Ch 04 02 Headache

well I’ve got a headache that’s no fun
so and so is that when you were looking at headaches the first thing to
always exclude is you must exclude evil things first you must exclude mass
things like tumors while people have tumors tend to have focal neurological
problems they tend to have pupil edema not that it looks nice anymore and these things are not recurrent
episodes that get better and go away for a while then come back two weeks later or
four weeks later people have tumors have headaches headaches don’t go away they
get worse and worse and worse and worse and they keep vomiting there pat focal
findings pupil edema and vomiting over time and it doesn’t get better it does
not get better. so subarachnoid hemorrhage is going to be very sudden
sudden sudden sudden sudden sudden sudden sudden and it’s going to look
like the sudden onset of meningitis with a stiff neck photophobiaKernig’s and Brudzinski sign not that I can remember either one which one either one
is like the sudden onset of headache sudden onset all of a sudden I ruptured
my berry aneurysm in my circle Willis and I have severe sudden headache with
fever headache stiff neck photophobia Kernig’s and Brudzinski sign. people
who have temporal arteritis also known as giant cell arteritis people
have temporal arteritis or giant cell arteritis they have tenderness they have
tenderness over the scalp tenderness over the temporal area and they have
visual problems because this stuff starts to damage the ophtalmic nerve there
ocular nerve ophthalmic artery they die and it’s the oculatory temporal
arteritis and this is a big deal by the way this is unique amongst a headache
syndromes are being most characterized by tenderness on the scalp so in order
before I get on to things like migraines cluster headaches and tension headaches
migraines cluster headaches and tension headaches I must first exclude something
that’s very dangerous as an etiology of headache a guy comes in and said: “Doc, I have very severe
headache it won’t go away!” -is it your first episode? -yes! maybe it’s going to turn out that
migrains, may be going to turn out that cluster headaches, maybe’s gonna turn out
just have a tension headache how do I know it’s not a tumor or subarachnoid or
something worse tumors are associated with focal findings, nousea, vomiting and they don’t get better
future tumor doesn’t get better as the intracranial pressure worsens the tumor
heading worsens the nausea and vomiting worsens the papilledema doesn’t were
some but all the gets worse and worse and worse over time I got a terrible
headache but the light bad for your eyes the lights bad for your eyes – it’s time for a head CT
fast look for SAG so let’s see first before you get onto migraine
clusters and tentions let’s first exclude evil things let’s first exclude evil
things. Now, meningitis what’s the difference between this and subarachnoid
hemorrhage subarachnoid hemorrhage is very sudden and subarachnoid hemorrhage
what is different which unique fifty percent of people with a subarachnoid
hemorrhage have a loss of consciousness fifty
percent of people with the subarachnoid hemorrhage have a loss of consciousness
fifty percent of people with a sub arachnoid hemorrhage have a loss of
consciousness so that 50% with the loss of consciousness is because the
subarachnoid hemorrhage is a sudden rupture of an aneurysm in the berry
aneurysm in the circle of Willis when this sudden loss of blood into the
intracranial space what happens is that intracranial pressure does it go up or
just intracranial pressure go down intracranial pressure should go because
I have bled into my brain when I bleed into my brain and I have increase in
intracranial pressure this sudden loss of vascular integrity with its sudden
increase in intracranial pressure provokes a sudden decrease in cerebral
perfusion cause how can I perfused my brain here I have no sufficient blood
pressure to get the blood up in here cerebral perfusion is based on the fact
that the pressure here in the heart is greater than the pressure here in the
head like pumping water up to the top floor of the house depressurized to be great to hear it up
here so the water will go up if you have a sudden bleed the pressure in here goes
up and perfusion goes down so you have a sudden loss of
consciousness now meningitis looks exactly the same except meningitis will
not give you a lost consciousness it looks like subarachnoid the sudden onset
of meningitis with loss of conscience and yes the sudden loss cause meningitis
with a loss of conscious yes now the initial test for all these here lets a
guy comes in a tumor in a CT scan the person who comes with a subarachnoid the
CT scan let’s look at this one we have a 35 year old guy that comes to the
emergency department he’s complaining of a severe headache he is complaining of a
severe headache he’s got tenderness of his temporal artery tenderness of his
temporal artery and visual disturbance what would you do next in the management
of this patient you got a 35 year old guy who’s got a headache he’s got a headache and he’s got tenders
over as temporal area and he’s got visual disturbance why would you jus
next what is the most appropriate actions step do management action step
do management look at the Puppy Bowl and the answer is
steroids if it gives you two choice is choosing between steroids and acct you
are going to choose this steroids first you will choose to steroids first if
