EXAM 2 – Study Guide
Primary Care Evaluation and Treatment of Headaches
OBJECTIVES
- Identify the most common types of headaches.
- Identify headache scenarios that are urgent and develop differential diagnoses of
headache.
- Describe office evaluation of and treatment strategies for headaches.
GENERAL HEADACHE INFORMATION
- One of the Top 10 complaints seen in primary care.
- Wide range in intensity and duration.
- Patients often self-diagnose.
- Two broad categories: Primary Headaches and Secondary Headaches.
PRIMARY HEADACHES
1. Migraine (With or without aura)
2. Tension-Type Headache (TTH)
3. Cluster Headache
SECONDARY HEADACHES
- HTN, ENT, Psychiatric, Dehydration, Eye-related, Neck injury, Trauma, Medication use,
Temporal Arteritis, Trigeminal Neuralgia, Herpes Zoster, Brain Mass.
RED FLAGS IN HEADACHES
- Sudden severe headache, "Worst headache of life", Fever/nuchal rigidity, New onset after
age 50, Neurologic signs, Visual disturbances, Trauma/falls.
OFFICE EVALUATION
- Subjective: Headache diary (OLDCART), Psych eval, Medication and social history, Family
history.
- Objective: Vitals, Neurological & cranial nerve exams, Strength/reflexes, Scalp tenderness,
Hydration, Labs.
ASSESSMENT & PLAN
- DDx: Primary vs. Secondary, red flags.
- Labs/imaging, Patient education, Referrals.
MIGRAINES
- Common and disabling. Peak age 25-34. 15% females, 6% males.
- Unilateral, throbbing, worsens with movement, moderate to severe.
- Associated with photophobia, nausea, vertigo, visual disturbances, etc.
,MIDAS Score: Disability grading (I-IV).
- Non-pharmacologic: Trigger ID and avoidance.
- Acute meds: NSAIDs, Triptans, Dopamine antagonists.
- Preventive: SSRIs, TCAs, Beta-blockers, CCBs, Anticonvulsants.
TENSION-TYPE HEADACHE (TTH)
- Bilateral, band-like, slow build, lasts days.
- Lacks migraine features.
- Tx: Tylenol, NSAIDs, Toradol, stress reduction, Amitriptyline.
CLUSTER HEADACHES
- Rare, more in men, linked to smoking/alcohol.
- Retro-orbital, severe, same hour daily.
- Acute tx: Oxygen, Triptans.
- Preventive: Steroids, Verapamil.
SECONDARY HEADACHES
- Temporal Arteritis: Age >50, vision loss, high ESR. Tx: Steroids, urgent referral.
- Trigeminal Neuralgia: Severe facial pain. Tx: Tegretol, Dilantin, TCAs.
- Herpes Zoster: Severe pain, may or may not have rash. Tx: Acyclovir, Valacyclovir.
BELL'S PALSY
- CN VII paralysis, abrupt onset. Rule out CVA.
- Tx: Eye protection, Prednisone taper, +/- antivirals.
, Dizziness and Neurologic Complaints in Primary Care
OBJECTIVES
- Identify differential diagnoses for dizziness and syncope.
- Identify urgent scenarios of dizziness and syncope.
- Articulate evaluation and management plans for dizzy, pre-syncopal, and syncopal
patients.
DIZZINESS OVERVIEW
- Common, subjective, hard to define.
- Types: Vertigo, Pre-syncope, Disequilibrium, Lightheadedness.
CAUSES
- Blood loss, Dehydration, Anxiety, Hyperthyroidism, Panic, Otitis media, Cerumen
impaction.
RED FLAGS
- Slurred speech, Focal neuro signs, AMS, Bloody stool, Orthostatic changes.
HISTORY
- Ask about spinning, falling, fainting, imbalance.
- Timing helps ID cause (seconds = peripheral, minutes = BPPV, hours = Meniere’s, etc).
VERTIGO
- Spinning sensation, worse with position changes.
- Causes: Otitis media, CN VIII dysfunction, BPPV, Meniere’s, Cerebellar lesion.
- BPPV: Positional, brief episodes. Tx: Epley.
- Vestibular Neuritis: Post-URI, inflammation of CN VIII.
TESTS
- Nystagmus pattern: Peripheral = unidirectional, Central = changes direction.
- Head impulse test, Dix-Hallpike.
OTOGENIC DDX MATRIX
- Episodic + Hearing Loss = Meniere’s
- Persistent + Hearing Loss = Labyrinthitis
- Episodic + No HL = BPPV
- Persistent + No HL = Vestibular Neuritis
MENIERE’S DISEASE
- Fluid overload in ear. Vertigo + HL + Tinnitus.
- Chronic condition, may lead to permanent HL.
