12 Headache Flashcards
primary headache - definition, treatment, overall assessment
- headache is primary feature of the disease
- symptomatic treatment of headache is usually sufficient in acute situation
- sometimes preventive treatment is necessary/possible
- underlying primary headache disorder is a predisposition that cannot be cured
secondary headache - definition, treatment, overall assessment
- headache is a symptom of another (underlying) disease
- treatment should mainly aim at underlying cause (+ symptomatic treatment)
- underlying disease can be cured in most instances
secondary headache underlying diseases
infection
- specific form: sinusitis, arteritis, meningitis
- symptoms: fever, signs of infection in blood
vascular
- specific form: stroke, subarachnoid hemorrhage
- symptoms: sudden onset of headache, negative neurological symptoms
neoplasm
- specific form: brain tumor
- symptoms: negative neurological symptoms
trauma
- specific form: head trauma
- symptoms: patient’s history
drugs
- specific form: alcohol, cocaine, etc.
- symptoms: patient’s history, drug test
exercise
- specific form: sports, sex
- symptoms: patient’s history
signs suggestive for secondary headache
- first time this kind of headache
- sudden onset of headache
- focal (negative) neurological symptoms
- fever, signs of infection
- anamnesis for drugs, exercise
major types of primary headache
- migraine
- tension headache
- cluster headache
migraine - general information
- prevalence: 5-20% of population
- gender: 60% women
- age of onset: first 3 decades
- frequency: sporadic, weekly, weekend, around menstruation
- side: 60% one side of the head
- onset: morning, but not always
- duration of attack: 4 - 72 hours
- pain intensity: medium to very strong
- pain character: typically pulsating
- pain localization: temporo-orbital or occipital
- influencing factors: physical effort, noise, light
- autonomic symptoms: nausea, vomiting, urinary retention
- heredity: in 70% family members are affected
- clinical forms: without aura, with aura, with prolonged aura, aura without headache
cortical spreading depression
wave of sustained depolarization (neuronal inactivation) moving through intact brain tissue
- aura can start everywhere (in the eye even)
- if starting in brainstem, patients get comatose
migraine - pathophysiology
- cortical spreading depression/aura transmits inactivity to spinal trigeminal nucleus
- leads to inflammatory response of meninges
- meninges informs brainstem
- brainstem informs pain centers
migraine - molecules
- CGRP plays important rule: major producer of neurogenic inflammation, major transmitter
- CGRP and Serotonin are most important targets for treatment
therapy of acute migraine attacks
- 1000mg Aspirin OR 1000mg Paracetamol OR 600mg Ibuprofen
if not working: - combine with MCP (Metoclopramide) (reduces vomiting, given 10 min before aspirin)
if not working: - 1000mg Aspirin intravenously OR Triptane (Sumatriptane most effective treatment, naratriptane) OR CGRP antagonist
- triptane leads to basal constriction of vessels, problematic for older patients
prevention of migraine attacks
- for patients with frequent and severe attacks (>2/months)
first try non-drug based approaches: - identify avoid potential migraine-triggering substances (chocolate, cheese, red wine, etc.)
- relaxation methods
- acupuncture
efficient drugs: betablocker, calcium antagonists, serotonin antagonists, antiepileptic drugs
New game changer: CGRP antagonists: once in 4 weeks (Erenumab)
tension headache - general information
- prevalence: 90% of all headache attacks, 3-5% chronic
- gender: 75% women
- age of onset: 30-50
- frequency: fluctuating, between rare and daily
- side: whole head in almost all cases
- onset: most pronounced in the morning, undulating during day
- duration of attack: 3 - 12 hours
- pain intensity: weak
- pain character: persisting, deeply located
- pain localization: frontal or occipital
- influencing factors: rare
- vegetative symptoms: none
- heredity: none
- clinical forms: episodic, chronic > 15 days/month
tension headache - pathophysiology
unknown (tension of neck muscles, depression?)
precipitating factors:
- stress: usually occurs in the afternoon after long stressful work hours or after an exam
- sleep deprivation
- uncomfortable stressful position and/or bad posture
- irregular meal time (hunger)
- eyestrain
- caffeine withdrawal
therapy for tension headache attack
- 1000mg Aspirin OR 1000mg Paracetamol OR 600mg Ibuprofen
- repetitive treatment with aspirin or paracetamol over many days or weeks
- avoid any strong pain drug such as opiods because high risk of secondary drug-induced headache
prevention of tension headache attack
try non-drug based prevention
- physical therapy
- relaxation approaches (meditation)
identify / treat potential underlying depression
try low-dose antidepressive drugs (amitriptilin, doxepine)