they give you a choice of steroids or a CT scan they are going to ask you to
choose steroids first why because it is better to give the steroids for a few
days while waiting for the temporal artery biopsy while waiting for the
temporal artery biopsy which is the most accurate test most actor test which of
the following is the most accurate estimate IFC it’s better to give the
stewards for a few days while waiting for the results of biopsy then to wait
for the results of biopsy and go up to the patient and say we’ve got the
results of your biopsy right here where right here we’re right here I don’t see
it why don’t you see it cause I’m Pillai it’s better to give the steroids then
wait to see whether you have to get your biopsy report translated into borough so give this steroids and wait for the
biopsy later or you have to have the biopsy report in break so steroids is biopsy is bad last if you do CT and wait
for results of the biopsy you will become the best doctor at the Lighthouse this is a major thing that you come here
to learn to step to the order in which to do things you’ve heard of CT she
heard a biopsy her to steroids but what’s next what some experts in next
best step the CT scan for subarachnoid hemorrhage and it’s going to be 90 to
95% Sin City 2 it’s going to be 90 to 95% sensitive as a test that is 90 to
95% sensitive you don’t have to do the lumbar puncture in the vast majority of
people only after the lumbar puncture in the 5% that have a false negative seated
in other words if you’re CT scan is negative you can do the lumbar puncture
to make a diagnosis now the lumbar puncture shows red cells
it will also show white blood cells if the white blood cells are up do you know
whether those white blood cells are be cause there is an infection because
meningitis causes headache how do you know whether white sales rep causes
infection how do you know what the white cells are up simply because there is
blood in the cerebrospinal fluid you see blood in the cerebrospinal fluid makes
the white cells go up blood and cerebrospinal fluid makes the white
cells co-op how do you know whether the white cells are up because there’s an
infection or whether simply because this is a dilute see be in the answer depends
if there’s an increased ratio of white cells normally there’s one white so for
every 500 to 1,000 red cells well what happens and if you have what
happens if you have 50 white cells and only one thousand red cells well that’s far too many white cells to
be accounted for by justice number of red cells a thousand red cells should only give
one or two white cells one or two white cells but if you have ten thousand red cells well then you should be having
10 to 20 white cells; but if you have 100.000 red cells than 50 white cells
is not a problem if its 100,000 red cells because this would just be a
dilute CBC; if the ratio is greater than the normal proportion which is about the
one white cell every five hundred to a thousand reds if their ratio of white
cells is greater than one white cell for every five hundred to a thousand reds
then there is infection their treatment for the tumors just
surgical removal radiation chemo surgical removal radiation chemo, but the
best initial therapy is Decsometason to decrease
intracranial pressure to decrease the swelling around the tumor while waiting
for the results of the biopsy was the most accurate test biopsies the most
accurate test the treatment for a subarachnoid hemorrhage the treatment
first subarachnoid hemorrhage is to do an angiogram and you say: well that’s
not my treatment that’s a test that’s not a treatment that a test while the angiogram
allows me to know where your blood from, the angiogram allows me to know where did you bleed from; where is the site of anatomic defect the angiogram allows me to
know where did this happen from I don’t to know where did this happen from, man; I don’t need an angiogram to diagnosis
subarachnoid hemorrhage it’s true, I could diagnose a diagnose subarachnoid hemorrhage off the head CT
and off the lumbar puncture I don’t need an angiogram to diagnose a subarachnoid
hemorrhage I can diagnose the subarachnoid hemorrhage office SCT or in
helping I need the angiogram to determine the site of surgical debris
cleaning it out surgical clipping surgical or embolization with a catheter I need
the angiogram to determine where will I surgically placed the clip so it doesn’t
really even if you believed fifty percent of people who really died so I
don’t need the angiogram to tell me you’ve got a subdirectory I need the
angiogram to tell me where is that summer actor where so I know where to
close coronary arteries use I don’t need for coronary downwards I don’t need for
coronary artery disease to know that the engine room that you get cornered sees I
can do a stress test I need the angiogram to tell me whether you have
three vessel disease hour left main disease to tell me whether to do surgery
I don’t need an angiogram to diagnose renal artery stenosis I could do
captopril nuclear arena grams magnetic resonance angiograms duplex
ultrasonography to determine the presence of renal artery stenosis I need
the angiogram before I do angioplasty and place a stint before do n Joe
plastic and placing a stint I don’t need the angiogram to make a diagnosis of
renal artery stenosis I need the angiogram to determine the anatomic
location so I can do angioplasty and placing a stunt so I can
