2.8 - Headache Flashcards
What are some stats about headaches?
- one-year prevalence of headache disorders is 50%
- 20% of what neurologists see and care for
- headache is highly disabling - 100,000 people are absent from work or school everyday
What can headaches be classified as by the International headache society?
Primary vs secondary
What are primary headache syndromes? (3)
- migraine
- tension-type headache
- trigeminal autonomic cephalalgias (including cluster headache)
What are secondary headaches?
Headache is precipitated by another condition/disorder - local or systemic. Serious causes of secondary headache are uncommon.
What kind of headache is more common?
Primary headache is a lot more common than secondary headache
What can primary headache disorders be further separated into?
- long-lasting headache (duration >4 hours) –> migraine + tension-type headache
- short-lasting headache (duration <4 hours) –> trigeminal autonomic cephalalgia –> cluster headache
What is medication overuse headache?
- due to painkillers
- makes migraine worse as those that take painkillers might then get medication overuse headache
What is the clinical approach to headache?
- history and examination
- red flag?
- if yes, secondary headache –> diagnostic tests
- if no, primary headache? preliminary diagnosis
- if this is another red flag then secondary headache –> diagnostic tests
What are four key red flags suggesting secondary headache?
- age - new onset or different headaches in a person >50yrs
- onset - sudden, abrupt onset of a severe headache (thunderclap headache)
- systemic symptoms - fever, neck stiffness, rash, weight loss
- neurological signs - confusion, impaired consciousness, focal neurology, swollen optic discs
What is key to the diagnosis of primary vs secondary headaches?
The history
What forms can a migraine exist in?
Episodic or chronic disorder
What are the characteristics of a migraine? (5)
- unilateral localisation (begins one side)
- pulsating quality
- moderate/severe pain intensity
- aggravation by routine physical activity
- lasts hours and sometimes days
What do the characteristics of a migraine need to be accompanied by to be classed as a migraine?
Either of:
- nausea and/or vomiting
- photophobia and/or phonophobia
What can be present in migraines?
Auras
What is an aura?
- complex array of symptoms reflecting focal cortical or brainstem dysfunction
- gradual evolution: 5-30min (<60min)
- usually before headache
What are some examples of auras? (4)
- zigzags
- flashes of light
- expanding ‘C’s
- elemental visual disturbance
What are the phases of a migraine? (5)
- premonitory
- aura
- headache
- resolution
- recovery
What are the symptoms of the premonitory phase? (7)
- yawning
- polyuria
- mood change
- irritable
- light sensitive
- neck pain
- concentration difficulty
What happens in the aura phase? (4)
- visual and sensory phenomena
- numbness/paraesthesia
- weakness
- speech arrest
What happens in the headache phase? (3)
- head and body pain
- nausea
- photophobia
What happens in the resolution phase?
Rest and sleep
What small issues does the recovery phase include? (4)
- mood disturbed
- food intolerance
- feeling hungover
- can take up to 48 hours
How is migraine managed (general)?
- lifestyle
- then pharmacological therapy (acute/abortive or long term preventative)
What lifestyle factors can help manage migraines? (5)
- avoid triggers
- diet
- sleep
- exercise
- mindfulness
What are examples of acute/abortive pharmacological therapy for migraines (take within 5-10min)? (5)
- paracetamol (analgesia)
- NSAIDs (high dose and soluble) - analgesia
- prokinetics
- triptans (5-HT 1B/1D/1F receptor agonists)
- anti-emetics
How does long term preventative pharmacological management of migraines work?
- used when migraines occur >5 days/month
- ‘low and slow’ with doses until at optimal dose
- e.g. SNRIs, beta-blockers, serotonin antagonists, anticonvulsants
- come with their own side effects
What should be avoided in the management of migraines?
Opiate-based and mixed analgesics
What are some migraine preventatives to be aware of? (8)
- tricyclic anti-depressants (TCA): SNRIs
- B-blockers
- serotonin antagonists
- anticonvulsants
- calcium channel blockers
- ACE inhibitors/angiotensin II receptor blockers
- non-prescription
- parenteral
What are CGRP antibodies?
New medicines for preventing migraines
What kind of headache is a tension-type headache?
Episodic
What does a tension-type headache feel like?
Tight muscles around the head and neck, as though head is in a vice
How long do tension-type headaches last?
Last around 30 mins but can be hours long
What are some characteristics of tension-type headaches? (4)
- bilateral
- mild/moderate
- not aggravated by movement
- no added features typically: nausea/vomiting; photophobia/phonophobia
How do we treat tension-type headaches?
- reassurance may suffice in the majority of patients
- individual attacks can be treated with simple analgesics e.g. aspirin/paracetamol
- preventative medications rarely required
What is a cluster headache?
Severe unilateral pain lasting 15-180 minutes untreated
What do you see in cluster headaches (at least one of the following ipsilaterally)?
- conjunctival redness and/or lacrimation
- nasal congestion and/or rhinorrhoea
- eyelid oedema
What are some characteristics of cluster headaches? (3)
- forehead and facial sweating
- miosis and/or ptosis
- a sense of restlessness or agitation
What is a cluster headache not associated with?
Primary headache so not associated with brain lesion on MRI
How do we acutely treat cluster headaches?
- triptan - nasal or subcutaneous route
- high flow oxygen - oxygen inhibits neuronal activation in the trigeminocervical complex
How do we prevent cluster headaches? (Prophylactic treatment)
- verapamil (calcium channel inhibitor) - get an ECG first
- greater occipital nerve block (inject anaesthetic near nerve to relieve pain causing headaches)
Migraine vs tension-type vs cluster: region affected?
Unilateral (though often bilateral) vs bilateral vs unilateral (never bilateral)
Migraine vs tension-type vs cluster: type of pain?
Pulsating vs pressing/tightening/non-pulsating vs -
Migraine vs tension-type vs cluster: severity?
Moderate or severe vs mild or moderate but not disabling vs very severe
Migraine vs tension-type vs cluster: aggravations?
- aggravated by/causing avoidance of routine physical activity VS
- no aggravation by/avoidance of routine physical activity VS
- restlessness, no aggravation by physical activity
Migraine vs tension-type vs cluster: associated features?
- nausea/vomiting, photophobia, phonophobia VS
- no nausea/vomiting, photophobia, phonophobia VS
- ipsilateral to pain: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, eyelid swelling/drooping
Migraine vs tension-type vs cluster: duration?
Attack lasts hours to days (usually 4-72h) vs attack lasts hours to days vs attack lasts from 15min to 3 hours
Migraine vs tension-type vs cluster: frequency?
1-2 attacks per months vs - vs 1-3 attacks per day (up to 8) and usually occur daily for 2-3 months at a time
