DIP Episode 372 - The Clutch Headache Podcast (for Step 1-3)

Okay, welcome. My name is Divine. This is episode 372 of the Divine Intervention Podcasts. And into this podcast I'm going to be talking about headaches. In fact, I'm going to be calling this the clutch headache podcast. The thing is whenever you take a USMLE exam, you know, a few questions on headaches typically pop up. This is for step one, step two, see, step three. So again, if you understand what's going on here, you can easily get these questions right. If you're taking the USMLE step two, see, go step three or complex level two or three exams within the next like three weeks or four weeks, I would recommend taking the courses I have next week. It starts with the MBA Me testing and strategies course on Monday and the 24 hours step two, see K slash step three course taking place from Tuesday to Friday from the 22nd to the 25th. If you're interested, they're going to be held over Zoom. If you're interested, you should put me an email through the website. You get a lot of tons of people take these courses and they've done extremely well on the exams. I've had people, you know, even the Acuban percentage is improved like 10, 20, 30% from taking the test taking strategy scores. I've had people scores on the exams improved 30, 40, even 50 points after taking my review courses. In fact, yesterday and the good thing about the courses is they're not still. I don't like just keep going over material from like 10 years ago that no one cares about.

No, we know that the MBA Me is the adjustments every year, right? So I make very continuous adjustments. It's almost like a software update. I make pretty continuous adjustments to the material. So again, what are you going to be getting is something that is very relevant to your current exam. So if you're interested in any of these courses, again, testing in a course on Monday, 24-review courses on Tuesday through Friday, just shoot me an email through the website. I'll give you some more details on registration, on cost and things like that. Again, the courses are going to be held by Zoom. So should me an email through the website, there's still some spots available and I'll be happy to have you registered. So let's talk about headaches, right? So what in the world does it mean to have a headache? Well, having a headache means your head hurts. That's it. Having a headache means your head hurts, right? And the thing is, you know, there are many types of headaches. I mean, like for those that are going into interim medicine residences, you learn or neurology residences actually, you learn about a ton of different kinds of headaches, right? But for the most part, the big headaches you want to be concerned about are tension headaches, migraine headaches, right? And cluster headaches. Now there are many other kinds of headaches, which will address actually, right?

But will address them more in viniate form because those are ones that the MDM is typically, we'll just, every now and then, you see a question on those, but definitely the three primary headaches syndrome, tension, migraines, and cluster headaches, you absolutely need to know a lot about, right? So I guess the first thing is, maybe, the biology, or it was the most common kind of headache. Well, I hope you're seeing, oh, the vine is going to be a tension headache. Tension headaches are very common, right? Very, very common. The second most common kind of primary headache is a migraine headache, right? Clostro headaches out, not as common, right? So, you know, what if they give you a question about a person that they have this positive health headache, right? And this headache many times is accompanied by nausea. They have to be in a quiet room, in a dark room, and fall asleep for a few hours before they feel better, right? There's going to be a migraine headache, right? There's going to be a migraine headache. Many of these things are just about recognition. And I will explain some pathophys behind headaches, and they help you organize some of this material in your mind, right? But the thing is, many times on MDM exams is not about recognizing that a person has a migraine. The MDM kind of surmises that at this point in a medical career, you probably know how to recognize a migraine. The thing they go after is how you treat it, and many people tend to mess this up.

Now, it's very important for migraines to differentiate the treatment as acute treatments or prophylactic treatments. If a person has an acute migraine, the thing you want to give them is a visual-constricting drug, right? Like a triptime, like sumatriptan, or an ergodamine-based agent. Now, if you don't see sumatriptan or ergodamine as an answer, you can pick the answer that says NSAI Ds. You can pick the answer that says NSAI Ds. The thing is actually for most migraines, NSAI Ds are pretty good as a body therapy. But it's when they start having like migraine plus weight stuff, like nausea, vomiting, photophobia, photophobia. That's when you begin to go into the triptime or the ergodamine-taritry. Now, remember these drugs. They have visual-constricting drugs, right? So, they are not drugs you want to give to people with certain problems, right? So, see, for example, if a person has like a variant angina, which was previously called Prince Medellangina, that's a disease that's really coronary visual spasms, right? That can certainly cause problems, right? Or remember people that, let's say, for example, if had like pulmonary embolite, or if had myocardial infarctions in the past, or if had like strokes, especially like an ischemic stroke, you know, giving those people a triptans may not be the smartest I'd game in the world, right? And remember, triptans also contain serotonin, right? So, they can absolutely cause serotonin syndrome in exams, right?

