119 Headaches – Get These Right!

Here we are in early October, and I want to make sure you’re aware that the last cohort of the 33 Days to Pass Your PANCE program begins November 1st. That’s right around the corner. So, if you’re someone who is struggling as they’re getting ready for the PANCE or worried about how they’re going to attack the PANCE, in fact, if you’re someone who’s failed the PANCE once, twice, three times, or even if you’re someone who’s struggling with their end-of-rotation exams or medicine exams or as far back as didactic year, if you can’t figure out how you study best, how you learn best, or how you take tests the best, the 33 Days program is designed to help with those things.

Now, initially, I created it to help students who were struggling with end of rotation exams and on their way towards the PANCE or having failed the PANCE, quite honestly. And I’ve gotten amazing results. Even more so, over the past year or so, I’ve had hundreds of students go through the program, and a good number of them are clinical PA students or didactic PA students who have found the course to be incredibly valuable, finding that they’re scoring their highest scores on end of rotation exams, on their exit exams, that they’ve scored throughout all of PA school. And we can achieve that by teaching advanced learning strategies, cognitive test taking techniques, and then optimizing performance for high stakes exams. Those are really the three things that I hit on hard in the 33 Days to Pass Your PANCE program. I’m looking so forward to this group because it’s going to be a ton of fun. Each group is individualized and takes on a personality of their own, so I can’t wait to see how this group shapes up, and I’d love for you to be a part of it.

You can find out more and register at physicianassistantexamreview.com/33. Yep, just the numbers, 33.

All right, welcome to episode 119 of the Physician Assistant Exam Review Podcast. This episode, we’re going to be covering headaches and how to easily get them right. My name is Brian Wallace. I am the host and creator here at Physician Assistant Exam Review, and I am thrilled to have you here with us today. I’ve just been having a ton of fun lately. Had a great conversation earlier with someone who just passed her PANCE. I’m going to bring that to you next week.

And she just had so many amazing things to share that I can’t wait to release that one to and have you hear that. That’ll come out, like I said, probably next week. I have to just make sure it’s edited correctly and go through all that process. Either way, today we’re going to be talking about headaches. Headaches are one of these things that sort of always drove me a little bit nuts. I don’t know why. They’re really not that hard.

The key here is just differentiating them from each other. The questions are going to come up with all three. You’re going to be in your answer choices, and you’re going to have to pick them apart. That’s going to be what it is. They should not be that difficult. A couple little caveats here and there, but nothing too, too crazy. So anyway, with that being said, let’s go ahead and get started with our priming questions.

What diagnosis should you be thinking of with a unilateral headache and a runny nose that occurs every day for the past few weeks? Oxygen therapy is used in the acute setting of which… which type of headache? Which type of headache is associated with an aura? Which is the most common type of headache? Which is the most common type of headache? So like I said, these should be pretty straightforward.

These should not be something that scares you or intimidates you. The problem with headaches to me and with when we talked about concussions, is thinking about worst case scenarios and making sure we’ve got those ruled out. And then just going down our list and comparing which are the symptoms we’re looking at and how to differentiate them from each other so that we treat them appropriately. We’re going to start with cluster head, I’m sorry, with tension headaches. Tension headaches are pretty straightforward. These is the most prevalent form of headaches accounting for approximately 90% of all headaches, right? So I just asked that question.

What was the most common type of headache? Here you have it. 90% of all headaches, tension headaches. These are often associated with lifestyle factors and stress. Stress is a big one here. Not that you know anything about stress, right? Our risk factors are stress, poor posture, lack of sleep, hunger, or dehydration.

That’s a good one. I harp on dehydration a lot. I feel like that’s a major cornerstone of treatment of anyone. And let me just break off here for a second. I’m just talking with someone whose whole family was getting over COVID and they had a nasty GI effect from it. And the one individual in the house almost wound up in the hospital and he had fainted. And a big part of that was dehydration, right?

So it’s always, you know, we go round and round on a lot of different medical treatments, but fluids are a big part of that. So stress, poor posture, lack of sleep, hunger or dehydration, minor head and neck traumas, and eye strain, long periods of reading or screen time. Again, you know, and these are all, are you all raising your hands right now? Clinical presentation. Persistent dull ache, often described as a band-like pressure around the forehead or the back of the head and the neck. So it’s like a tightness is how well people describe it. It’s bilateral, meaning, you know, I’m going to explain that like you don’t know what it is, but it affects all sides of the, it affects both sides of the head.

