8b.) Headaches Flashcards
Headaches can be primary or secondary; what do we mean by this?
- Primary: due to a headache condition
- Secondary: due to another condition
Are the majority of headaches benign, non-life threatening headaches due to a primary headache disorder?
Yes
Are primary headache disorders life or sight threatening?
No, primary headache disorders are non-life threatening and non-sight threatening. Many of them are chronic
State 3 examples of primary headache disorders
- Tension headache
- Migraine
- Cluster headache
Secondary headaches can be life or sight-threatening; true or false?
True
State some broad causes for secondary headaches
- Space occupying lesions (although we think that secondary often present acutely- a SOL will often present with a chronic, gradually progressing headache)
- Intracranial haemorrhage
- Intracranial infections
- Other infections: e.g. sinusitis
- Opthalmic: e.g. acute glaucoma
- Temporal arteritis (giant cell arteritis)
- Medication-related and medication overuse
- Systemic: e.g. pre-eclampsia, hypertension
Describe some important aspects of the history that you take from someone presenting with a headache
- History of presenting complaint: SQITARS
- Past medical history: have you had headaches in past? How do they compare? Any conditions that could pre-dispose to headaches?
- Drug history: analgesic use- need to know what, how often and if it works to see if it is
- Family history: e.g. of migraines
- Social history: e.g stress, sleep, alcohol, caffeine, diet (triggers)
State what you typically find on clinical examination for a:
- Primary headache
- Secondary headache
- Primary: clinical examination typically normal
- Secondary: clinical examination MAY be abnormal
Describe some red flag features of a headache (include what each of the red flags could indicate)
(SNOOP)
- Systemic signs & disorders: e.g. of meningitis would have neck stiffness etc, hypertension, pregnant (could be pre-eclampsia)
- Neurological symptoms: point towards space occuping lesion, intracranial heamorrhage, glaucoma
- Onset new or changed & patient >50yrs: malignancy, giant cell arteritis
- Onset in thunderclap presentation: vascular (haemorrhage)
- Papilloedema, pulsatile tinnitus, positional provocation, precipitated by exercise: indicating raised ICP
Describe what your clinical examination, on someone who has presented with headache, should include
- Vital signs (BP, HR, temp)
- Neurological examination (cranial & peripheral)
- Other relevant systems to be guided by history
Order these headaches in terms of how common they are:
- Cluster headache
- Migraine
- Medication over-use
- Tension-type headache
MOST COMMON:
- Tension-type
- Migraine
- Medication over-use
- Cluster headache
Who are tension type headaches more common in; males or females?
At what age are tension type headaches common?
- More common in females
- Young (teens & young adults). If first onset is >50yrs unusual
Describe the pathophysiology of tension-type headaches
Thought to be due to tension in muscles of head & neck
Describe tension-type headaches, include:
- Where headache is felt
- Intensity
- When it is worse
- Aggrevating factors
- Response to simple analgesia
- Associated symptoms?
- Clinical examination findings
- Generalised in frontal & occipital regions (may be described as a band around head) and can radiate to neck. Non-pulsatile
- Worse at end of day
- Aggrevating factors: stess, posture, lack of sleep
- Often responds to simple analgesia
- Few associated symptoms- maybe nausea
- Clinical examination normal
Who are migraines more common in; males or females?
At what age do migraines typically present?
- Females
- Most have first attack early to mid-life (so should present before 30yrs if not unusual)
Are migraines common?
Yes (15 in every 100)
Describe the pathophysiology of a migraine
- Pathophysiology unclear
- Possible theories proposed e.g. vasodilation of meningeal vessels
Describe migraine headaches, include:
- Where headache is
- Quality of the headache
- Severity
- Duration
- Possible triggers
- Family history
- Response to simple analgesia
- Associated symptoms
- Clinical examination findings
- Unilateral (often in temporal or frontal region)
- Throbbing, pulsating
- Moderate-severe (disabling)
- Prolonged headache (4-72hrs)
- Triggers: certain foods, menstrual cycle, stress, lack of sleep
- Often there is family history
- Can respond to simple analgesia but may need triptans
- Associated symptoms: nausea & vomitting, photophobia & sometimes phonophobia, neurological symptoms (some get aura before migraine and some can get aura and no migraine)
- Clinical examination is normal
Who are medication over-use headaches more common in; males or females?
How often do medication over-use headaches ofen present?
- Females
- Present at least 15 days a month (constant)
Who do medication over-use headaches occur in?
ONLY occur in patients who are using analgesics regularly for headaches (has to be for headaches not analgesia for other pain and by regular we mean at least 10 days a month) due to underlying primary headache disorder. And the medication (over the counter medication) no longer works
What is a medication over-use headache?
What does it often co-exist with?
- Headache that is present for at least 15 days a month (constant) due to regular use of analgesics (at least 10 days a month) for a primary headache disorder leading to the headache not responding and hence causing a secondary headache disorder
- Co-exists with depression and sleep distuance
What analgesic is the most common cause/commonly used to create medication-over use headaches?
