3. Headaches Flashcards
What are the primary types of headaches and the secondary causes of headaches?
Primary-typeHA- 69%
migraine- 16%
Cluster- 2
Other- 13%
Secondary: -systemic infection-63% -head injury- 4% -Drug Induced- 4% vascular- 1% Brain haemorrhage
How would you take a case history with someone with headaches?
Headache specific
Site - Where is the pain?
Onset - When did the pain start, and was it sudden or gradual?
Character - What is the pain like? An ache? Stabbing?
Radiation - Does the pain radiate anywhere?
Associations - Any other signs or symptoms associated with the pain? Time course - Does the pain follow any pattern?
Exacerbating/Relieving factors - Does anything change the pain?
Severity - How bad is the pain
Headache specific:
Age of onset
Onset time & mode
Link with endocrinology & metabolism e.g. menstrual cycle, hormones Constitutional signs & symptoms
Physical Examination for a headache?
General appearance Mental state Speech Skull, Spine Gait & stance Special senses Cranial nerves Motor & sensory system General examination
What would be some sinister signs?
Special concerns (red flags)
- new headache’
- change in character
- significant increase in frequency
- fever + other constitutional signs/ symptoms
- neurological symptoms
- onset >50yrs
Red flags:
new onset after 50 years of age
new onset in person with a higher risk for HIV or cancer signs of illness such as fever, rash and neck stiffness
awakening from sleep
history of head trauma within the last 2 weeks
associated neurological symptoms
progressing intensity or frequency
signs of papilloedema
sudden onset of headache
worsening with exertion or Valsalva manoeuvre – why?
elevated blood pressure
sudden severe with flu-like symptoms, aching muscles, jaw pain when eating and visual disturbances
no previous personal or family history of migraine
What are your 3 steps in handling a headache patient?
1- determine if headache is sinister > then decide if its primary or secondary
2: creat Dx> Investigations?
3- treatment plan/ referral
tell me all types of primary, secondary and other?
Part I: The Primary Headaches
- Migraine
- Tension-type headache
- Cluster headache and other trigeminal autonomic cephalalgias 4. Other primary headaches
Part II: The Secondary Headaches
- Headache attributed to head and/or neck trauma
- Headache attributed to cranial or cervical vascular disorder
- Headache attributed to non-vascular intracranial disorder
- Headache attributed to a substance or its withdrawal
- Headache attributed to infection
- Headache attributed to disorder of homoeostasis
- Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures
- Headache attributed to psychiatric disorder
Part III: Cranial Neuralgias Central and Primary Facial Pain and Other Headaches
- Cranial neuralgias and central causes of facial pain
- Other headache, cranial neuralgia, central or primary facial pain
Cervicogenic headaches? Clinical presentation? -pain -location -ass. with -onset -duration
Managament?
Pain
Dull often non throbbing, non-lancitating
Intensity is moderate to severe
Location
Unilateral, upper cervical or occipital region
May radiate to frontal or orbital region, vertex, temples or ears
Associated with
Trauma, sustained neck postures, mechanical faults,
Onset
Trauma or insidious
Duration:
3 week- 3months
frequency:
- every 2 days to 2 months
Time course:
-may be present on waking and worsen during the day
Ass symptoms:
-phonophobia, dizziness, ipsilateral eyelid oedema, ipsilateral blurred vision
Management:
- pain killers if needed
- treat biomechanical dysfunctions with:
- manip
- STT
- traction
- rehab
Recommended tx options:
- SMT 2x per week for 3 weeks
- joint mobs 8-12 visits over 6 weeks
- deep neck flexor exercises 2x daily over 6 weeks
Tension headaches: 17
Clinical presentation:
-pain, location, ass with, onset, duration, frequency, time course, ass symptoms?
Prescipitating factors?
What would you dins on Examination & Investigations:
Pathophysiology cause?
Pain
Non throbbing, mild to moderate tightness, pressure or dull ache
Location
Usually bilateral
Radiating from forehead to occiput
It can be a band-like pain or radiate to shoulders, scapula and interscapular areas
Associated with
Stress, anxiety, fatigue, lack of sleep
Onset
Variable
Duration
Can last from 30 minutes to several days
Frequency
Infrequent episodic 10 but less than 15 times per month Chronic > 15 times per month for > 6 months
Time Course
variable
Associated symptoms
Tenderness in musculature around head and neck.
Precipitating factors Stress Exercise Emotional overload Life events Who know sometimes?
Examination & Investigations
Generally unremarkable
Trigger points
Spinal fixation, Joint dysfunction
Pathophysiology
Speculative at best:
(1) muscle tension, (2) vasodilatation (as opposed to constriction), (3) low 5-HT, (4) but link with low emotion/depression
How would you manage someone with a tension headache?
Acute vs Chronic
-pain killers if needed
-treat biomechanical dysfunction with:
Manipulations (the evidence suggests that a recommendation for or against SMT
can not be made)
STT – low load craniocervical mobilisation (eg resistance Exercise Systems, Theraband) 10 mins 2 x per day for 6 weeks.
Rehabilitation
Frequency:
-depends on severity and whetehr acute or chronic
Acute:
- 2-3 x per week for 2 weeks
- 1 X per week for 4-6 weeks
- 1 x per 2/52 for 6 visits
Chronic:
1 x per week for 6-8 weeks
1 x per 2/32 for 6-8 visits
-1 x month or similar as needed until rehab is complete (very pt specfic)
Migraine headaches;
Presentation with/ without aura?
What are the phases of a migraine?
Whats the clinical presentation of someone with migraine headaches
Migraine without aura
Assoc with nausea, vomiting, photophobia
Migraine with aura
Plus visual disturbance
Severe cases cause hemiplegia, basilar syndrome
Premonitory symptoms or prodrome:
- 24hrs or more before headache
- changes in mood, yawning, change in appetite, irritable
- pt knows HA is coming
Aura:
- originates in occipital lobe/visual field
- scintillating scotomas
Phases of migraine:
- primarily unilateral but may swap sides
- frontotemporal area and eye
- pain radiates to neck and occiput
- 4hrs to several days
- dull then becomes throbbing and intense, sometimes no throbbing
Resolution:
- exhausted, tired for several days, varies in intensity
- sometime euphoria
clinical presntation:
Pain- very severe, throbbing pain that may start out as a dull steady ache
location: usually unilateral but ut can switch sides
-localised to the temple, forehead, eye or back of head
assosiated with: stress, fatigue, too much/little sleep, skipping meals etc
Onset: males 10-13yrs
females- menarche
Duration
4 – 72 hours
Frequency
At least 5 attacks per year Can be daily!
Time Course
Usually upon waking and takes several hours to build to maximum
intensity
Associated symptoms
Nausea, vomiting, anorexia, abdominal cramps, polyuria, sweating, pallor of face, phonophobia, photophobia, mental impairment, fatigue,
How would you manage someone with migraine headache?
medications have been shown to be the best treatment
evidence-based tx options;
1. Spinal manipulations 1-2x per week for 8 weeks
2. weekly massage for episodic migrains
3. multimodal, multidisciplinary care
Treatments duration:
- time taken to stop treatment depends on teh frequency of migraine
- if pt has them every 3 months, then u dont need to have tx go for 3 months but u wont see if tx has positive effects untill 3 months has passed