do engine plasti and placing a stint you know for the peripheral arterial disease
I don’t need to do an angiogram to determine whether or not your peripheral
artery disease I could do ankle brachial indexes ankle brachial
indexes and look for a decrease in ratio greater than point 94 ankle brachial
index I do the angiogram to know where am I gonna buy best where do i do
surgery where do i do surgery where do I buy a house where do i bypass you know I
don’t need to do it angiogram to diagnose carotid stenosis I
can do a duplex underground to diagnose carotid stenosis I do an angiogram to
determine the diameter in order to guide and are directed to me and Archer
wrecked peripheral arteries carotid arteries coronary arteries Rana lawyers
I use the angiogram to guide surgical repair I don’t need to do an angiogram
to diagnosis subject to a hemorrhage and Graham to diagnose a surgical repair
which in this case is to put in a clip before you leave because of you bleed
you die we use 9:02 p.m. and 9:15 is a calcium channel blocker that decreases
the risk of stroke nimodipine is a calcium channel blocker that decreases
the risk of stroke we use my motive keen to prevent vasospasm to decrease the
risk of stroke and the last thing for subarachnoid is if there is
hydrocephalus we put in a ventricular peritoneal shunt to drain the
hydrocephalus subarachnoid blood drains out of the subarachnoid graduations like
my hair in a bathtub during and my hair goes into the bathtub drain clogs up
blood goes into your summer acknowledged regulations and clogs them up and causes
hydrocephalus if I get hydrocephalus shanti shanti shanti shanti shanti
shanti sake rupiah now chante chante should we
get shanty with a shunt that’s a good show and that shanti shanti put a hole
in your head and it makes you feel peaceful and relaxed their shunned
Ishant at sex I love that that’s fantastic job fantastic you get shunned so the good
news is that everybody who gets a bad subarachnoid get hydrocephalus gets a
shunt the bad news is as you don’t necessarily get Shanti surgery now I’m
OTP let’s look at the next slide ok primary headaches are recurrent primary
headaches primary headaches are recurrent in other words two murders
people go like this all primary headaches bad their recurrent she was
says primary headaches usually recurrence Haldex bad their recurrent that must be
bad it’s recurrent they keep coming back and back well tumors not recurrent is
that good no because she died the reason you see
you have to be alive long enough to have something recurrence you mean is I
gunshot wounds to the head to go listen look at the bright side I can happen
again ok secondary headaches k severe and sudden and severe that’s talking
with some brake fluid accompanied by worrisome signs I like this it’s welcome
to my editors worrisome signs here so worrisome sign so what was that
worrisome sign was worrisome where his some worrisome oh you mean when the guy
had syncope drove his car into a telephone pole was worrisome or how
about this one when the person when blood test that was worrisome that was a
worrisome sign oh yes here in the tumor when the guy had a seizure on the subway
system and fell under training got run over definitely I i found that quite
worrisome yes sir i want to see if these are some very worrisome signs and
symptoms here and I hate it when people of syncope while they’re driving down
the opposite lane of traffic from me for me he pulled yes that rose worries and
yes it’s worrisome ok let’s look at the thing here intracranial hemorrhage were static in
my life beware of this phrase worst headache of my life beware of that
what’s the worst headache in your life so is the one you’re having right now ok in reality it’s been
studied and although this phrase is out there were stuck in my life I really
prefer that you say worst headache of my life would suck up associated with
sudden loss of concert on Sunday meningitis loss of conscious sudden
onset of meningitis and the worst headache of my life tumor well the thing is the pain is so
bad I can wake you up but also remember which of these things here can present
with the seizure which can present with a seizure all of them rumor trauma infections bleeding can all
present with the seizure now the first thing to do is to CT scan CT CT only if
there’s temporal artery tenderness we biopsy only if there’s temporal artery
by tenderness William biopsy all of his temporal artery tennis will you buy me
the temporal artery so it’s the same thing as seizures number we should and
seizures windy you doin eg when do I do an electroencephalogram I’ve excluded
hypoxia excluded calcium excluded magnesium I
think students sodium hypoxia glucose and toxins have excluded intracranial
mass lesions by CT scanning the brain I excluded all those things they’re still
having seizures electroencephalogram electroencephalogram the same thing here
once these things have been excluded once these things have been excluded
then you go and you say oh I excluded these things now let’s look at the other
forms of primary headache syndromes I’ve excluded all this stuff now the question
is is this a tension headache while tension headache so bi-lateral band-like
tension headaches a bilateral band-like tension headaches are bilateral role and
band-like going around my head like a somebody wrapped a belt around my head
so many rap the belt around my head to head easing may head screening my head is grieving the
