Headaches (Cephalalgia)

Headaches (Cephalalgia)
  • Evaluation
    • General—pain affecting the head, although typically not confined to a particular nerve distribution
    • Classification
      • Common primary headache disorders
        • Tension-type headache
        • Migraine headache
        • Cluster headache
      • Secondary headache disorders
        • Vascular (e.g., subarachnoid hemorrhage, stroke, arteritis, arteriovenous [AV] malformation, etc.)
        • Intracranial (e.g., neoplasm, pseudotumor cerebri, infection, posttrauma, etc.)
        • Metabolic (e.g., hypoglycemia, hypoxia, hypercapnia, dialysis, etc.)
        • Myofascial (e.g., cervical spine disorders, etc.)
        • Sleep disorders (e.g., obstructive sleep apnea)
        • Substance use or withdrawal
    • Diagnostic algorithm
      • Initial task—rule out a potentially life-threatening etiology for the patient’s headache.
  • Common primary headaches and acute management
    • Tension-type headache
      • Clinical—bilateral, band-like pressure around the head with varying location and intensity
        • Attacks last 30 minutes to 7 days (sometimes months in extreme cases).
        • It is associated with tightness of the neck and shoulders.
        • There is no nausea, vomiting, aura, or photophobia.
      • Etiology—usually results from stress (emotional upset)
        • Associated with physical causes (muscle strain/tension of the neck and shoulders)
      • Treatment
        • Nonpharmacologic
          • Stress avoidance, stretching, relaxation exercises, physical therapy, and so on
        • Pharmacologic options for abortive therapy (i.e., acute treatment)
          • Nonsteroidal anti-inflammatory drugs (NSAIDS) (avoid in those with gastrointestinal [GI] or bleeding disorders)
            • Naproxen (Naprosyn) 250 to 500 mg PO BID
          • Muscle relaxants
            • Cyclobenzaprine (Flexeril) 5 to 10 mg PO TID.
            • Diazepam (Valium) 2 to 10 mg PO BID to QID
          • Combination analgesics
            • Midrin 325/100/65—take one to two capsules PO q6h. Midrin is composed of:
              • Acetaminophen 325 mg = Tylenol
              • Dichloralphenazone 100 mg—an anxiolytic
              • Isometheptene 65 mg—a sympathomimetic
            • Fioricet 325/50/40—take one to two tablets PO q8h. Fioricet is composed of:
              • Acetaminophen 325 mg = Tylenol
              • Butalbital 50 mg—a barbiturate (abusable agent)
              • Caffeine 40 mg—a stimulant
    • Migraine headache
      • Clinical—unilateral (or sometimes bilateral) pulsating headache lasting 4 to 72 hours
        • It is associated with nausea, vomiting, photophobia, and/or phonophobia.
        • Can be worsened by physical activity as mild as walking stairs.
        • Patients try to lie still in a dark room in order to get comfortable.
      • Mechanism—disturbance in serotonin activity in the central nervous system (CNS) with cerebral vascular dilation
      • Etiology—genetic
      • Epidemiology—3♀: 1♂ in adults; affects 10% of Americans
      • Precipitants—foods (e.g., chocolate), alcohol, stress, odors, exertion, hormonal changes, and so on
      • Classification
        • Migraine with aura (formerly classic migraine)
          • General—an aura is a short-lived (10-30 minutes) neurologic process.
            • Auras are usually visual (tunnel vision, scotoma, etc.)
        • Migraine without aura (formerly common migraine)
          • General—occur gradually or present on waking from sleep
      • Treatment
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Aug 28, 2016 | Posted by in PSYCHIATRY | Comments Off on Headaches (Cephalalgia)

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