So, like you don't want to be given a person a triptan and like an SSRI or triptan and a TCA, you know, things are not going to end well for that patient. You don't want to do that, right? And then, remember that for you to say, oh, I'm going to put a person on mygrimperphylaxis, they actually need to meet certain criteria. You can just give everybody mygrimperphylaxis, right? The people who give mygrimperphylaxis that would have eight or more migraines a month. That number is very high you to know. So, for Brazil's having six episodes of migraines a month, they are not candidates for prophylactic therapy or nbimim exams. But if you have eight or more migraines a month, they are absolutely eligible for prophylactic therapy, right? So, what is this prophylactic therapy? It can be something like a bit of blocker, right? It can be a tricyclic type of patient, especially people that are depressed, right? For Brazil, it's depressed and you know, giving them a TCA is maybe not the worst idea in the world. You can also use topiramid, right? Topiramid, many people call it, I think, topermax in the hospital, right? It's also very good as migraine-perphylaxis. Remember, topiramid, right? It can cause cognitive slowing. It doesn't mess up your brain, but it can just kind of make you slow mentally, right? And don't forget, topiramid also likes to cause kidney stones, right?

So, they can give you a present, and I recently started on migraine-perphylactic therapy, and has this acute onset flank pain, reducing to the groin. I want you to think about topiramid toxicity. It can cause a crystalline nephropathy, right? And don't forget your tricyclic and take your presence, right? Remember, they can widen your QRS, they can prolong your 15-trival. They have this anti-hamside effect, right? So, anti-heach one, so they can cause sedation, right? Anti-alpha one, they can cause orthostatic hypotension, anti-muscarinic, right? So, they can cause those anti-colonurgical side effects. And then don't forget that these tricyclic and tydipresens, right? Don't forget that, again, they can call... People will actually use these things to commit suicide, which is a... which is a pretty unfortunate thing. We're going to treat the toxicity of sodium by carbonyl, right? Because remember, these T Cs for the most part are also sodium channel blockers, right? So, that's the way you handle migraine perphylaxis. Now, how about attention, Haley? How does that... how does that present? Well, it's going to be like a person that has been in a stressful situation or a tired situation. For example, like studying for USML exam or just taking a USML exam. Right? Many times these people, they won't have nausea, they won't have vomiting, they won't have any auras, right? Like we may see in migraines, right?

And, you know, many of those times, it's going to be like a band-like pain, it's going to be on both sides of the head, right? How do we treat these people? Just give them an answer, tell them to relax and chill a bit, and they'll be fine, right? Now, what if they give you a question about a person, and they tell you that they have this intermittent headache, right? Shows up as like a short severe pain, right? Usually the pain is going to be severe around one eye, right? It's a unilateral. That's a very high-yield thing to know. Plus, your headaches are unilateral, right? So, it's a bit around one eye, right? And then they have all these autonomic symptoms, you know? So, they have like tearing in the eye, redness in the eye, nasal congestion, right? Sometimes they may even have this thing called a partial-honored syndrome, right? So, they will have toses and meiosis, right? But they won't have anhydrosis, right? When you see those things, think of cluster headaches, right? Again, cluster headaches is one of these things you want to be careful of, right? How do we treat it acutely versus how do we prevent it? Right? So, our busy has an acute episode of a cluster headache, right? Go ahead and give those people a hundred percent oxygen, you know? Just high-flow oxygen. It's really helpful, right? But if you don't see that as an answer, you can also give a triptan. Triptans are actually first-line agents as well, for treating a cluster headache acutely, right?

You can even use these triptan-nizel sprays, right? Now, the thing is for prophylaxis, though, right? For praises having so many cluster headaches, and you're like, man, okay, what can I do to prevent these things from happening? Consider verapamella's first line for your exam. Remember, for your upper male, is one of those non-dihydropyredine calcium phenyl blockers? Remember, verapamella can cause a lot of problems, right? It can cause cardiac adiabia, right? It can cause, I mean, it's literally... It can last for an terithmic, it can cause cardiac adiabia, because it blocks calcium channels, it can cause constipation, right? Because you kind of need calcium for your smoke muscles in your GI tract or contract. And don't forget that verapamella can also cause hyperprolactinemia, right? So, it can cause low libido, galactorea, genocomastial, and stuff like that, right? But again, for perphylaxis, against cluster headaches, verapamella is first line. If you don't see that as an answer, consider using steroids, right? Many times, you use like a 10-D course of steroids, and it's very helpful in these people. We can also use lithium, right? So lithium is not only for... what is this psychiatric disorder? It's not only for a person that is bipolar, right? You can also use it for cluster headache, perphylaxis, right? Now, what if they give you a question about a person, they tell you that they have this lancinitin theme over their face, right?

