Master the board step 3

Neurology
The following symptoms may precede the headache:
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Aura of bright flashing lights
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Scotomata
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Abnormal smells
Diagnostic Testing
Head CT or MRI should be done when the headache has any of the following
characteristics:
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Sudden and/or severe
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Onset after age 40
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Associated with focal neurological findings
Treatment
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Best initial (abortive) therapy: Sumatriptan or ergotamine.
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Prophylactic therapy (requires several weeks to take effect):
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When 4 or more headaches occur per month, the patient should receive
prophylactic therapy with beta blockers (propranolol).
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Alternate prophylactic medications are calcium channel blockers, tricyclic
antidepressants, or SSRIs.
Basic Science Correlate
Mechanism of Triptans
Triptans constrict vessels. Migraine is thought to be vasoconstriction followed
by vasodilation, then pain. Triptans function by reconstricting the cerebral
vessels. This is why they are dangerous in hypertension, pregnancy, and
coronary disease. Triptans constrict vessels in the heart as well, and can
provoke cardiac ischemia.
Cluster Headache
Cluster headaches are 10 times more frequent in men than in women.
Cluster headaches are exclusively unilateral with redness and tearing of the
eye and rhinorrhea.
Treatment
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Best initial (abortive) therapy: Triptans or 100 percent oxygen. Triptans are
generally used because they are easier to give at home. Sumatriptan is used
in the same way as with migraine headache. Steroids can also be used.
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Best initial prophylactic therapy: Calcium channel blockers such as verapamil.
By definition, cluster headaches occur multiple times in a short
period and then resolve. The “cluster” is often over by the time prophylactic
therapy has taken effect. Verapamil does prevent cluster headache.
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