5.2 Headaches and Pain Flashcards
What examinations might you do as part of a headache presentation?
1) fundoscopy
2) cranial nerves
3) BP
4) temperature
5) HR
6) skin and neck
Name three investigations you might do as part of a headache presentation
1) CT
2) MRI
3) inflammatory markers
What differentiates a primary from a secondary headache?
A primary headache is not caused by underlying disease or structural problems and are therefore not dangerous.
Secondary headaches are caused by something external or an underlying disease and can be harmless or dangerous.
Name three types of primary headaches and identify which are the more common
1) Migraine - common
2) Tension headache - common
3) Cluster headaches and trigeminal neuralgia
List 4 causes of Secondary headaches
1) Head trauma
2) Med overuse
3) Cancer
4) Infection
5) Vascular
Name six potential mechanisms of a headache
SIT RAT
1) Skeletal muscle tension
2) Arterial dilatation
3) Traction on arteries
4) Traction or dilation on venous sinuses
5) Inflammation
6) Referred pain
Name a potential cause for extracranial and intracranial
a) arterial dilation
b) inflammation
a)
- extracranial - migraine
- intracranial - hypertension, infection
b)
- extracranial temporal arteritis
- intracranial -meningitis
Which mechanism of a headache might occur post lumbar puncture?
Traction or dilation on venous sinuses (when patient sits up)
Name three things which may cause traction on arteries
1) raised intracranial pressure (ICP)
2) tumour
3) hemorrhage
What may cause reffered pain that presents as a headache?
Disease of ears /sinuses/c-spine
How does the prevalence of migraines in M vs F change pre and post puberty?
Name one other non-modifiable predisposing factor
Pre-puberty: M=F
Post-puberty: 1:3 (M:F)
Genetics are a strong component
What is a migrane?
Recurrent, unilateral headaches +/- aura
How commonly are auras experienced in migraines?
Which types of auras are most commonly experienced?
20% have auras, usually visual (photophobia) or sensory
Name six possible precipitating factors for a migraine
Foods, alcohol, emotion, menses, bright light, OCP
Name the two hypothesized theories explaining the pathogenesis for migraines?
1) Vascular Theory
2) Central Neural Circuitry
BUT theory is unclear
Describe the 4 stages of a migraine
PAHR:
1) Prodromal fatigue: vague change in mood/appetite
2) Aura phase
3) Headache phase
4) Resolution
What kinds of management are provided for acute and chronic migraines?
Acute: analgesia, triptans, antiemetic (prevents vomiting)
Chronic: precipitant avoidance, beta blockers/topiramate, acupuncture
Describe the following features of a tension headache:
a) Time it lasts
b) Sensation
c) Intensity variation throughout the day?
e) frequency
a) 30 min-7 days
b) bilateral pressure, rarely systemic upset and no aura
c) worse during the day
d) ranges from infrequent attacks to daily pain
* most common type of headache in primary care
How are tension headaches managed?
Lifestyle: stress, alcohol, exercise, mood, med abuse, reassurance
Medication: OTC (paracetamol, ibuprofen), use low dose amitriptyline if experienced for >2days/week
Compare 5 differences between a migraine and tension headache
Where?
- M- unilateral
- T- bilateral
Feeling?
- M- pulsatile
- T- tight band pressure
Aura?
- M- yes
- T- no
Triggers
- M- yes
- T- stress
Responsiveness to migraine meds
- M- responsive
- T- limited response
Describe the sensation and typical frequency of a cluster headache
How common is it?
Bouts of severe orbital pain lasting 15 min-3 hours that occurs frequently- daily for several weeks
Uncommon (M:F 6>1)
How might a cluster headache affect one’s routine differently from a migraine?
Makes patients restless- often wake people during the night
Name 3 symptoms that someone with a cluster headache is likely to experience
Name 2 symptoms/signs which are occasionally experienced
Likely: Conjunctival injection, lacrimation and nasal blockage
Occasionally: ptosis and horner’s syndrome
How are cluster headaches managed?
