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With cluster headache, each headache episode goes on for about 5-10 minutes. Still unilateral, but the duration is brief. Muscle tension or tension-type of headache is a more continuous headache. The duration is important. Precipitating factors: cluster headache, alcohol is a very important precipitating factor. If you have headaches when you bend down, look for increased intracranial pressure. If you have headaches when you get up, what does that mean? Very serious pathology, intracranial pathology, that typically gets worse when you get up. Colloid cyst, third ventricle. So when you have headaches when getting up, think post-LP, low pressure, idiopathic low pressure, think colloid cyst. Now exertional headache is usually vascular migraine. Running, climbing stairs, etc.
Visual phenomena appear in migraine. You see colored zigzags, whorls, patterns. They typically go on for about five, six, seven, ten minutes. Focal seizures, if they start in the occipital area, the positive visual symptoms last only about 10, 15, 20 seconds. That’s the difference you need to know. Migraine, longer. Sensory seizures, brief. Seconds only. Same thing for the migraine march. If you have numbness creeping up one side of the body due to migraine, this takes time. This takes about five, six, seven minutes. Whereas if you have a focal-sensory seizure, the sensory sometimes comes up very quickly, in a matter of seconds. So those are the differences you need to remember. Nausea and vomiting; it could be meningitis, could be subarachnoid hemorrhage or it could be migraine. But you do not have nausea and vomiting in tension-type headaches. In fact, the International Headache Classification specifically talks about vomiting as an important feature. I’ll come back to that in a second. Tearing, nasal discharge, cluster. Nasal discharge only, acute, think sinusitis. Chronic sinusitis does not give you chronic headache. Sinusitis will give you headache almost always in the acute phase. Sinus headache typically gets worse as the day goes on, like in the afternoon. It gets worse when you bend down. It has some features of migraine. Soma online.
Family history; about 50% of people with migraine have positive family history of migraine. Medications can give you headaches. Indocin is one of them, although we use Indocin for treating some types of headaches. Many seizure drugs, believe it or not, can give you headaches. Psychotropic drugs can give you headaches. In fact, if you look at the textbooks there are tons of medications that are said to give headaches. So take a medication history. Human growth hormone cheap medications.
What are some of the common problems? Migraine, cluster, chronic paroxysmal hemicrania is usually in females. Unilateral, severe, sharp, five to ten minute pains, but you have many bouts. Ten, 15, 20 a day. Whereas cluster is half-hour, one-hour headache bouts, two, three, four in 24 hour cycle. So that’s the difference. Sex is difference, duration, number of attacks is different. Chronic paroxysmal hemicrania dramatically responds to Indocin. Meningitis. An obese female, menstrual irregularities, maybe on birth control pills, comes to you with a lot of headaches, early morning headaches, vomiting. Neuro-exam shows papilledema. Think benign intracranial hypertension, pseudotumor cerebri. Viagra professional articles.

Miscellaneous: I hate to throw things in miscellaneous. It always appeared to me that when somebody says miscellaneous that is was an afterthought. They didn’t think well enough to put it into the handout where it actually belongs. I promise you, this is not the case here. I just honestly could not find a spot that it fit anywhere else so I put it into miscellaneous. And that is: the combination of monoamine oxidase inhibitors, both the type A and the type B, when used with meperidine – and I don’t know if any of you remember the case that hit the lay press, the Libby Zion case. This is the case that kind of led to the big discussion of residents are overworked, they spend too much time in the hospital. Their term of duty or the length of time that they are on call is too long. This is a situation where this teenager had a history of migraine headaches. Always came into the emergency room to get treatment for her migraine headaches. She was on a monoamine oxidase inhibitor as preventative therapy and came in and the resident ordered Demerol and Phenergan. The patient progressed to have agitation seizures and she ultimately died as a result of this interaction. To this day we don’t know exactly the mechanism behind it. It does not happen with the other narcotics. But it does happen with Demerol or meperidine and monoamine oxidase inhibitors. So obviously this is a combination that you want to avoid.
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Adenosine: we’ll move on and talk about adenosine. If you have a patient who needs adenosine and they are previously receiving methylxanthine, whether it be theophylline or they tend to be very high caffeine ingestors. Larger than recommended doses may be needed. It doesn’t mean that adenosine will not work but you may need to use more than what you would have needed to use in a typical patient in order to get conversion. Patients who are on dipyridamole and need adenosine typically require smaller than recommended doses because the metabolism is blocked and so less of the drug is needed.
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As far as some conclusions, hopefully with what I’ve talked about you may be able to recognize or at least think about some potential drug/drug interactions and then go to some resources to investigate further. What I would suggest to you – which isn’t actually very easy for someone in the area of family practice, because family practice is so diverse – but certainly become familiar with the drugs that you use most frequently. If you have never had a patient on cyclosporine don’t worry about cyclosporine. There’s too many interactions to think about to worry about drugs that you don’t ever use. This is always a good rule: prescribe as few drugs as possible. Don’t fall into the polypharmacy trap where you use a drug, the patient complains of a side effect, and so you think of another drug to treat that and then they have a side effect. So then there’s another drug added on board. That sometimes is hard to avoid, but it’s best if they can be on a very very small number of drugs. Also, always, always, always inquire about OTC drugs. This is becoming more and more important as more and more drugs are available over the counter. When you think about the number of non-steroidals over the counter that before were only available by prescription. Also the H2 antagonists that are available over the counter. So you want to be sure and ask about OTC medications. Cheap soma online.
Serum drug level monitoring: if you have a drug that has a narrow therapeutic range, use serum level monitoring if you have questions or you are concerned. Watch out for the pitfalls in literature evaluation. Remember that there is a tremendous amount of inter-patient variability and don’t use your experience on a previous patient to discount the possibility of it happening in another patient. Remember than many of the drug interactions can be predicted and you can actually make alterations so that they can be used together.