see: [Rosen - headache](x-devonthink-item://1781B09F-B327-4348-AA6F-F427FF97CA97), [Dunn - Migraine](x-devonthink-item://824D07EC-533F-4B36-8E5C-6EA7AF8F66FD), [Hayes' Migraine](x-devonthink-item://39507633-6C68-4ED1-B035-D012C3F2035D) # Headache in pregnancy see: [[drugs in pregnancy]] | diagnosis | supporting features | | ----------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------ | | [[Pre-eclampsia]] | - oedema of feet, hands, face<br>- hyper-reflexia<br>- HTN | | Migraine | - aura preceding onset<br>- unilateral throbbing, photosensitive, phonophobia | | [[Cerebral venous thrombosis\|cavernous venous sinus thrombosis]] | - eye symptoms, proptosis<br>- CN II, IV, VI palsies<br>- **preceding sinusitis or facial cellulitis** | | [[Subarachnoid haemorrhage\|SAH]] | thunderclap, polycystic kidneys, aneurysms | | [[Meningitis]] | - neck stiffness,rash , sepsis | | [[Thrombotic Thrombocytopaenic purpura\|TTP]] | | | [[haemorrhagic stroke\|ICH]] | | | [[Brain Tumours]] | | # migraine **POUND**ing: - Pulsating - duration 4-72 hOurs - Unilateral - Nausea - Disabling 4 criteria - LR 24 doesn't usually have fever, altered conscious state, neck stiffness, focal neuro signs, purpuric skin rash ## treatments see [[#medication options table]] - Aspirin 900mg - metoclopramide 10mg po/IV/IM - prochlorperazine 12.5mg - sumatriptan 6mg s/c - chlorpromazine 15mg in 1000mL saline over 60 min - dexamethasone 10mg prevent recurrence ## migraine in pregnancy - exclude [[#Headache in pregnancy]] DDxes in escalating order (per ETG) - paracetamol soluble 1g - metoclopramide - sumatriptan if severe headache - IV rehdration - magnesium sulfate IV - prednisolone 50mg po for 2 days ## migraine PPx - amitriptyline 10mg po nocte - valproate 200mg nocte - pizotifen 0.5mg nocte - verapamil 90mg - from ED shot of dexamethasone 10mg # tension headache - lasting 30 min-7 days - at least 2 of - bilat location - pressing, non-pulsating quality - not aggravated by routine physical activity - no nausea or vomiting - no more than one photophobia or phonophobia # other causes - [[Giant Cell Arteritis|GCA]] - [[Glaucoma]] # medication options table #tables | medication | dose/route | benefits | drawbacks | | ------------------------------------------------ | --------------------------------- | -------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | metoclopramide | 10mg IV | less sedating than others, also treat nausea | dystonic rxn | | Aspirin | 900mg po | oral route | gastritis, maybe cannot tolerate oral | | Ketorolac | 15mg IV or IM | - NSAID benifits in vomiting pt<br>- no hypotension or neurological side effects | - GI upset<br>- renal failure<br>- avoid in elderly<br>- bronchospasm in asthma | | sumatriptan | 50-100mg po<br>20mg IN<br>6mg s/c | doesn't require IV | - relative contraindication in HTN, CAD, pregnancy<br>- risk of ACS/CVA<br>- chest pain, through tightness, flushing<br>- seritonergic effects with SSRI/MAOI<br>- cannot use within 24 h of ergot<br>- generally works best early | | prochlorperazine<br>chlorpromazine<br>droperidol | 10mg IV<br>12.5mg IV<br>2.5mg IV | - concurrent anti-emetic | sedation<br>dystonic rxn<br>akathesia<br>prlonged QTc | | dexamethasone | 10-20mg IV | - reduced recurrence<br>- anti-emetic | - gastritis<br>- avoid in diabetes<br>- mood altering | | magnesium sulfate | 2g IV | - effective in migraine w/ aura | - hypotension<br>- reduced reflexes | | greater occipital nerve block | 6mL of bupivacaine 0.5% bilat | direct local effect | variable efficacy | # greater occipital nerve block ![[Pasted image 20240309021516.png]] The injector identified the appropriate location using landmarks on the patient’s head. The medial landmark was the occipital protuberance. The lateral landmark was the mastoid process. Using these landmarks to form a line, the injector identified the correct location, which was one-third of the distance from the occipital protuberance along this line (two-thirds of the distance away from the mastoid process). The injector felt for pulsation of the occipital artery and attempted to elicit pain or paresthesia in the distribution of the GON by pressing slightly. The injector then used a fan technique, placing 1 mm of anesthetic at the correct spot, 1 mm slightly medial of the correct spot, and 1 mm slightly lateral to the correct spot.