cameramen said he was leaving a head band like around the brain pan like
around the brain but the ready whenever I look up up up there is no focal
finally she felt the findings intention of the findings are evil evil not quasi
even marginally be four or five minutes no stiff neck no stiffness no neck
stiffness no hora now or no focal findings and you know what no seizures the reason is that we don’t
know what causes tension and I’m sorry I shouldn’t say like that I should say you
don’t know what caused it I’m an expert what makes me an expert because I have
deeper ignorance than you I wanna scream with you I say you don’t know me too
chicken to say well Conrad do you know if you to check in to say I can you
wanna kiss you don’t know but if you ask me do I know the answer is No how do we go from being ignorant to an
expert in 15 seconds ignorant I don’t know expert nobody
knows medical school professor the data is not conclusive ignorant I don’t know
what causes tension headaches expert it is not known research scientist the data is
inconclusive all different ways of saying I don’t know migraine migraine
comes from the original Latin for me mania India half ahead in the crania
half ahead and that is because these were you need latter all 50 percent of
the time they were unique lateral 50% of the time sometimes it can be associated
with an aura sometimes it can be associated with visual problems visual spectra
fortification one of my favorite words spectro fortification you ready somebody along time ago said that if you
look if you look at a second Monet paintings monet’s years at something
something he said this looks like the mist are sending over the battlements of
a cast on into the future into the distance up ahead in the distance I saw a
shimmering light spectrum visual spectral fortifications to the 19th
century man who described it he said with the person with migraine gets looks
like a castle in the distance with the sunlight coming over the clouds of the
castle’s battlements spectra of the fortifications me and I don’t know but I
love the poetry and that terminology you know me and I love the poetry spectra
fortification looks like a castle in the distance visual problems smells as an aura abnormal smells
sometimes the migraine can actually cause focal neurologic runs what’s it
called when you have focal neurologic findings of a migraine when you have a
complicated very complicated like that that’s pretty complicated when you when
it’s complicated by focal neurologic findings when it’s complicated by focal
neurologic findings what kind of migrated as a cold one is complicated by
focal neurological findings were kind of migraine is that that’s a complicated
migrant yeah it’s complicated but you have to be so constipated complicated
complicated k so the answer is complicated migraine means that there’s
such days 0 spasms it actually causes a stroke yago man visual problems can be
focal can be focal you see we’re not really sure what caused the migrant we
used to think that migraine was caused by they so spasm followed by
vasodilation and in the vasodilation you get the headache we’re not sure what
caused it however you know that’s not really a great mechanism for thinking
about the drugs because even though we don’t know what caused is it it does underline why beta
blockers and calcium channel blockers are effective prophylactic therapy
because even though we don’t know what caused it if this is vasospasm followed by vision
dilation beta blockers and council channel blockers prevent the days of
spasm loss had a cluster headaches are unique cluster headaches are unique
because they are 10 times more common in men they call are associated their
exclusively unilateral it is like an ice pick being stuck in the air I you know
I’m attending physician the largest city hospital New York largest municipal
hospital Kings County Medical Center in Brooklyn down stay warm social TV medicine and
we’re talking about cluster headaches one day and just as we were there man
came by was coming into the emergency room and he was complaining of a
terrible headache and I said quick over there and asked me what it feels like
and we just finished this discussion in the guy who was a man he said I have
unilateral sudden severe pain it was associated with tiering rhinorrhea
because tears go into the duct so you get to that is the right area a red eye
and I went oh my god we’ve just diagnosed cluster headaches unilateral
it’s a man unilateral hearing rhinorrhea redness and the I diagnosed a cluster
headache I said the same thing will be like this is the man what he feels like
the student runs in those days I think it’s a cluster headache he’s gonna say
it feels like an ice pick being stuck in my student loans in a few months back he
calls me and says he feels just like an ice pick being stuck in as I think it’s
a cost headache we should give this guy quickly give him 100 percent oxygen
because this the therapy for this 100% oxygen we can
use our trip down for a board if therapy we can use ergotamine for abortive
therapy we can use things like lithium and steroids forms chronic suppressive
therapy with lithium and see rise for chronic suppressive therapy and I’m all
set to run in there with the oxygen in the trip that ends in there gotta mean
and I said are you sure it feels like a nice pic stuck in the eye and a student
said yes it does and I walk into the man and I see a man who’s got a nice pics