And it's worsen by like wind blowing over their faces, or them lying on their pillows, or whatever, right? This is going to be trigeminal neuralgia, right? The key thing is just this lancinitin, just really, really terrible pain. You can happen actually a lot. It's actually more of a seizure disorder than an actual headache, right? But we're going to let that go for that, right? So how do we treat trigeminal neuralgia? They love to test this all the time. Remember, you're going to use carbamizapine, right? You're going to use carbamizapine. carbamizapine is an anti-piliptic drug that is great for treating. It's actually the first line for treating trigeminal neuralgia, right? Now, don't forget carbamizapine can cause lots of problems, right? It can cause e-gram loss like toces, you know? So they can give you a question about a person that will start it on, you know, therapy for this trigeminal neuralgia, and they develop like a fever, right? Think about e-gram loss like toces from carbamizapine. Remember, it can also cause neural tube defect, right? It can also cause SIDH, right? So they can give you a person that has like hyponitremia with very hyperatonic urine, right? Now, let's just go over some other quick veneers that we point you towards specific diagnosis on exams. Think of this as kind of like a rapid review of headaches, right? So if they give you a question about a person that has a stiff neck and a headache, what are you thinking about?

I really hope you're saying, oh, divine, you know, this could potentially be meningitis, right? Well, they give you a question about a person that has like a headache, they have fevers, they have neuro deficits, it's a triad, fevers, headache and neuro deficits. I hope you're saying, oh, divine, this person potentially has a brain abscess, right? If you don't say that as an answer, you know, you may be big answer to the system, so I feel like this, but typically, I'll say almost like 95% of the time, there's going to be a brain abscess when you're exams, right? What if they give you a question about a person that has like sodium onset, severe headache, right? And let's say they have a history of like morphans, right? Or they have a history of a normal dominant, polycystic kidney disease, or is a person that has a history of hypertension, which is actually the VB-guest risk factor, or the person has a history of like Alzheimer's or something, right? You know, like aminoid and geopathy or whatever, right? I'll really hope you're thinking about a sub-rocknoyd, a hemorrhage. Remember for that, you're going to do a non-conheads CT, right? If you don't see anything, you're not done. You're going to do a number of puncture looking for Zantholcromia, right? And don't forget those people will have to betray them, you're going to give them an amodic pain to prevent that post-stroker visus pausin, right?

When you see a person that is an older person, you know, they have this chronic headache accompanied by nausea and vomiting, right? And you notice that that headache is worsened by changes in position, right? If you see that, don't you think about a brain tumor, right? Or it can be re-biting the morning. Think about a brain tumor. Many times for those people, you're going to get an MRI of the head, right? You're going to not a CT scan, an MRI of the head is going to be great to find that brain tumor, you know? And a no-person, we're probably worried about glium blastoma-multiforme, right? You know, a young kid, we're worried about like a pilot-seric astrosyctoma. Remember, pilot-seric astrosyctomas are the most common brain tumors in kids, right? And then in adults, it's going to be GBM, right? Glium blastoma-multiforme. Right? Obviously, GBM is a terrible disease, right? And what if they give you a question about a person, and they tell you that, you know, they have like this, you know, just fever, weight loss, really bad headache, right? And he's very worse on the sides of their heads, and they tell you that, oh, wow, this person has like pain with chewing, and they have like pain in their proximal arm muscles. If you see that, right, that's going to be temporal arthritis, right? Remember, for these people, you're not going to be messing around. You're going to go ahead and give them a ton of steroid. You're going to give them like IV steroids, right?

And then you can do temporal artery biopsy. You have about three days after the symptoms start. So do a temporal artery biopsy to get the yield from the biopsy, right? But again, you're not going to be trying to delete treatment, because you want to meet the diagnosis. No, and you're usually going to be in a woman on your exam, although they can give it in men on tests as well. Just go ahead and treat those people first. They treat first diagnosed leader. That's kind of like the name of the game where temporal artery arthritis, right? Well, you see your person, they have like severe headache, and they have like this fixed mid-dialythetopial. If you see this, right, to think about like an acute anguaglochoma, right? Especially like this headache that just starts suddenly, right? Suddenly suddenly suddenly suddenly lessy, they go into a movie theater, right? Because they just, when you go into a movie theater, because of the darkness, you're going to die leave your pupils, right? If you see that think about an acute anguaglochoma, right? For those, you can give like timolol, eye drops, you can give pylocarpine, right? You can do a laser aerodotomy, right? Those are things to keep in mind, right? Or they give you a question about like an obese woman, you know, they tell you that she has like heavy blurry vision, and she's on OC Ps or acne medications. I want you to think of pseudo-tomersary bright, right?

