12) Headache Flashcards
What are symptoms of (herpes) encepahlitis and what treatment is recommended?
Symptoms include:
- mild headache
- slightly elevated temperature
- forgetfulness
- unusual happiness
Test for enecephalitis:
- cererbospinal fluid
–> contains too many leukocytes, too much protein (and DNA from herpes virus)
- cerebrospinal fluid is usually transparent (like water) but can change colour when something is wrong
Therpay
- antiviral therpay (Acyclovir)
What are symptoms of Migraine (with aura) and how to treat it?
Symptoms include
- distrubances of vision (moving bright edge)
- loss of vision and subsequent language disturbances, etc
- nausea, vomiting, etc
- afterwards severe headache
Therapy
- Paracetamol (Acetaminophen) or Aspirin
What are symptoms of subarachnoid haemorrhage and how to treat it?
Symptoms include
- headache (sudden onset)
- slowly fades away (within hours)
Diagnostic
- CT scan –> subcortical haemorrhage –> aneurysm
–> very life-threatening
Therapy?
- NO blood thinning medication (high chance of more bleeding)
- surgery or neuroradiological intervention ASAP
What are symptoms of a cluster headache and how to treat it?
Symptoms include:
- extremly strong headache on left side for about 1 hour
- headaches come back (fades and returns)
- rhinorrhoe
Therapy
- oxygen mask
In patients with acute headache, what is the most important diagnostic challenge?
differentiation of primary vs secondary headache forms
What is a primary headache?
= headache is the primary feature of the disease –> is a predisposition that cannot be cured
Treatment
- symptomatic treatment is usually insufficient
- sometimes preventative treatment necessary/possible
What is a secondary headache?
= headache is a symptom of another (underlying) disease –> underlying disease can be cured in most situations
Treatment
- should mainly aim at underlying cause (+ symptomatic treatment)
Underlying diseases
- infection: sinusitis, arteritis, meningitis
- vascular: stroke, subarachnoid haemorrhage
- neoplasm: brain tumor
- trauma: head trauma
- drugs: alcohol, cocaine, etc
- exercise (headache): sports, sex
What are major types of primary headache?
- Migraine
- Tension headache
- Cluster headache
Migraine stats
Prevalence: 5-20% of population
Gender: 3:2 (more females)
Onset age: childhood, second or third decade
Periodicity/Frequency: sporadic-weekly-weekend-around menstruation
Side: 60% one side of the head
Onset: morning, bur not always
Duration: 4-72hours
Pain intensity: medium to very strong (2-4 on a scale of 5)
Pain character: typically pulsating
Pain localisation: temporo-orbital or occipital
Influence factors: physical effort, noise, light
Autonomic symptoms: nausea, vomiting, urinary retention
Heredity: in 70% family members are affected
Clinical forms: without aura, with aura, prolonged aura, aura without headache
Different forms of migrain attacks
What produces the initial neurological symptoms of Migraines (theory)?
- neurons more active
- symptoms ‘move’ relativly slow
Cortical spreading depression
- animal researcher: observed cortex exposed to excitatory aminoacids
–> movement starts and then stops - start in adjacent area and stop - start in …
–> similar to movement of migraine aura
Cortical spreading depression
- in humans: fMRI of college who could elicit an aura by playing basketball
–> brain activity at certain point would increase and then decrese and move across brain areas
–> increase and then depression
Why?
- cortical spreading depression (aura) activates Spinal trigeminal nucleus –> trigeminal nerve –> causing neurogenic inflammation at trigeminal ganglion and terminal
Supporting mechanism
- cortical spreading depression leads to expression of gene for CGRP (Calcitonin gene-related peptide)
- TNC (trigeminal nucelus caudalis) has receptors for it and signals pai to the brain
–> can be affected by serotonin (5HT-1) which can reduce the production of CGRP
–> modern medicine behaves like serotonin or reduces effect of CGRP
Therapy of migraine attacks
1000mg Aspirin
or
1000mg Paracetamol
or
600mg Ibuprofen
–> if they don’t work combine
Aspirin, ibuprofen, paracetamol with MCP (Metoclopramide)
–> if that does not work
1000mg Aspirin intravenous
or
Triptane (sumatriptane, naratriptane
or
CGRP receptor antagonist (rimegepant, ubrogepant)
Migraine prevention
Who?
- subjects with frequent and severe attacks (>2/months)
How?
- first non-drug based approaches
> identify and avoid migraine-triggering substances (chocolate, cheese, red wine, etc)
> relaxation methods
> acupuncture
What are efficient drugs for migraine prevention?
betablocker (metoprolole, propanolol)
calcium antagonists (flunrizin, cyclandelate)
serotonin-antagonists (pizotifen)
antiepileptic drugs (valproic acid)
Monoclonal antibody against CGRP receptors (erenumab, injected once in 4 week) –> BUT very expensive if insurance does not cover it (274€)
Tension headache stats
Prevalence: ~90% of all headache attacks, chronic: 3-5%
Gender: 3:1 (more females)
Onset age: 30-50 years
Periodicity/Frequency: fluctuating between rare and daily
Side: whole head in almost all cases
Onset: most pronounces in the morning, undulating during day
Duration of attack: 3-12 hours
Pain intensity: weak (1-2 on a scale of 5)
Pain character: persistent, deeply located
Pain localisation: frontal or occipital
Influencing factors: rare
Vegetative symptoms: none
Heredity: none
Clinical forms: episodic, chronic (>15days/months)
Pathophysiology of tension headache
Unknown cause
- could be tension of neck muscles, depression etc
Precipitating factors
- stress
- sleep deprivation
- uncomfortable stressful position and/or bad posture
- irregular meal time (hunger)
- eyestrain
- caffeine withdrawal
Therapy of tension headaches
1000mg Aspirin
or
1000mg Paracetamol
or
600mg Ibuprofen
BUT AVOID
- strong pain drugs (opioids)
- repetitive treatment with aspirin or paracetamol over many days or weeks
–> associated with a 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)
Cluster headache stats
Prevalance: 0.1%
Gender: 1:10 (more males)
Onset age: 30 - 60 years
Periodicity/Frequency: 1-3 episodes/year, daily for 2-6 weeks
Side: always on one side, usually remains on same side
Onset: often same onset time, typically during the night
Duration of attack: 15-180min per attack, cluster period: 1-2 month
Pain intensity: very strong to unbearable
Pain character: acute-throbbing
Pain localisation: retro-orbital
Influencing factors: movement decreases pain intensity
Vegetative symptoms: rhinorrhoe, Ptosis/miosis, face flush
Heredity: 2% pos
Clinical forms: episodic/chronic
What is the course of a cluster headache
multiple episodes per year
- all episodes are made up of multiple attacks
- attacks become more frequent, peak, become less frequent
Pathophysiology of cluster headaches
(largely) Unknown cause
- Hypothalamus seems to play a major role –> perhaps interplay with testosterone
Treatment of a cluster headache attack
- Oxygen mask
- Sumatriptan (or other triptan)
Prevention of attacks during a cluster period
- Calcium antagonist Verapamil
- Corticosteroids
