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Semester 4 - Clinical Neuroscience > 13. Headache > Flashcards

13. Headache Flashcards

1
Q

how can headaches be divided?

A
  • Primary (due to a headache disorder) or
  • Secondary to another condition
  • Non- Life threatening
  • life (or sight)- threatening
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2
Q

are primary headache disorders, usually life threatening? are they usually acute or chronic?

A

Non- ‘life or sight’ threatening

Many chronic (i.e. recurrent)

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3
Q

are secondary headache disorders, usually life threatening? are they usually acute or chronic?

A

Some are life or sight threatening

Many ‘acute’

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4
Q

What are 3 primary headache disorders (most common first)?

A
  • Tension headache
  • Migraine
  • Cluster headache
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5
Q

What are secondary acute causes of headaches?

A
  • vascular
  • infective/inflammatory
  • ophthalmic
  • situational
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6
Q

what are vascular causes of secondary headaches?

A 
• Haemorrhage
o Subarachnoid haemorrhage A&E 
o Subdural haemorrhage A&E
o Extradural haemorrhage A&E
• Thrombosis
o Venous sinus thrombosis A&E
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7
Q

what are infective/inflammatory causes of secondary headaches?

A
  • Meningitis A&E
  • Encephalitis A&E
  • Abscess A&E
  • Temporal arteritis A&E
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8
Q

what are ophthalmic causes of secondary headaches?

A

glaucoma

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9
Q

what are situational causes of secondary headaches?

A
  • Cough
  • Exertion
  • Coitus
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10
Q

What are secondary chronic causes of headaches?

A
  • drug side effects (analgesics, caffeine, vasodilators)
  • trigeminal neuralgia
  • raised intracranial pressure (e.g. tumours)
  • giant cell arteritis
  • systemic (hypertension, pre-eclampsia)
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11
Q

of the causes of secondary headache disorders, which ones are life threatening?

A

• intracranial lesion:

  • tumour
  • haemorrhage

• meningitis

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12
Q

of the causes of secondary headache disorders, which ones are sight threatening?

A 
giant cell (temporal) arteritis
acute glaucoma
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13
Q

of the causes of secondary headache disorders, which ones are non life or sight threatening?

A

sinusitis
medication overuse headache
trigeminal neuralgia

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14
Q

WHat is the difference between clinical examination in primary vs secondary causes of headaches?

A

Primary: typically normal
Secondary: may have clinical findings

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15
Q

What is important in taking history of headaches?

A
  • HPC - SQITARS/SOCRATES
  • PMH - prev. headaches, conditions causing secondary headache?
  • DH - Analgesic use (medication over-use)? Causative of headache?
  • FH - Migraines with aura?
  • SH - Stress? Sleep? Alcohol and caffeine consumption, diet (triggers)?
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16
Q

What are the red flags of headaches?

A

SNOOP:

  • systemic signs and disorders
  • neurological symptoms
  • Onset new or changed and patient >50 yo
  • Onset in thunderclap presentation
  • papilloedema, positional provocation, precipitated by exercise
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17
Q

what are some systemic signs or disorders that can be red flags for headaches?

A 
Meningitis (fever, neck stiffness)
hypertension 
Immunosuppressed (e.g. HIV) 
Pregnant ? 
Underlying Cancer ?
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18
Q

what can neurological symptoms as a red flag for headache indicate?

A

SOL, ICH, glaucoma (visual)

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19
Q

what can Onset new or changed and patient >50 yo as a red flag for headache indicate?

A

Malignancy, GCA

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20
Q

what can a thunderclap presentation as a red flag for headaches indicate?

A

Vascular (haemorrhage) such as SAH

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21
Q

what can papilloedema, positional provocation, precipitated by exercise as a red flag for headache indicate?

A

Indicators of raised ICP

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22
Q

What is important in clinical examination of headache presentation?

A
  • Vital signs e.g. BP, PR, temp
  • Neurological examination (cranial and peripheral nerve examination)
  • Other relevant systems, guidance by history
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23
Q

what will the vital signs be like in raised ICP?

A

raised ICP can cause bradycardia / hypotension.

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24
Q

what are 4 common causes of headache with most common at top and least at bottom?

A
  • Tension-type headache (primary headache disorder)
  • Migraine (primary headache disorder)
  • Medication over-use (secondary headache)
  • Cluster headache (primary headache disorder)
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25
Q

WHat is the epidemiology of tension-type headaches?