These, these, they call pseudo-tomersary bright, idiopathic intra-cranial hypertension, right? Well, you see a person that has been on NSAI Ds, you know, they start taking NSAI Ds very regularly for like chronic headaches or whatever, or you know, I mean for chronic like joint pain or back pain or whatever, right? Think about something called a medication or overuse headache, right? Many times those people, the way you're going to fix the problem, is tell them stop taking those medications, it's going to be terrible for a few days, but things are going to get better, right? Many times before, great calm calms, usually a storm that calms in, right? Probably talk about a quick life lesson there at the end here, with that, right? And then if you see a person that has like a sodium onset severe headache, and they have like a non like productive, prolactinoma for example, or you know any kind of pituitary adenoma, if you see that, I would really hope you're thinking about pituitary apple plexi, right? Remember, pituitary apple plexi is like a sub-acnet hemorrhage of the pituitary gland, right? Usually it's going to happen in a person that has like a big massive adenoma, has like no relationship with pregnancy at all, right? They have like this big massive adenoma, right? And then they just bleeding to say that adenoma, right? That's going to be pituitary apple plexi, right?

Or you see a person that has like very severe headache, and they just had like recent blunt force trauma to the head, hitting the head by a baseball bat, blah, blah, blah, blah, blah, they think about an epidural hematoma, right? Epidural hematoma, right? And then the last thing I think I'm going to say about headaches, because this is actually going to be a short podcast, you know, headache is not a long topic, but it's a very high-yield topic, right? You know, what's the primary pathophysiology behind just headaches in general? Again, this is a gross oversimplification, but this is something that may help you learn this material well. The primary pathophys behind most headaches, to be honest with you, is actually a visual dilation. That's the truth, right? Visual dilation causes headaches in the intracranial vessels. So many times the drugs you use to treat headaches are visual constrictors. I mean, just think of it on the most basic level, right? Many headaches treated very nicely with what is it called? With an insect? Well, how do insects work? In hippy-cycloxiginies. If in hippy-cycloxiginies, you're going to make less in the way of first the glandings. If you make fewer first the glandings, then you're going to have less visual dilation, more visual constriction, and headache goes away, right? So visual constriction is the pathophys behind the headaches, right?

And you can already see that if you have a visual constriction disorder, like variant anginandins like that, you know, triptans may not be a good idea, because triptans being serotonin receptor agonists can absolutely cause a visual constriction, right? That's one of the ways they help in people to have migraines, right? So I think I'm going to go ahead and stop here. Again, as I do at the end of every podcast, I do offer one or one tutoring for all the USMD exams, step one, step two, CK, step three, preclinical medical exams, 30-ish-off exams. And then, if you're an internal medicine resident, I do offer tutoring, one or one tutoring for the internal medicine, including exams, the internal medicine board exams, the EVIM board exam. And then, if you're looking for, again, if you're taking the USMD step two, CK, or step three, or the complex level two or three courses, again, I have an in-be-me-test taking strategy scores and a 24-review course. Those are taking place next week from Monday to Friday. And also have a USMD step two, CK school is going to be taking place in the summer. It's going to be 75 hours long, basically. If you're taking the USMD exams in the summer, and you want like an extremely comprehensive, super-thr-review, that pretty much attempts to cover the vast majority of what's tested on the USM Ds. I would encourage you to attend the school. And for the school, there's going to be lots of really good things.

We're going to be reviewing content, like a ton of content. And again, we're going to be using primarily Viniettes for most of those things. And then, we're going to have an adaptive learning section for about 10 hours, where we use the keyword strategy that's used in many anesthesia or radiology residences to very rapidly review lots of content. And then, we're going to have an expanded test-taking strategy scores. I do have a podcast where I specifically talked about this school. It's called the DISC, the ISK school. Again, I'm going to copy it at 40 people because I really want to invest in every single person attending. It's in the first two weeks of May, right? So if, again, if you want to reserve a spot, just shoot me an email through the website and I use some more information. And then, I have a You Tube channel, you know, dividing intervention USMD podcasts and videos. That's where I post the videos that I make. And then, I have these podcasts on Apple podcasts, Google podcasts on Spotify, at least the most recent 150 podcasts. If you want everything from a piece of one, all the way to 372, which is this one, you need to go on the website, divininterventionpodcasts.com. If you actually have a Word Press account and you subscribe, you'll get an email notification whenever I meet a new podcast. And then, the next thing I want to say here is, I do have a new website. It's called the Divine Intervention Life Lessons website.