Acute:
- O2
- triptan
Prophylaxis:
- specialist advice
- avoidance of triggers (alcohol, nicotine)
- verapamil
List 3 presentations of a brain tumour
1) visual problems
2) vomiting
3) seizures
Not commonly headaches
Name 4 types of secondary headaches
1) Temporal arteritis
2) Trigeminal neuralgia
3) Toothache
4) Med overuse headache
5) Meningitis
6) Sinusitis
7) Subarachnoid hemorrhage
8) Raised ICP
Name two things which may cause raised ICP
Tumour or idiopathic intracranial hypertension
Name 7 red flags for a secondary headache
1) Worsening headache with FEVER
2) Sudden onset headache reaching max intensity in 5 MIN
3) PERSONALITY change
4) Impaired level of CONSCIOUSNESS
5) Recent (typically within 3 month) HEAD TRAUMA
6) ORTHOSTATIC headache (changes with posture)
7) NEW ONSET: cognitive dysfunction, neurological deficit
If a headache is triggered by exercise, cough, valsalva or sneeze, what should you think?
RED FLAG!! Secondary headache
Is neck pain or cluster/tension headaches more common?
Neck pain! (Esp in elderly)
What is the most common cause of a headache seen in clinical practice?
Medication overuse (> brain tumour)
Is a tension headache or temporal arteritis more common?
Tension headache
Define ‘chronic pain’
Give 4 examples
Pain which persists beyond the natural healing time– usually > 3months
Commonly
- Back pain / shoulder pain / neck pain / pelvic or abdominal pain
- Phantom limb
How might ‘healing with plasticity’ influence one’s healing process? (compared to normal healing)
Can lead to hyperalgesia and allodynia, which manifests into chronic pain
List 4 things that inflammation may alter (in terms of neurons/APs)
1) Ion channels on neurons
2) Sensitivity of neurons/receptors
3) Decreases the threshold for firing
4) Alters the trigger for firing
List 4 ‘central NS’ alterations that may occur as a result of chronic pain
1) Spontaneous firing from dorsal horn
2) altered descending inhibition
3) Personality/perception
4) Psychology
Describe CRPS and its associations
COMPLEX: varied and dynamic clinical presentation
REGIONAL: non-dermatomal distribution of symptoms
PAIN: out of proportion to the precipitating events
SYNDROME: constellation of signs and symptoms
Linked to the sympathetic nervous system and usually involves a single limb (No correlation between injury and degree of CRPS)
Compare the two types of complex regional pain syndrome, which is more common?
Type 1: no identifiable lesion
Type 2: after a nerve injury
Name one example of type 2 CRPS
Causalgia: severe burning pain in a limb following injury to a peripheral nerve
What triad of symptoms may CRPS may present with?
1) Autonomic
2) Sensory; pain may be spontaneous, hyperalgesia, allodynia
3) Motor: weakness, tremor, dystonia, myoclonus
Describe the pain distribution associated with CPRS
Spontaneous, hyperalgesia, allodynia
List 4 signs associated with a CRPS?
1) Distal edema
2) Skin temp and color changes
3) Altered sweating
4) Bone changes (periarticular osteoporosis, joint stiffness)
What are the 3 hypotheses explaining the mechanism behind CRPS?
1) Neurogenic inflammation
2) Autonomic dysfunction
3) Neuroplastic changes in the CNS
How is CRPS managed? (incl pharmacological and non pharmacological)
Pharmacological: Steroids, analgesia, neuropathic meds, sympathetic nerve blocks
Non pharmacological: physio, occupational therapy, psychotherapy (CBT)
Explain the general mechanism of CPRS
Name structures of the head and neck which contain pain receptors for:
- 4 vessels
- 2 general nerves
- 2 Muscle locations
- 6 other structures
Vessels: extracranial arteries, MMA, large veins, venous sinuses
Cranial and spinal nerves
Head and neck muscles
Meninges, falx cerebri, parts of brainstem, eyes, teeth and lining of mouth
What is thought to be the cause behind tension headaches and cluster headaches?
Tension headaches: activation of peripheral nerves in the head and neck muscles
Cluster headaches: over activation of the trigeminal nerve and hypothalamus in the brain (but exact cause is unknown)
What is the mechanism of action for triptan?
Blocks serotonin receptors and constricts blood vessels *treats migraines