didn’t do as well that chose to show us that when a patient says doc I feel like
I’ve been hit in the head with a hammer you should actually asked have you been
hit in the head with a hammer lock it feels like I’ve been run over by a bus
today she actually asked have you been run over by a bus today and the same
with ice pick like headaches no RMX lawyer what we see is migraine headaches
this word pulsatile is very non-specific throbbing is very non-specific its true
pulsatile throbbing however the big issues this is that they are unilateral
migraines most of the time that’s what the word originally meant mania half
ahead however they can be bilateral now this thing about tension headaches word
says band-like that’s very important because tension headaches are banned
like they feel like a belt around your head and it is associate neck muscle
tension and all these things but it’s still very difficult to be precise
cluster headaches this is very important incapacitating the person can’t move
one-sided incapacitating incapacitating and the other thing about cluster
headaches is that the nasal the lion andrea is from the lack of a nation the lack of nation causes the rhinorrhea
the red eye caused the lacquer mation lack compassion cause the runner in the
rain area causes the nasal congestion you see when you ever read teetering on it goes into the puncta which drains
into the nose that causes the Rhino real so that’s the thing about clusters
clusters lasts a short amount of time they class 20 to 90 minutes each they go away you have several episodes
and they go away and they come back the following year you can have him for
three or four weeks at a time two or three times a day for five times a week
they happened ten twenty times over a few weeks and then they gone until they
come back the following year remember the single biggest things this
unilateral icepick excruciating read i Rana yet tears tears now migraines most
of the time only seventy most of the time seventy to eighty percent
unilateral can be liable visual problems flashing lines visual problems also get
flashing lights and other ocular and visual disturbances spectra
fortification misty misty castles in the distance and if it causes complicated
means that the Bezos spasm is so severe that it can actually result in a stroke it’s a complicated migraine so let’s
look at treatments for a second and here we have a CT scan of a person’s got a
subdirectory this white stuff I’m looking at here well white stuff over here might be OK
of its choroid plexus but this white stuff to hear this is blood in the
subarachnoid system there’s blood in the subarachnoid system so this is a CT scan
of the head showing the blood remember that the CT scan for subarachnoid is 95%
sensitive on the first day you lose about five percent to sensitivity it
each day because the blood reset every absorbs the blood license and as the
blood alliances you lose the ability to detect the subarachnoid hemorrhage on
the CT scan so therefore as the blood reabsorbed you lose the ability to
detect the blood on the skin because the blood licenses and it disappears the
blood license and it disappears so therefore 95% sensitive on the first day now you may notice that this thing is a
CT scan that this blood is here in the CT scan now that MRI is a better test
for almost everything else the MRI and neurology the MRI let’s look at the MRI
for second the MRI for multiple sclerosis better than the seat the MRI
for a stroke embolic stroke much better than the CT it’s visible 95% the
twenty-four hours the MRI much better much better at looking at the cerebellum
and looking at the posterior fossa much better much better than looking at the
cerebellum in the posterior fossa MRI is in fact bad for everything except blood
it’s better for everything except blood it’s better for everything except when
you looking for blood is a seat in the city so bright moments in drama and
trouble now let’s look at this extraordinarily important slide
important slide here abortive therapies in other words doc I
got pain now nonsteroidal and acetaminophen from mild pain triptans
for severe pain from migraine or cluster our God I mean derivatives for migraine
headaches or a cluster in other words aboard his means I have pain now I got pain now prophylactic
treatments is that a person gets recurrent episodes of headaches in other
words the treatment for migraines and the treatment for cluster headaches has
enormous overlap what do they both have in common both migraines both migraines
and cluster headaches can be treated with that ripped an acutely now you
notice that we say trip to we don’t say sumatriptan sumatriptan Alyssa trip 10
that a trip down because the difference in efficacy is none and anybody who says
they’re different is selling something for a drug company so any of the trip
stands is ok my greens is probably may be caused by the azo spans and caused by
vasodilation when the vasodilation occurs you have a headache they so
special can be so bad as the cause of stroke or seizure days a dilation and
they had a professional neurologist and turn around the next sentence and go
well that’s not really the mechanism accept all the Therapeutics is based on
that mechanism they are spasm followed by vasodilation then they had a trip to
construct this ribbon buses got constricts the cerebral blood vessels so these pains get better when giving