In fact, it's literally divininterventionlifelessons.com. Again, many of you that listen to this podcast on a Christian and I've got tons of emails from people that, wow, I love these little life lessons podcasts you put at the end of, you know, I mean, life lessons that you put at the end of your podcasts. So people have been like, wow, the vine, I really love these things. So I just figured, I'll just make a separate website where I, you know, use Bible based teaching to address common problems of humanity. And I think right now I have like 59 episodes, I post about two every week. And most of them are like 10, 15 minutes long. So if you want to listen to those kind of like a devotional that's perfectly fine. Right? Everyone have the podcasts on Apple podcasts. It's called the Divine Intervention Life Lessons Podcasts. So what's the final thing I want to say today as a life lesson? Remember, before any grid calm, usually comes a storm. Right? So I think many people think that when they're going through stormy situations of life, they say, oh man, this storm is going to kill me or whatever. No. Right? Just remember, there's no problem that does not have an expiry date. At some point, a problem is going to give way. At some point, a problem was end. Right? But again, many times, because think about it, right? Like when you have like a really bad, a very bad, severe storm, or a really bad severe rain. Right? You know, it looks like, wow, everything has gone off the rails.

But you notice that after that great rain, then comes a great calm. Right? So I'll just encourage you because to be honest with you, I know you're medicine. We face some very tough situations, especially with COVID and just all the stuff that's been happening in the healthcare system, the challenges with, you know, there are many challenges in healthcare. Right? So the thing I'll just see is just be calm, calm down, and everything is going to be fine. Just remember, just without the storm. Right? Do your best in the storm. But remember that that storm is going to be over at some point. Right? Again, remember, even before deep breaks, right? You're going to go through nighttime. Right? Again, there is usually going to be some nighttime experience. Right? But after that, nighttime ends, day comes. Right? So just keep up your hope, keep hope alive. I'm just trying to use this to encourage anyone. Let's just go through a rough patch now. You know, there's so many things happening in medical education now with the match list, going out, parent deadline, blah, blah, blah, blah, blah, USMD exams, changing, and all that stuff. Right? So just keep hope alive. Right? All is going to be well. Right? You need to work hard. You can't just wait it out. You need to work hard. But remember that tough times. They don't last for about tough people do. So thank you for listening to me today. Have a wonderful day. I will see you in the next podcast. God bless you. Thank you.

Tension headache, migraine headache, and cluster headache.

Unilateral pain accompanied by ipsilateral autonomic symptoms (e.g., tearing, rhinorrhea, ptosis).

Triptans or ergotamine-based agents (visual constrictors). If those aren't available, NSAI Ds can be used.

To prevent severe attacks; prophylaxis criteria often require a high frequency (e.g., $\ge 8$ migraines/month).

TC As can cause anti-muscarinic, anti-alpha, and QRS widening; Topiramate can cause cognitive slowing and kidney stones (renal calculi).

Meningitis or brain abscess.

Sudden onset severe headache (often unilateral), blurry vision, and difficulty in dark environments (like a movie theater). Treatment involves miotics like pilocarpine and topical agents like timolol.

Carbamazepine. Be aware of its side effects, including agranulocytosis and potential neurotoxicity (e.g., hyponatremia).

Age, history of morphin use, chronic hypertension, polycystic kidney disease, or Alzheimer's/amniogenicopathy.

Cognitive slowing ("mental slowness") and nephrolithiasis (kidney stones).

Xanthochromia in the cerebrospinal fluid.

Brain tumor (or mass effect). Imaging should prioritize MRI over CT scan for better soft tissue visualization.

Sudden onset severe headache (often unilateral), blurry vision, and difficulty in dark environments (like a movie theater). Treatment involves miotics like pilocarpine and topical agents like timolol.

Carbamazepine. Be aware of its side effects, including agranulocytosis and potential neurotoxicity (e.g., hyponatremia).

Age, history of morphin use, chronic hypertension, polycystic kidney disease, or Alzheimer's/amniogenicopathy.

Cognitive slowing ("mental slowness") and nephrolithiasis (kidney stones).

Xanthochromia in the cerebrospinal fluid.

Brain tumor (or mass effect). Imaging should prioritize MRI over CT scan for better soft tissue visualization.