4. Headache Flashcards
name some structures that can be affected and so cause a headache
trigeminovascular system meninges CSF containing structures muscle nerves
name some processes that cause a headache
neurogenic inflammation inflammation infection pressure obstruction
how common are migraines
affects around 1 in 5 women and 1 in 12 men
migraines are thought to be precipitated by cortical spreading depression (CSD). What is CSD
propagated waves of depolarisation in neurones and glial cells followed by a suppression of sponntaneouus neuronal activity
note that occurs alongside changes in brain blood flow through alterations in vascular calibre
what other conditions does cortical spreading depression (CSD) occur in
cerebrovascular accident
subarachnoid haemorrhage
TBII
epilepsy
cortical spreading depression (CSD) can activates which centre in the brainstem which is known to be associated with headache symptoms
trigeminal nucleus caudalis (TNC)
name some common triggers that may cause migraine attacks
o Flickering lights on a TV screen
o Any foods containing tyramine: Red wine, cheese, chocolate and citrus fruits
o Jet lag or change in sleep pattern
o Menstruation- precipitated by the fall in oestrogen concentration just prior to onset of menstruation
o Contraceptive pill- particularly in the withdrawal period between cycles
o Relaxing after stress
what medication is contraindicated in women who suffer migraine with aura, and for all women with migraine over the age of 35 due to potential increased risk of cardiovascular events (particularly ischemic stroke)
combined OCP (oral contraceptive pill)
what would be the first line approach to treatment of a migraine
- early use of NAIDS eg naproxen, ibuprofen. (important to note paracetamol may help some suffers)
- antiemetics
- triptans (sumatriptan, zolmitriptan)
how do triptans work
- have strong agonist actions at the serotonin (5-HT) receptor
- They induce vasoconstriction as there action is on 5-HT1B receptors in arterial smooth muscle
- Triptans also act on the CNS in midbrain and also in the trigeminal nucleus caudalis (TNC). TNC thought to be an area involved in the production of migraine headaches
name some medical conditions in which triptans are contra-indicated in
o In patients with a history of TIA and cerebrovascular accident (CVA)
o In patients with history of ischemic heart disease due to the peripheral vasoconstrictor action on arterioles
o In patients with poorly controlled hypertension
stepwise approach to treatment of an acute migraine: if you are going to increase a patients triptans to 2 doses a day what do you need to explain to the patient
not to take the second dose til at least 2 hours apart
patients can relapse following triptan treatment and develop rebound headaches
when considering preventative treatment for migraines what criteria would be deemed as a good reason to prescribe preventative treatment
o Quality of life/business duties/school attendance is severely affected
o Two or more attacks a month
o Migraine attacks do not respond to acute drug treatment
o Frequent, very long, or uncomfortable auras occur
what are the first line choices for prophylaxis of migraines
beta-blocker such as propranolol or low dose amitriptyline (a tricyclic antidepressant drug)
What medication increases serum levels of tricyclic antidepressants and so needs to be considered when prescribing preventative treatment for migraines
SSRI medications
what SSRI does sumatriptan interact significantly with
citalopram
if a patient has PMH of gastro issues and is on omeprazole then what medications should be avoided
NSAIDs
why do migraines occur in relation to women’s menstrual cycle and what medication can they try
the fall in estradiol at the end of the menstrual cycle
- can try transdermal patches to prevent migraine symptoms, starting 3 days before the onset of menstruation
if first line medications don’t work in the prophylaxis of migraines what else can be considered
• Anti-epileptic medication such as sodium valproate or topiramate
• Other antihypertensive medication including ACE inhibitors and angiotensin II receptor blockers
o Calcium channel blockers including verapamil and amlodipine may help some patients
Describe the difference in pain location for the following kinds of headaches
- Tension type headache
- Migraine (with or without aura)
- Cluster headache
- bilateral pain
- can be unilateral or bilateral
- Unilateral (around the eye, above the eye and along side of head/face)
Describe the difference in pain quality and pain intensity for the following kinds of headaches
- Tension type headache