Co-codamol
How do you treat medication over-use headaches?
Discontinue medication (headache worsens before improves. Typically completely resolved by 2 months)
Describe the pathophysiology of medication over-use headaches
Up-regulation of pain receptors in meninges
Generaly what happens to the severity of migraines with age?
Severity generally decreases with age
Who are cluster headaches more common in; males or females?
What is the usual age of onset/presentation of cluster headaches?
- MALES
- 20-40yrs
Describe the pathophysiology of cluster headaches
Unknown but its questions whether this is hypothalamic activation with secondary trigeminal and autonomic involvement
Describe cluster headaches, include:
- Where the headache is
- Quality of headache
- Severity
- Duration
- Remission
- Triggers
- Effect of simple analgesia
- Associated symptoms
- Clinical examination findings
- Unilateral, around or behind eye
- Sharp, stabbing, penetrating
- Very severe/intense, often disabling and pt may be agitated
- Rapid onset and can last between 15mins and 3hrs and happen 1-2 times a day. Cluster attacks may last up to 12 weeks
- Have remissions between clusters which can last anywhere between 3 months-3 years
- Triggers: alcohol, cigarettes, volatile smells, warm temp, lack of sleep, histamine (hayfever), exercise,
- Simple analgesia often ineffective hence use oxygen and triptans
- Ipsilateral autonomic symptoms due to decreased sympathetic activity:
- Red, watery eye
- Nasal congestion
- Ptosis
- Clinical examination shows autonomic features during attack
*
If a headache is due to a space occupying lesion it often has other suspicous historical or examination findings; true or false?
True
Describe a headache due to a space occupying lesion, include:
- Onset
- Quality of pain
- Severity
- Aggravating factors
- Use of simple analgesics
- Associated symptoms
- Clinical examination findings
- Graudal onset, progressive (this is unusal for secondary headaches)
- Dull
- Mild in severity but worse in morning or on waking
- Aggravating factors: leaning forward, cough, Valsalva manoeuvre
- Simple analgesics may be effective in early stages but perhaps not in later stages
- Associated symptoms: nausea, vomitting, focal neurological or visual symptoms and potentially others e.g. personality/behaviour change, seizues etc..
- Clinical examination- focal (unilateral) neurological signs, papilloedema
Describe the pathophysiology of headaches caused by space-occupying lesions
Raises ICP (could also compress structures)
Who is trigeminal neuralgia more common in; males or females?
At what age is the peak incidence?
- Females
- 50-60yrs
Describe headaches caused by trigeminal neuralgia, include:
- Where headache is
- Quality of pain
- Severity
- Duration
- Onset
- Aggravating factors
- Simple analgesia use
- Precding symptoms
- Clinical examination findings
- Unilateral, pain often felt in >1 division of trigeminal nerve
- Sharp, stabbing, electric shock, burn
- Severe
- (lasts few seconds-mins)
- Sudden onset
- Aggravating factors:
- Light touch to face
- Eating
- Cold wind
- Combing hair
- Vibrations
- Simple analgesics not often effective- difficult to treat
- Preceding symptoms:
- Tingling or numbness
- Clinical examination often normal
Describe the pathophysiology of trigeminal neuralgia
Most cases caused by compression of CNV by a vascular malformation; alternatively could be compressed by tumours, skull base abnormalities or as symptom of MS.
Who is temporal arteritis more common in; males or females?
At what age is temproal arteritis most common in?
- Females
- >50yrs, common in >75yrs
Describe the pathophysiology of temporal arteritis include whcih artery is often invovled
- Vasculitis involving small & medium sized arteries of head
- Superficial temporal artery
Who must you consider temporal arteritis in? HINT: 4 identifaible features
Consider in anyone >50yrs with abrupt onset of headache + visual disturbance or jaw claudication
Why is it VITAL that you don’t miss a headache due to temporal arteritis?
It is sight threatening
How would you treat someone who has suspected temporal arteritis?
Immediate high dose steroids (don’t wait for biopsy results)
State some symptoms, other then headaches and loss of vision, of temporal arteritis
State some ways we can investigate causes of headaches
- Headache diary for chronic headaches
- Imaging may be indicated if red flags
- THOROUGH history
Discuss how we treat headaches
Depends on underlying cause:
- Simple analgesia
- Triptans for migraines
- Cluster headaches may respond to high flow oxygen
- Remove aggravating factors
Suggest some circumstances in which you may refer soemone with a headache to be investigated by specialists
- Suspicion of tumour
- Suspicion of raised ICP
- Recent onset seizures
- Previous cancer
- Unexplained focal deficit
- Unexplained cognitive or personality changes
How do you determine if tension headaches are:
- Chronic
- Episodic
- Chronic: >15 times per month
- Episodic: <15 times per month