PRE-SYNCOPE
Primary Care Evaluation and Treatment of Headaches
OBJECTIVES
- Identify the most common types of headaches.
- Identify headache scenarios that are urgent and develop differential diagnoses of
headache.
- Describe office evaluation of and treatment strategies for headaches.
GENERAL HEADACHE INFORMATION
- One of the Top 10 complaints seen in primary care.
- Wide range in intensity and duration.
- Patients often self-diagnose.
- Two broad categories: Primary Headaches and Secondary Headaches.
PRIMARY HEADACHES
1. Migraine (With or without aura)
2. Tension-Type Headache (TTH)
3. Cluster Headache
SECONDARY HEADACHES
- HTN, ENT, Psychiatric, Dehydration, Eye-related, Neck injury, Trauma, Medication use,
Temporal Arteritis, Trigeminal Neuralgia, Herpes Zoster, Brain Mass.
RED FLAGS IN HEADACHES
- Sudden severe headache, "Worst headache of life", Fever/nuchal rigidity, New onset after
age 50, Neurologic signs, Visual disturbances, Trauma/falls.
OFFICE EVALUATION
- Subjective: Headache diary (OLDCART), Psych eval, Medication and social history, Family
history.
- Objective: Vitals, Neurological & cranial nerve exams, Strength/reflexes, Scalp tenderness,
Hydration, Labs.
ASSESSMENT & PLAN
- DDx: Primary vs. Secondary, red flags.
- Labs/imaging, Patient education, Referrals.
MIGRAINES
- Common and disabling. Peak age 25-34. 15% females, 6% males.
- Unilateral, throbbing, worsens with movement, moderate to severe.
- Associated with photophobia, nausea, vertigo, visual disturbances, etc.
,MIDAS Score: Disability grading (I-IV).
- Non-pharmacologic: Trigger ID and avoidance.
- Acute meds: NSAIDs, Triptans, Dopamine antagonists.
- Preventive: SSRIs, TCAs, Beta-blockers, CCBs, Anticonvulsants.
TENSION-TYPE HEADACHE (TTH)
- Bilateral, band-like, slow build, lasts days.
- Lacks migraine features.
- Tx: Tylenol, NSAIDs, Toradol, stress reduction, Amitriptyline.
CLUSTER HEADACHES
- Rare, more in men, linked to smoking/alcohol.
- Retro-orbital, severe, same hour daily.
- Acute tx: Oxygen, Triptans.
- Preventive: Steroids, Verapamil.
SECONDARY HEADACHES
- Temporal Arteritis: Age >50, vision loss, high ESR. Tx: Steroids, urgent referral.
- Trigeminal Neuralgia: Severe facial pain. Tx: Tegretol, Dilantin, TCAs.
- Herpes Zoster: Severe pain, may or may not have rash. Tx: Acyclovir, Valacyclovir.
BELL'S PALSY
- CN VII paralysis, abrupt onset. Rule out CVA.
- Tx: Eye protection, Prednisone taper, +/- antivirals.
, Dizziness and Neurologic Complaints in Primary Care
OBJECTIVES
- Identify differential diagnoses for dizziness and syncope.
- Identify urgent scenarios of dizziness and syncope.
- Articulate evaluation and management plans for dizzy, pre-syncopal, and syncopal
patients.
DIZZINESS OVERVIEW
- Common, subjective, hard to define.
- Types: Vertigo, Pre-syncope, Disequilibrium, Lightheadedness.
CAUSES
- Blood loss, Dehydration, Anxiety, Hyperthyroidism, Panic, Otitis media, Cerumen
impaction.
RED FLAGS
- Slurred speech, Focal neuro signs, AMS, Bloody stool, Orthostatic changes.
HISTORY
- Ask about spinning, falling, fainting, imbalance.
- Timing helps ID cause (seconds = peripheral, minutes = BPPV, hours = Meniere’s, etc).
VERTIGO
- Spinning sensation, worse with position changes.
- Causes: Otitis media, CN VIII dysfunction, BPPV, Meniere’s, Cerebellar lesion.
- BPPV: Positional, brief episodes. Tx: Epley.
- Vestibular Neuritis: Post-URI, inflammation of CN VIII.
TESTS
- Nystagmus pattern: Peripheral = unidirectional, Central = changes direction.
- Head impulse test, Dix-Hallpike.
OTOGENIC DDX MATRIX
- Episodic + Hearing Loss = Meniere’s
- Persistent + Hearing Loss = Labyrinthitis
- Episodic + No HL = BPPV
- Persistent + No HL = Vestibular Neuritis
MENIERE’S DISEASE
- Fluid overload in ear. Vertigo + HL + Tinnitus.
- Chronic condition, may lead to permanent HL.
PRE-SYNCOPE