- Migraine (with or without aura)
- Cluster headache
- pressing/tightening (non-pulsing) + mild to moderate
- pulsating (thriving or banging in young people aged 12-17) + moderate to severe
- variable (can be sharp, boring, burning, throbbing or tightening) + severe or very severe
Describe the difference in effect on activities for the following kinds of headaches
- Tension type headache
- Migraine (with or without aura)
- Cluster headache
- Not aggravated by routine activities of daily living
- Aggravated by or causes avoidance of routine activities of daily living
- Restlessness or agitation
Describe the difference in other symptoms for the following kinds of headaches
- Tension type headache
- Migraine (with or without aura)
- Cluster headache
- none
- Sensitivity to light/sound/nausea and vomiting
Aura
Symptoms can occur with/without headache and:
Are fully reversible
Develop over at least 5 mins
Last 5-60 mins - On the same side as the headache:
Red and/or watery eyes
Nasal congestion and or runny nose
Swollen eyelid
Forehead and facial sweating
Constricted pupils and/or drooping eyelid
Describe the difference in the duration for the following kinds of headaches
- Tension type headache
- Migraine (with or without aura)
- Cluster headache
- 30 mins- continuous
- 4-72 hours in adults
1-72 hours in people aged 12-17 - 15-180 mins
there are many differential diagnoses for headaches. Can you name some of the less serious ones
- Tension headaches
- Migraines
- Cluster headaches
- Sinusitis
- Analgesic headache
- Hormonal headache
- Cervical spondylosis
- Trigeminal neuralgia
there are many differential dianogses for headaches; can you name some of the more serious ones
- Secondary headaches
- Giant cell arteritis
- Glaucoma
- Intracranial haemorrhage
- Subarachnoid haemorrhage
- Cervical spondylosis
- Raised intracranial pressure (brain tumours)
- Meningitis
- Encephalitis
It is important to consider red flags when taking a history and managing patients with headaches. Name some red flags
- Fever, photophobia or neck stiffness (meningitis or encephalitis)
- New neurological symptoms (haemorrhage, malignancy or stroke)
- Dizziness (stroke)
- Visual disturbance (temporal arteritis or glaucoma)
- Sudden onset occipital headache (subarachnoid haemorrhage)
- Worse on coughing or straining (raised intracranial pressure)
- Postural, worse on standing, lying or bending over (raised intracranial pressure)
- Severe enough to wake the patient from sleep
- Vomiting (raised intracranial pressure or carbon monoxide poisoning)
- History of trauma (intracranial haemorrhage)
- Pregnancy (pre-eclampsia)
what big red flag are you looking for when performing a fundoscopy
Papilloedema which indicates raised ICP which may be due to a brain tumour, benign intracranial hypertension or intracranial bleed
describe briefly a tension headache
Tension headaches are very common.
Classically they produce a mild ache across the forehead and in a band-like pattern around the head.
This may be due to muscle ache in the frontalis, temporalis and occipitalis muscles.
Tension headaches comes on and resolve gradually
don’t produce visual changes.
what are tension headaches associated with
- Stress
- Depression
- Alcohol
- Skipping meals
- Dehydration
what is the treatment for tension headache
- Reassurance
- Basic analgesia
- Relaxation techniques
- Hot towels to local area
what is a secondary headache and give some examples of things that cause secondary headache
give similar presentation to a tension headache but with a clear cause
produce a non-specific headache secondary to;
- Underlying medical conditions such as infection, obstructive sleep apnoea or pre-eclampsia
- Alcohol
- Head injury
- Carbon monoxide poisoning
Briefly describe sinusitis
headache associated with inflammation of the sinuses
produce facial pain behind the nose, forehead and eyes
tenderness over the effected sinus
what is the treatment plan for sinusitis
usually resolves within 2-3 weeks mostly viral nasal irrigation with saline can be useful steroid nasal spray if prolonged antibiotics are useful
What is a analgesic headache
similar to tension headache (ie non-specific) but secondary to excessive use of analgesia
What is a hormonal headache
related to oestrogen so when oestrogen falls around the menstrual period, menopause and pregnancy they can cause headaches
if headaches occur in which part of pregnancy is it worrying and investigation for preeclampsia be carried out
in the second half of the pregnancy
What condition often presents with headache as well as neck pain
cervical spondylosis (but remember the triad for meningitis too !)
