity ASA and Tylenol have not provided relief What next?

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Слайд 23: Case 2

A 72 y.o. woman presents with a four month history of a bitemporal headache with aching and morning stiffness of her shoulders She has noted a low grade fever and some weight loss What next?

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Последний слайд презентации: Approach to Headaches: Case 3

A 62 y.o. man is referred for new onset headaches For the last 4 weeks he has awoken with a diffuse headache and nausea What next?

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