Cluster Headaches: 丛集性头痛
Headaches that have a sudden onset, severe in pain. It can affect orbital, supraorbital, temporal, or any combination of sites, that is unilateral in location. Cluster headaches have a duration of 15 mins to 2 hours. Frequency can be from every other day to several times per day. Patients will often express a feeling of agitation during that time of an attack.
Incidence/ Prevalence: Only occurs in a small percentage of the population (0.05-1%). This occurs in males five times more than females between the ages of 20-40. May be inherited in up to 20% of cases.
Pathophysiology/Etiology: Pathophysiology is controversial, but it felt to be a result of the posterior hypothalamic gray matter becoming activated, resulting in activation of in the trigeminal and parasympathetic areas.
Physical assessment and examination: A patient will report having an attack during a conjunctival injection or lacrimation. May be associated with nasal congestion, rhinorrhea, facial sweating, or Horner’s syndrome. Horner’s syndrome usually are signs and symptoms associated with one side of the face with signs presenting with small pupils, drooping of the upper eyelid, delayed dilation of the pupil, and often lacks sweating in one side of the face or only a portion of the face, complain of agitating during an attack (Mayo Clinic, 2018).
The evidence-based treatment plan for the management of Episodic:
- Prophylactic treatment should be initiated at the onset of the cluster and tapered.
- Acute: Inhaling 100% oxygen via a face mask at 12-15L/min, this works in 60-80% of patients. Utilization of sumatriptan, zolmitriptan.
- Chronic: Again, start prophylactic treatment, increasing doses until control is obtained.
Medications to consider for episodic and chronic cases: Verapamil 240mg PO in a day and increase to 960 mg in a day. Given in 3 doses may be more effective than extended-release. Topiramate 50 mg PO 2 times daily and may be given in addition to the verapamil. Lithium 200 mg PO 3 times daily (this will require frequent monitoring of lithium levels). Methysergide 1-2 mg PO 3 times daily, ergotamine tartrate 3-4 mg in a day, given during clusters. Prednisone 60 mg PO daily for one week, with a taper (Ferri, 2018).
Migraine Headaches: 偏头痛
Migraine Headaches Are recurrent headaches that often are associated with an aura (Chawla, 2017).
Incidence/Prevalence: Often is more common in women than men. Incidence increases as we age, peaking in the ’30s and then will start to decrease. Peak prevalence is between 18 and 49 years. There is a familial predisposition, 50%.
Pathophysiology/Etiology: Unfortunately, the pathophysiology is unclear. However, there is involvement of the trigeminovascular reflex. The aura is a result of cortical spreading being depressed (Ferri, 2018).
Physical assessment and examination: The physical assessment will be normal between episodes and those without an aura. Focal motor or sensory deviations can be varied.
Typical symptoms of migraine include throbbing or pulsatile headache that increases with movement or physical activity. A unilateral and localized pain in the frontotemporal and ocular area and may wrap around the head and neck. The pain increases over time. It may last from 4 hours to 2-3 days. Often patients will report nausea and vomiting, with sensitivity to light and sound. Reporting they need to be in a quiet dark room (Chawla, 2017).
The evidence-based treatment plan for the management of
- Acute: NSAID (ketorolac, ibuprofen, naproxen). Triptans, such as rizatriptan 5 or 10 mg at the time of headache, repeating every 2 hrs as needed with a max dose of 30 mg in a day. Eletriptan can be given in the same way with dosages of 20 or 40 mg tabs with a max of 80 mg in a day.
- Chronic: Prophylaxis treatment
- Episodic: Prophylaxis treatment
- Includes beta-blockers (propranolol, timolol, atenolol, metoprolol). Tricyclic antidepressants (amitriptyline), and antiepileptic medications of topiramate and sodium valproate (Ferri, 2018).
Tension Headaches: 紧张性头痛
Tension Headaches are highly prevalent and primary cause of headaches. Tension headaches are not associated with complaints of nausea or vomiting.
Incidence/Prevalence: The most common type of headache accounting for 70% of patients who seek care from their primary care provider. Women are affected more than men.
Pathophysiology/Etiology: No longer related to a psychological problem, often a heterogeneous disorder that can have many pathophysiological mechanisms. Also, not associated with muscle contraction.
Physical assessment and examination: The patient may complain of the headache from less than once a month to chronic, have at least 10 headaches, lasting 30 mins to 7 days. Patients with tension headaches may also have light and sound sensitivity. Concurrent conditions may be anxiety, depression, overuse of analgesics. Pericranial tenderness during palpation on the exam.
Treatment: Combination of nonpharmacological and pharmacological. Having patients modify their sleep, acupuncture, cognitive-behavioral therapy, relax training.
- Acute: NSAIDS, acetaminophen, Caffeine.
- Preventative Treatment: Amitriptyline 10-50 mg is the first choice (Ferri, 2018).
References:
Chawla, J. (2018). Migraine Headache. Retrieved from https://emedicine.medscape.com/article/1142556-overview
Ferri, F.F. (2018). Ferri’s Clinical Advisor 2018: 5 Books in 1 (Ferri’s Medical Solutions)
Mayo Clinic (2018). Horner’s Syndrome. Retrieved from https://www.mayoclinic.org/diseases-conditions/horner-syndrome/symptoms-causes/syc-20373547
Very informative. Great post