what causes trigeminal neuralgia and what can trigger it
electricity-like shooting pain, gets worse over time and lasts anywhere from a few seconds to hours
cold weather , spicy food, caffeine and citrus fruits
What is the treatment for trigeminal neuralgia
carbamazepine (anticonvulsant and analgesic)
surgery is also an option
Name the typical features of a migraine headache
- Headaches last between 4-72 hours
- Moderate to severe intensity
- Pounding or throbbing in nature (pulsating)
- Usually unilateral but can be bilateral
- Discomfort with lights (photophobia)
- Discomfort with loud noises (phonophobia)
- With or without aura
- Nausea and vomiting
aura is used to describe visual changes associated with migraines, describe the types of aura pt can feel
- Sparks in vision
- Blurring vision
- Lines across vision
- Loss of different visual fields
what is a hemiplegic migraine
they can mimic a stroke so need to exclude this in pt presenting with symptoms
Symptoms include
• Typical migraine symptoms
• Sudden or gradual onset
• Hemiplegia (unilateral weakness of the limbs)
• Ataxia
• Changes in consciousness
what are some potential triggers for migraine
note that often some people have no triggers
- Stress
- Bright lights
- Strong smells
- Certain foods (e.g. chocolate, cheese and caffeine)
- Dehydration
- Menstruation
- Abnormal sleep patterns
- Trauma
often migraines can be broken down into 5 stages. They are not typical of everyone but what is the course of the migraine
- Premonitory or prodromal stage (can begin 3 days before the headache, subtle symptoms such as yawning, fatigue or mood changes)
- Aura (lasting up to 60 minutes)
- Headache stage (lasts 4-72 hours)
- Resolution stage (the headache can fade away or be relieved completely by vomiting or sleeping)
- Postdromal or recovery phase
what is the acute management of migraine
often pt will go and lie in a dark quiet room and sleep
• Paracetamol
• Triptans (e.g. sumatriptan 50mg as the migraine starts)
• NSAIDs (e.g ibuprofen or naproxen)
• Antiemetics if vomiting occurs (e.g. metoclopramide)
What is the mechanism of action of triptans
5HT receptors agonists (serotonin receptor agonists). They have various mechanisms of action and it is not clear which mechanisms are responsible for their effects on migraines. They act on:
• Smooth muscle in arteries to cause vasoconstriction
• Peripheral pain receptors to inhibit activation of pain receptors
• Reduce neuronal activity in the central nervous system
what is the treatment for migraine prophylaxis
*keeping headache diary to identify triggers and then avoiding those triggers
• Propranolol
• Topiramate (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant)
• Amitriptyline
which prophylactic migraine treatment is tetrogenic and can cause a clef lip/palate
topiramate
what conventional therapy is an option for prophylaxis of migraine that is recommended by NICE
acupunture
*Vitamin B2 (riboflavin) may reduce frequency and severity
shown to be as effective as medication
if migraine is specially triggered around menstruation then what prophylaxis treatment is recommended
NSAIDS (e.g. mefanamic acid) or triptans (frovatriptan or zolmitriptan)
Describe a cluster headache
severe and unbearable unilateral headaches, usually around the eye
come in clusters of attacks and then disappear for a while
Attacks last between 15 minutes and 3 hours.
a typical patient with cluster headaches in your exam will be what kind of person
30-50 year old male smoker
what can trigger cluster headaches
alcohol, strong smells and exercise
what are the symptoms of a cluster headache
- Red, swollen and watering eye
- Pupil constriction (miosis)
- Eyelid drooping (ptosis)
- Nasal discharge
- Facial sweating
what is the treatment for the acute management of cluster headaches
- Triptans (e.g. sumatriptan 6mg injected subcutaneously)
* High flow 100% oxygen for 15-20 minutes (can be given at home)
what is the treatment for the prophylaxis of cluster headache
- Verapamil
- Lithium
- Prednisolone (a short course for 2-3 weeks to break the cycle during clusters
which migraine prophylaxis medication should be avoided in asthmatics and which is preferred
propranolol should be avoided in asthmatics
topiramate should be offered but need to be very careful in women of child bearing age