drugs that cause of these are construction he said actually better
decrease the pain we think the most common adverse effect of these in whom I
they contraindicated coronary artery disease why because in coronary artery
disease you don’t want there’s a special I don’t corners you want a suspect it
won’t be as bad as it was just a suspension that’s been had caused
vasospasm so the problem is that it causes vasospasm that’s going to be a
headache but is bad four corners now these drugs are these useful in 10
genetic and the answer is no attention had a good idea Pathak not vascular
headache these are for vascular types of headache
and migraines and clusters migraines for sure clusters probably are some form of that
headache what does that mean they so spasm followed by vasodilation in the
pain from mild headaches non-steroidal some both of them but that’s for all
that’s had a congenital non-steroidal that’s even here to intention that’s
even here to know the point of differences is that cluster headaches
get a hundred percent oxygen as abortive therapy 100% oxygen as abortive therapy
now here’s the next question what happens when you’re having more than
three to four of these bad boys per month while when you’re starting to have
a lot of these bad headaches every month men I wouldn’t do that to incapacitate
we are talking about some very serious pain here very serious pain
incapacitating pain excruciating life-changing crippling discomfort I wouldn’t even let people go three to
four times its once a week likely taken action for four hours once
a week moon no way no way prophylactic therapy prophylactic therapy
beta-blockers like pro praying all law propranolol as a prophylactic therapy
that’s the number-one prophylactic therapy calcium channel blockers SSRIs
such as prozac calcium channel blockers SSRIs k tricyclic anti-depressants
phenytoin and other seizure meds these are definitely second line number one
prophylactic medication is preparing a law or parental its proposal now what’s
different about clusters is that for prophylactic treatment lithium and
steroids can work why do lithium and steroids work while they work based on
the same mechanism of cluster headaches and what’s that I don’t know how do they
work I don’t know why do get a cluster
headaches I don’t know why is it a men-only I don’t know man you are so
damn ignorant I thought you were like a medical school professor know but I play
one on TV wow you know we’ve done some any
standardized patients for step TOCs we’ve decided to come up with
standardized triangle and the answer is what causes these things the answer is
of course obvious the data are inconclusive the data are inconclusive
we just know that these work to prevent headaches triptans Sargodha aboard a
headache now oxygen aborts a cluster now you’re getting three to four month
prevent it would propranolol propranolol to work for rapin all-time highs or the
SSRIs try cyclists and you know what as a general rule all the seizure
medications phenytoin carbamazepine valproic acid promoter gene that it’s OK
when motor gene topiramate which is topamax a a seizure medication to pee
remains a seizure medication lamotrigine lamictal a seizure medication did you know that although seizure
medications are also pain medications for for neuropathic pain not like I but
I bump my arm and I have pain and neuropathic pain meaning perform
neuropathy did you know that all the seizure medications all of them anytime
car maze pain topiramate lamotrigine valproic acid did you know every single
one of those seizure medications can also work for neuropathic pain I have
peripheral neuropathy from diabetes have tried everything mother worked nothing
worked neurontin gabapentin didn’t work
pregabalin didn’t work lyrica pregabalin didn’t work new fee of new few I know that didn’t
work gabapentin didn’t work I don’t know what
to do try seizure medication phenytoin carbamazepine valproic acid all except
ethos oxman actually all the time people suck someone has been absent from this
disease if I’m song seizures so thing is is that all seizure medications are also
work for neuropathic pain he say well how do you know which is the best one
for you don’t you don’t see neuropathic pain like headaches performer on but
these are we just don’t know which ones gonna work we know that propranolol the
best prophylactic medication for headaches widespread in calcium blockers
we don’t know what it is it’s just the way it is hundred percent oxygen aborts the
clusters here’s our headache story a guy comes in with a headache the first time
all severe focal findings had CT all the severe overwhelming worst headache and
my wife looks like meningitis head CT I get tenderness over here steroids alright have excluded the
secondary cause of headache what do I do now primary headaches band-like around the
head tension and experience to rattle monstruo doesn’t work try and opiate no
focal findings no or no visual nofollow findings no or no visual migraines visual migraines unilateral premium most of the time
aboard the that treatment with trip plans are gotta me but not if you’re pregnant or
have myocardial infarctions because the triptans Sargodha mean will constrict
the vessels in the heart as well and the patients not gonna lie I’ve got some
good news and some bad news good news I major headache better with a bad news a close look once everything and that is
the end of our relic

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