00:01
Let’s talk about hypertensive urgency as
being a presentation of acute headache.
00:07
Dull, bilateral ache head pain,
no focal deficit,
possible diminished
level of consciousness
if associated with reversible posterior
type of leukoencephalopathy.
00:25
Usually seen when systolic
blood pressure is above 180
or the diastolic blood
pressure is above 120.
00:32
Treatment here is you need to make sure
that you take care of the hypertension.
00:36
Urgency versus your crisis, or emergency,
and your crisis is the one in
which you don’t mess around.
00:43
At that point, you need to
make sure that you give IV,
do everything in power in which
you give IV nitroprusside
to take care of the
blood pressure ASAP.
00:51
Remember, we talked about
hypertension urgency versus crisis.
00:56
Here, let’s talk about
a cluster headache.
00:59
The duration becomes important.
01:01
Abrupt in onset,
peaking approximately five
to ten minutes later.
01:06
That is important.
01:08
Pay attention to that.
01:10
Persists for 45 minutes to 2 hours.
01:13
And clusters, meaning to
say over days to weeks.
01:17
So it comes in these clusters,
over days to weeks.
01:22
Peak of five to ten, persists for 45
minutes to 2 hours, and comes in clusters.
01:29
Consistently unilateral
and orbital in location.
01:34
“Doc, it feels like I have pain in my eye.
01:38
It feels like someone is
stabbing me in the eye.”
Orbital location.
01:42
Pain described as deep, intense, boring,
meaning to say like a needle being put.
01:48
So, they don’t call
this being throbbing.
01:50
Throbbing will refer to as being
our giant cell arteritis.
01:54
“Doc, I feel like these pulsations
of throbbing headaches.”
Boring is more like a
needle, being stabbed.
02:02
These patients are moving around the
room, banging their head on the wall,
screaming for medication because could you
imagine putting a needle into your eye?
Isn’t a good feeling.
02:13
Nausea and vomiting are atypical,
associated with lacrimal
or nasal secretions.
02:20
Who does it occur in?
Young adult men.
02:23
Usually, onset will be 30s.
02:26
Male to female ratio, males much more
so than females with cluster headaches.
02:31
Now, suicide, an
occasional complication.
02:35
This darn headache is so bad
that that patient is not able
to handle and manage this
by himself or herself,
most likely himself,
that he wishes to
then kill himself
due to the intense nature and
predictable recurrent rate of the pain.
02:50
That becomes important.
02:51
Even though we just
call this a headache,
we understand the implications
can quite literally be grave.
02:58
Let’s take a look at management
of cluster headache.
03:00
Abortive therapy is often
ineffective due to the rapid onset.
03:04
Remember, short duration of attacks.
03:06
So the peak is five
to ten minutes.
03:08
However, you say short duration.
03:10
Keep that in mind,
it’s all relative.
03:12
Forty-five minutes is actually not a lot
of time over a grand scheme of things.
03:18
However, for the patient,
it feels like eternity.
03:21
“Doc, my headache feels
like it’s forever.”
Yes, when you’re in that type of
pain, even 30 seconds is too long.
03:29
The first-line therapy consists of oxygen,
specifically 100%,
administered via a nonrebreathing facial mask
at a flow rate of at least 12 liters per minute.
03:39
The second-line therapy includes triptans,
such as subcutaneous sumatriptan.
03:45
It is important to note
the contraindications for sumatriptan,
which are ischemic cardiovascular disease,
history of stroke, or uncontrolled arterial hypertension.
03:54
Third-line therapies are more varied
and include intranasal lidocaine,
oral ergotamine,
and intravenous dihydroergotamine.
04:02
Preventive treatment for cluster headaches
includes the following options:
Verapamil is commonly used.
Glucocorticoids are prescribed with a tapering dosage.
04:11
Among alternative options are:
Galcanezumab, also known as Emgality.
04:18
This s a Calcitonin
Gene-Related Peptide antagonist.
04:22
Lithium and topiramate are
other medications which can be used.
04:26
A greater occipital nerve block
is an interventional method.
04:30
In summary of cluster headache:
Risk factors: male, much
more so, young male, 30s.
04:37
Signs and symptoms: unilateral
boring, boring, boring.
04:41
By boring, you know what
I’m referring to now.
04:42
I’m not saying, “Well, I’m sitting on my
couch watching TV because I’m bored.”
No, no, no, this is boring
like you’re stabbing someone.
04:53
Differential diagnosis:
glaucoma, dissection,
cerebral vein thrombosis.
04:58
Diagnostic workup: H&P,
image can rule out other diagnoses if
it’s causing this type of headache.
05:07
Otherwise, H&P.
05:09
For acute treatments, we discussed oxygen,
triptans, intranasal lidocaine, and ergotamines.
05:17
For prevention, you can use verapamil,
glucocorticoids, galcanezumab, lithium, topiramate,
or a greater occipital nerve block.