A
  • F>M
  • Young (teenagers and young adults [20-39 yr])
  • Young > old
  • First onset >50yr unusual
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26
Q

What are tension headaches thought to be due to?

A

Pathophysiology thought due to tension in muscles of head and neck
- Usually no family history

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27
Q

site of tension headaches?

A
  • Generalised- predilection for Bilateral frontal and occipital regions
  • Can radiate to neck
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28
Q

quality of tension headaches?

A

Squeezing / Tight band like constriction, +/- radiating into neck
Non-pulsatile

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29
Q

Intensity of tension headaches?

A

Mild-moderate

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30
Q

Timing of tension headaches?

A
  • Worse at end of day (as stress builds up)
  • Chronic if > 15 times per month
  • Episodic if <15 times per month
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31
Q

Aggravating factors for tension headaches?

A
  • Stress
  • Poor posture (e.g at a computer)
  • Lack of sleep
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32
Q

Relieving factors for tension headaches?

A

Simple analgesics can help

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33
Q

How long do tension headaches last?

A

30 mins to 1 Hr

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34
Q

What symptoms may be associated with tension headaches?

A

• Sometimes mild nausea

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35
Q

what is found on clinical examination of tension headaches?

A

Clinical examination is normal

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36
Q

What is the epidemiology of migraines?

A
  • F>M (1 in every 5 F) Common (15 in every 100)
  • Presents early to mid-life
  • Most have first attack by 30
  • Severity decreases as age increases
37
Q

site of migraine?

A

Unilateral, temporal or often frontal

38
Q

quality of migraine?

A

Onset can be sudden or gradual. Throbbing / pulsating

39
Q

intensity of migraine?

A

Moderate

40
Q

How long do migraines typically last?

A

prolonged headache - Lasts between 4 and 72 hours, possibly with cyclical character

41
Q

What can trigger migraines?

A

Certain food(cheese, chocolate), menstrual cycle, stress, lack of sleep aggravates, often is a FH

42
Q

Aggravating factors of migraine?

A

Photophobia / phonophobia (dislike of loud noise)

43
Q

Relieving factors of migraines?

A

Can respond to simple analgesics (may need triptans); tend to want to lie down

44
Q

What symptoms are associated with migraines?

A
  • nausea, vomiting, sweating
  • aura - peculiar sensory signs e.g visual - zigzag lines, shimmery lights etc
  • neurological features - e.g. speech disturbance
  • photophobia
  • phonophobia
45
Q

Pathophysiology of migraines?

A
  • Pathophysiology unclear
  • Possible theories proposed e.g.
  • neurogenic inflammation of trigeminal sensory neurons innervating large vessels and meninges
  • Alters way pain processed by brain; sensitized to otherwise ignored stimuli
46
Q

What is the epidemiology of medication overuse headaches?

A
  • 3rd most common type of headache
  • 1-2% of UK population
  • 20% of headaches are due to medication overuse
  • 30-40 years old
  • Females > males
47
Q

What causes medication overuse headaches?

A

Often using regular analgesics (at least 10 days/month) - Headache not responding
-Related to upregulation of pain receptors in meninges

48
Q

to diagnose medication overuse headaches how long should they have the headache for?

A

• Headache present on at least 15 days/month (constant)

49
Q

in which patients do medication overuse headaches normally occur in?

A

• Occurs in patients with pre-existing headache disorder
• Using regular analgesics (for headache)(at least 10 days/month)
– Headache not responding

50
Q

How are medication overuse headaches treated?

A

Discontinue medication

- headaches will get worse before they improve

51
Q

quality of medication overuse headaches?

A

Variable character- can be dull, tension-type or migraine-like

52
Q

What is the epidemiology of cluster headaches?

A

M >F
1 in 1000
Usual onset 20-40 years old

53
Q

site of cluster headaches

A
  • unilateral
  • Around / behind one eye
  • No radiation
54
Q

quality of cluster headaches?

A

Sharp, stabbing, penetrating, often at night

55
Q

intensity of cluster headaches?

A
  • Very severe
  • Constant intensity
  • often disabling, agitated
56
Q

How long do cluster headaches last, and how often do they occur?

A
  • Rapid onset
  • Attacks last 15 min – 3hrs and occur 1-2 times per day
  • Usually at night
  • Clusters of attacks last 2-12 weeks
  • Remissions between clusters can last 3 months – 3 years
57
Q

Aggravating factors for cluster headaches?

A
  • Head injury
  • Alcohol
  • Smoking
58
Q

Relieving factors for cluster headaches?