It can be circumferential. The other thing is it’s not aggravated by motion or physical activity. Why is that line important? Because we’re differentiating it from the other types of headaches, right? When we get to migraines, for example, people will complain about when they move, it hurts. These can last from 30 minutes up to several days, right? Some of us, you know, I usually can go to bed and when I wake up in the morning, my headache is cleared out.

But sometimes when you wake up in the morning, you have a headache, oh, that’s just going to be terrible because it’s hard to get it to clear, right? But when you get that stress reduced, that relaxation sets in, sometimes that’ll help. Absence of other symptoms like nausea, vomiting, or light sensitivity commonly seen in migraines. So they don’t have any of these other symptoms that you might see in a more, let me just say like in a migraine or in something like a concussion or something along those lines. Lab studies and physical exam findings.

Okay. Is going to be great as we move through this section because it’s going to be the same for all of them. Generally, no neurologic deficits are present. Diagnosis is primarily clinical based on patient history and symptoms. So you’re really going to be talking with your patient. Imagine that, right? You’re going to be talking with your patient, picking apart the symptoms, just like you’re going to do on a test question.

You’re going to look at headaches just like that. How are they going to be presentable? A patient’s going to come in complaining of a headache. You’re going to ask what their symptoms are like, what they have going on. Have they had any trauma? Is there anything else that could make this better or worse? Is there anything else that shows you this is a more significant problem?

Or is it just a headache? You know, either way, you’re going to have to figure that out, just like you would on a test. You can do imaging in other studies, but they’re usually not necessary unless you suspect some other type of condition, right? Unless you suspect that they’ve got a, you know, a subdural or something like that. Treatment for tension headaches over the counter analgesics are going to be the mainstay of treatment here. So NSAIDs, ibuprofen, naproxen, aspirin, or something like acetaminophen. The other big one, and this is something I really want to make sure that you understand, especially as it pertains to yourself and maybe treating these, and then you can pass along to your patients.

Lifestyle modifications is a big one. This is tremendous for tension headaches. Stress management techniques such as relaxation, training, or biofeedback. Some deep breaths, right? Breathing in to a count of three, breathing out to a count of three. There’s a double inhalation practice where you breathe in, pause, breathe in again, and blow out. That’s also been found to be very helpful.

Physical therapy for posture correction. I like this one because it’s something we don’t usually think about. But the way you hold your head, the way you keep your shoulders, all of these things will affect the rest of your body. Sleep hygiene improvements, so a good sleep, like we said, poor sleep is a risk factor for this, right? So sleep hygiene is a big one. I was just horrified yesterday to hear a commercial for sleeping medication for children as young as four years old. And the commercial was something like, you know, my daughter is amazing until she gets a poor night’s sleep and then she’s cranky all day.

And I was just stunned because sleeping, as I was talking to my 12-year-old in the car, as we heard this commercial, sleep is a skill, right? It is something you can get better at. And we overlook that. Sleep hygiene is incredibly important. If you’re having trouble sleeping, if your patients are having some trouble sleeping and it’s leading to these other problems, sleep hygiene is a huge one. Is there a routine before bed? Are there screens off?

Is there a shutdown time? If you’re watching, not that people do this so much anymore, but you used to watch the 11 o’clock news, and if it was the local news, it would be all murders and suicides and killers and fires and things, and then you try to go to bed. It’s impossible. You can’t do that. You know, I find sometimes, depending on what book I’m reading, I’m currently reading the Wheel of Time series, and the main character was captured and on the risk of death, and it’s very exciting. And then I try to go to sleep, and it’s harder, right? So you have to consider these things and consider them for your patients.

It might be an awkward conversation for someone who comes in wanting a pill or some other way to make them feel better. Sleep hygiene is tremendous. Consider it for yourself and the reason I’m spending so much time on it is because it’s also tremendous for students, for people trying to learn things, right? So part of it is that I’m harping on it because it’s important for this diagnosis isn’t a way of treating it, but part of it is I’m spending extra time on it because it matters to you. Regular exercise, stretching, and particularly for the neck and back muscles. Again, tension headaches come from tension or can come from those muscles tense throughout your neck, throughout your shoulders, throughout your back, all connected, all leading to increased pain and things you can solve. Cluster headache is next.

