Primary Headache vs.Secondary Headache Primary: Tension Migraine Cluster Frequency episodic and chronic episodic and chronic clustering pattern Duration hours 4-72 hr 30 minutes - 3 hr Location Band like, bilateral Unilateral Always Unilateral, (classic)/bilateral always on same side Quality of Pain pressure pulsatile Sharp, boring Intensity mild-moderate moderate - severe severe Associated Photo OR Photo AND rhinorrhea Symptoms phonophobia BUT phonophobia OR NO nausea nausea Aggravated by moderate activity; Aura Treatment NSAIDs Tx: NSAIDs, triptans Transitional: Preventative: TCA PPx: Topiramate, Prednisone (to break beta blockers, TCA, the cluster) Valproic Acid Abortive: 100% O2 or subq triptan Preventative: Verapamil **Episodic (less than ½ days), chronic (more than 15 days/month) Can disappear for a long time, the come back for a few weeks/month or two then disappears. Primary: Intrinsic neurologic problem, patients brain genetically/chemically wired to have headaches. **Vomiting WITHOUT nausea = ALARM symptoms. Makes you think of increased ICP Aura: Lasting 20-30 minutes, occuring before headache starts. Usually visual. **Only 30% have aura. Most patients DON’T have it. Fun fact: Risk of stroke in females with aura higher. Patient comes in w/ headache; Check: Vital Signs, Fundoscopy Medications - Topiramate : Anti epileptic with brittle diabetes or a long distance runner TCA: Side effects: urinary retention. confusion (all anticholinergics) Valproic Acid: Don’t give to pregnant women or even considering pregnancy .teratogenic → neural tube defects Secondary: Subarachnoid Hemorrhage CNS Infection Disorders that increase or decrease ICP Giant Cell Arteritis: more common in women ANY visual symptoms (then immediately give prednisone).Patients who have essential tremor Don’t give to patient with asthma. dry mouth. not red flag) .Nuchal Rigidity .Vomiting WITHOUT nausea (if with nausea. IF NORMAL.Older age of onset (50+) Increased ICP → can cause false localizing 6th nerve palsy (because of stretching of 6th nerve) If suspecting SAH - 1st Step : get CT. Red Flags: .causes cleft palate Don’t give to patients who have kidney stones Beta Blockers: Give to .Dont give to pregnant women .Started NEW headache. do LP (only way to be confident that there is NO SAH is to have zero WBCs on LP) . where you wake up EVERY morning with headache (**few times a month in morning is NOT a red flag) . if no visual symptoms the just get a sediment rate.Fever .