A

Simple analgesics often ineffective; oxygen and triptans used

59
Q

What are triggers for cluster headaches?

A 
 Alcohol
 Histamine (hayfever)  GTN
 Heat
 Exercise
 Solvent inhalation
 Lack of sleep
60
Q

What are associated symptoms with cluster headaches?

A

• Features associated with decreased sympathetic activity - Ipsilateral autonomic symptoms
o Red, watery eye
o Nasal congestion
o Ptosis

61
Q

What are the findings on clinical examination of cluster headaches?

A

evidence of autonomic features (during attack)

62
Q

What are the findings on clinical examination of migraine headaches?

A

Clinical examination is normal

63
Q

pathophysiology of cluster headaches?

A

Pathophysiology unknown ?hypothalamic activation with secondary trigeminal and autonomic involvement

64
Q

how is the response of individuals different in migraine and cluster headaches?

A

migraine - tend to lie down

cluster - agitated

65
Q

what are 4 common causes of secondary headache?

A
  • Intracranial haemorrhage*- some can cause signs/symptoms of meningism e.g. subarachnoid haemorrhage
  • Raised ICP due to a space occupying lesions e.g. a tumour)
  • Trigeminal neuralgia
  • Temporal (giant cell) arteritis
66
Q

How are SOL headaches described?

A
  • Gradual, progressive
  • Dull, but often variably described; key is progressiveness of severity
  • May be mild in severity, worse in mornings
67
Q

When are SOL headaches worse?

A

Early-morning, on waking (rarely: headache wakes them)

68
Q

aggravating factors of SOL headaches?

A

Worsened with posture (leaning forward), cough, Valsalva manoeuvre, straining

69
Q

relieving factors of SOL headaches?

A

Simple analgesics may be effective in early stages

70
Q

What are associated symptoms with SOL headaches?

A

Nausea, vomiting, focal neurological or visual symptoms (other neurological signs could include behavior/ personality change, seizures)

71
Q

What are the findings on clinical examination on a SOL headache?

A
  • focal (unilateral) neurological signs, papilloedema
72
Q

what are Additional features of raised ICP

A

 Early morning headache
 Nausea and vomiting
 Worse on coughing and bending

73
Q

What is the epidemiology of trigeminal neuralgia and what causes it?

A

F>M
25/100,000 UK popn
50 -60 years

Most caused by compression of CN V due to loop of a blood vessel.
A few cases can be found to be caused by tumours, MS or skull base anomalies

74
Q

site of trigeminal neuralgia headache?

A

• Unilateral pain felt in ≥1 divisions of CN V, often over one eye
• Radiates to eyes, lips, nose and scalp (think distribution
of CN V)

75
Q

quality of trigeminal neuralgia headache?

A

Sharp, stabbing, ‘electric’ shock (sometimes burning)

76
Q

intensity of trigeminal neuralgia headache?

A

Severe

77
Q

How long do attacks of trigeminal neuralgia last?

A

Seconds to 2 mins

- sudden onset

78
Q

What can trigger attacks of trigeminal neuralgia?

A
  • Light touch to face
  • Eating
  • Cold wind
  • Vibrations
  • combing hair
79
Q

how is trigeminal neuralgia treated?

A

Simple analgesics not effective; can be difficult to treat

80
Q

What associated symptoms are there with trigeminal neuralgia?

A

Maybe preceding symptoms: tingling, numbness; pain can radiate to areas within CNV distribution

81
Q

what can be found on clinical examination of trigeminal neuralgia headaches?

A

Clinical examination –normal

82
Q

What is temporal arteritis and epidemiology?

A

Vasculitis involving small and medium sized arteries of head
• F>M
• >50 years (most common in>75)

83
Q

When might temporal arteritis be considered as a diagnosis?

A

Any >50 year old with abrupt onset of headache + visual disturbance or jaw claudication

84
Q

Which artery is commonly involved in temporal ateritis?

A

Superficial temporal artery

85
Q

What risk is associated with temporal arteritis?

A

Irreversible loss of vision due to ischemia of CN I

86
Q

How is temporal arteritis treated?

A

Steroids

87
Q

Investigation of headaches?

A

o Clearly, dependent on cause (e.g. if subarachnoid haemorrhage then investigate accordingly
o Headache diary can be useful for chronic headaches
o Imaging may be indicated if red flags

88
Q

Treatment of headaches?

A

o Dependent on underlying cause
o Simple analgesia
o Triptans for migraine
o Cluster headaches may respond to high flow oxygen

Semester 4 - Clinical Neuroscience (19 decks)

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