This is an extremely painful unilateral headaches which occur in clusters throughout the day and may continue for months. The key here that I really didn’t understand is how painful these are. When I was doing a little bit of research into it, I think it was a Yale professor was talking about how these are on par with passing a kidney stone or childbirth, like that kind of pain, like really, really painful. And the interesting thing here, and the way that you can discern them from something like tension headaches or migraines, we’ll get to migraines shortly, is that they’re unilateral, right? So, as opposed to tension headaches, which go around the head like a band, like it feels like that tension, that squeezing of your head. This is unilateral extreme pain, and it often involves one of the eyes. So that people feel it like, as if it were behind your eye or in your eye.

So that’s how that description will come from your patients. And not every patient follows a textbook, right? And we’ll describe it that way, but a lot of these will be described that way. These can last between 15 minutes and three hours, but I’m not sure how relevant that’s going to be for your diagnosis or for your testing. But the idea that they come in clusters, which is not the way that I would name it. I’m not sure if I’m just missing something here, maybe somebody can email it and explain it better to me. I looked it up in four or five different ways.

They’re called cluster headaches because they occur in clusters and occur on schedule each day, right? So what happens is you sometimes they’ll wake someone up at five in the morning and they will do that every day or they’ll get them in the afternoon every day at a similar time. So that’s definitely a characteristic here. The other symptoms, again, if you think about where this pain is, they can get watery eyes, a drooping eyelid. They can also get a runny nose as one that comes up a lot in blushing here. So again, as you’re going through this, why is this different? Why is this different than a tension headache?

Somebody walks in, how do you immediately know whether they’ve got a tension headache or a cluster headache? Unilateral versus bilateral. Occurs every day at the same time. Can a tension headache occur every day at the same time? Of course it can. Sure it can. Would they complain of one eye and a runny nose?

Probably not. Lab studies and physical exam findings. Again, it’s that good history. There’s not really going to be any exam findings here. There’s not really going to be any labs you’re going to order. Yes, are you going to try to rule out other causes? Yeah, perhaps you are.

But that’s what your labs are going to be doing. They’re simply going to be ruling out other issues. You’re not going to order an MRI or a CAT scan unless, again, you’re just trying to rule out more severe issues. Treatments for acute attacks, opiates are not going to be helpful. They are just as likely to make things worse. Oxygen is going to be the one that stands out. Oxygen is going to be the treatment that stands out for cluster headaches.

Triptans are also on the list, sumatriptan, zolmitriptan, and steroids may be helpful in the short term. Hopefully you’re aware, but we don’t love long-term steroid use. It causes all kinds of problems, all kinds of issues. Femur necrosis being at the top of my list for things that just sound terrible. And I’ve seen that working in orthopedics with the femoral head dies because someone was on steroids for a long period of time. It’s really, really nasty. I don’t mean to oversell it, but you don’t want people on steroids for a long time.

But a short course may be helpful here. Preventative therapy. Calcium channel blockers like verapamil may help to prevent these. Our last one for today is going to be migraine headaches. Migraines are typically unilateral. They’re moderately severe pain and usually pulsatile. So they hurt.

I’m not going to say they don’t hurt, but compared to a cluster headache, the pain is not the same. They’re unilateral, right? So that’s going to take you away from tension headache, but might confuse you with cluster headache. But that pain level is what’s going to help separate it. They can have an aura. A classic migraine has an aura. A common migraine does not have an aura.

About 30% are classic. These usually last between 2 and 72 hours. So kind of like a tension headache where it can last longer than cluster headaches. Cluster headaches come and go. They cycle, right? Migraines stick with you for a period of time. There’s often a family history of migraines.

And interestingly, before puberty, more boys than girls have these. And after puberty, more women than men have them. Clinical presentation. Recurrent severe headaches. And these become worse if I move at all. People can get nausea, vomiting, photophobia, sensitivity to sound. Those are the characteristics that should make a jump off the page and make this a really easy diagnosis when someone walks through the door, but also a really easy diagnosis on your exam.

If someone comes in saying that they have a headache that’s so bad that they feel like they just need to stay in a dark room and pull the covers over their head and not move, you’re probably talking about a migraine. If someone comes in and said they have a, feels like there’s a stake through their eye every day at about 2 o’clock for the past week, and then it clears out later, but it’s so incapacitating, it’s so painful that they can’t move, you’re probably talking about a cluster headache. Lab studies and physical exam findings, once again, not a whole lot to do here. The only question is going to be, is there something worse going on? Is there a problem? Was there trauma? If there was, obviously I’m going to want to get a CAT scan or an MRI or something.

