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  1. Headache syndromes

    1. Migraine

      1. aka trigeminovascular syndrome

      2. Paroxysmal headache (HA) associated with multiple signs and symptoms that can overlap with sinus symptoms

        1. Unilateral

        2. Throbbing pulsatile headache in the frontotemporal or orbital area

        3. Aura

          • Can arise before or during the HA

          • Usually visual but can be sensory or motor

        4. Pain builds over 1 to 2 hours and progresses posteriorly

        5. Headache lasts 4 to 72 hours

        6. Photophobia, phonophobia

        7. Nausea—80%, vomiting—50%, anorexia and food intolerance and light headedness

        8. Signs

          • Cranial/cervical tenderness

          • Horner syndrome

          • Conjunctival injection

          • Tachycardia or bradycardia

          • Hypertension or hypotension

          • Hemisensory changes or hemiparesis

          • Adie’s-like pupil (light-near dissociation)

      3. Diagnosis

        1. Two of the following characteristics

          • Unilateral location

          • Pulsating quality

          • Moderate to severe pain

          • Aggravated or caused by physical activity

        2. During the HA patient must have one of the following

          • Nausea and/or vomiting

          • Photophobia and phonophobia

      4. Imaging

        1. Diagnostic imaging is not necessary in patients with stable history of migraine headaches and a normal neurologic examination.

      5. Management recommendations

        1. CT is not recommended for headache evaluation when MRI is available, unless in an emergency situation.

        2. Persistent over-the-counter (OTC) pain medication for the treatment of unrelenting headache is not advised as this symptom may indicate underlying brain pathology.

        3. First-line treatment of migraine should not include opioid or butalbital-containing medications.

        4. Lifestyle modifications

          • Avoidance of carrying heavy purses or bags over one shoulder

          • Avoidance of certain foods

          • Maintaining hydration status

          • Sleep hygiene

          • Limit stress

        5. Integrative medicine

          • Magnesium

          • Riboflavin

          • Coenzyme Q10

        6. Abortive medications

          • These medications aim to reverse or at least stop the progression of a headache.

          • Most effective when given within 15 minutes of symptom onset when the pain is mild.

          • Types

            1. Triptans: selective serotonin receptor agonists

            2. Ergot alkaloids: ergotamine, dihydroergotamine

            3. Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs)

            4. Combination medications

              • Acetaminophen, aspirin, and caffeine (ie, Excedrin)

              • Butalbital, aspirin, and caffeine (Fiorinal)

              • Isometheptine, dichloralphenazone, acetaminophen (Midrin, Duradrin, and others)

            5. Antiemetics

        7. Prophylactic medications

          • Indication

            1. More than two headaches per month

            2. Duration of headache is more than 24 hours

            3. Significant disability for equal to or more than 3 days

            4. Abortive therapy fails or is overused

            5. Abortive medications used more than twice a week

          • Types

            1. Antiepileptic drugs

            2. Beta blockers

            3. Tricyclic antidepressants

            4. Ca2+ channel blockers

            5. Botulinum toxin: up to nine treatment cycles for progressive improvement in symptoms

        8. Tension headache

          1. Most common type of recurring headache thought to be related to muscular factors and psychogenic forces (stressful event).

          2. Throbbing quality with onset more gradual than migraines; usually tension headaches are more constant and less severe.

          3. Headaches can last up to 7 days.

          4. Not associated with nausea or vomiting, photophobia, and/or phonophobia.

          5. Diagnostic criteria

            1. Two of the following must be present:

              • Tightening in frontal-occipital locations

                1. Occipitonuchal

                2. Bifrontal

              • Bilateral

              • Mild to moderate intensity

              • Not aggravated by physical activity

            2. Management

              1. Imaging is only required if headache pattern changes and is not a common primary headache disorder, such as migraine, cluster or tension headache

            3. Treatment

              1. Massage, relaxation techniques

              2. Lifestyle modification: regular exercise, balanced meals, adequate sleep

              3. Trigger points injection/occipital nerve block

              4. NSAIDs

              5. Tricyclic antidepressants, muscle relaxers

            4. Cluster Headache

              1. Group of headaches ...

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