Was there a reason to consider something like a subdural? How are we going to treat these? In the acute phase, NSAIDs, so ibuprofen, naproxen, aspirin, caffeine seems to help. But I’ve also known people who will make things worse. Triptans, so serotonin receptor agonists, sumatriptan and rizatriptan are the two that came up in the list. Alkaloids or ergotamine and steroids, so dexamethasone or prednisone can help in the short term. You want to try to break that headache.

After that, we have prophylactic or preventative treatment. You can use beta blockers like metoprolol or propranolol. I can’t say the back-to-back. Metoprolol or propranolol. My mouth doesn’t quite do that. Calcium channel blockers like verapamil, ACE inhibitors like lisinopril, and antidepressants can have some effect here as well, like amitriptyline or serotonin reuptake inhibitors.

All right. That’s as much as I wanted to cover today. I wanted to do headaches separately and keep it a little tight, keep it a little short because I want that to stand out to you as to how easy it would be to differentiate them from each other. And I want you to walk away knowing that. I want you to walk away excited to see those questions on a test. I want you to know that you can get those right. So if you’re in neuro and you’re struggling with neuro like I do and you’re thinking, wow, I really struggled to get any of these right.

Where can I pick up some points? To me, it’s going to be on headaches and concussion. Those are going to be areas to pick up points. If you’re going to struggle with EEGs, I’m not sure if I said that funny. If you’re going to struggle on things, make up your points somewhere. You know, we just had this conversation with my children, which is if you’re going to, if you struggle on a test, right, and you get an 85 or you get a 70 or something, how do you get out of that hole? Well, you make up those points with homework, with the easy stuff that you maybe don’t care about.

You maybe don’t think is that important, but that’s where you make up the points against the things that are hard. Lose the points in the hard things. I’m okay with that. And I know in PA school, that’s hard to swallow, right? We all want to get hundreds on everything. But to me, you need to do a balancing act. You got to find what is, how do you get the easy points right?

And maybe you give up some of the hard points. Maybe you let some things slide because you’re too busy. But get the easy things right. And to me, these last two sections for neuro are going to be where you’re going to pick up your points. So I’m excited to bring you those. I’m excited to talk about those. But that’s why I want to keep these a little bit separate.

All right, our study tip for today. Again, I’m going to keep this episode nice and tight and short. So the study tip for today is going to be really simple. The study tip for today is going to be go get the 54 study tips I put together for you. physicianassistantexamreview.com/54. The numbers will bring you right to the site and you will get the 54 study tips that I have there for you all nice and neat and organized. So that way you don’t have to listen to one on each of these shows.

You get a whole bunch of them packed in really tight, really ready to rock, and really ready to go there. physicianassistantexamreview.com/54.

All right, let’s talk about our priming questions. These should now be so easy for you. I’m really excited. Like I said, this should be something you should be able to nail. What diagnosis should you be thinking of with a unilateral headache and a runny nose that occurs every day for the past week? It’s cluster headaches, right? Oxygen therapy is used in the acute setting of which headache?

Again, cluster headaches. That you’re just going to have to memorize, that oxygen therapy is the mainstay of treatment there. Which type of headache is associated with an aura? Which type of headache is associated with an aura? Again, not hard, that’s a migraine. Which is the most common type of headache? The one you probably have right now, or will have later on today, a tension headache.

All right. So, there’s a lot to take away from this, but really, just comparing those headaches and being able to determine which is which. How do you know if it’s a concussion? How do you know if it’s a tension headache? How do you know if it’s a cluster headache? How do you know it’s a migraine? How do you know if it’s a subdural hematoma, which we’ll get to later?

But that’s what we’re trying to build up to. That’s what we’re trying to work through.

All right. Awesome. So, that’ll take us out for today as we make our way through neuro. I’ve been working really hard on getting Wallace’s Notebook together. Hopefully, that’ll be out, I think, January-ish, early 2024. Got a lot of things going on with the website, a lot of things going on within the community. I’ve been hearing from a ton of people who are making out really well, passing their exams, getting better on the end-of-rotation exams and so forth.

Really excited to get all that news. Talk to you soon. And again, next week, I want to bring you that interview with our PANCE passer.