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Sem 4: Nervous System > 8b.) Headaches > Flashcards

8b.) Headaches Flashcards

1
Q

Headaches can be primary or secondary; what do we mean by this?

A
  • Primary: due to a headache condition
  • Secondary: due to another condition
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2
Q

Are the majority of headaches benign, non-life threatening headaches due to a primary headache disorder?

A

Yes

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3
Q

Are primary headache disorders life or sight threatening?

A

No, primary headache disorders are non-life threatening and non-sight threatening. Many of them are chronic

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4
Q

State 3 examples of primary headache disorders

A
  • Tension headache
  • Migraine
  • Cluster headache
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5
Q

Secondary headaches can be life or sight-threatening; true or false?

A

True

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6
Q

State some broad causes for secondary headaches

A
  • 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
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7
Q

Describe some important aspects of the history that you take from someone presenting with a headache

A
  • 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)
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8
Q

State what you typically find on clinical examination for a:

  • Primary headache
  • Secondary headache
A
  • Primary: clinical examination typically normal
  • Secondary: clinical examination MAY be abnormal
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9
Q

Describe some red flag features of a headache (include what each of the red flags could indicate)

(SNOOP)

A
  • 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
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10
Q

Describe what your clinical examination, on someone who has presented with headache, should include

A
  • Vital signs (BP, HR, temp)
  • Neurological examination (cranial & peripheral)
  • Other relevant systems to be guided by history
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11
Q

Order these headaches in terms of how common they are:

  • Cluster headache
  • Migraine
  • Medication over-use
  • Tension-type headache
A

MOST COMMON:

  • Tension-type
  • Migraine
  • Medication over-use
  • Cluster headache
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12
Q

Who are tension type headaches more common in; males or females?

At what age are tension type headaches common?

A
  • More common in females
  • Young (teens & young adults). If first onset is >50yrs unusual
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13
Q

Describe the pathophysiology of tension-type headaches

A

Thought to be due to tension in muscles of head & neck

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14
Q

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
A
  • 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
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15
Q

Who are migraines more common in; males or females?

At what age do migraines typically present?

A
  • Females
  • Most have first attack early to mid-life (so should present before 30yrs if not unusual)
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16
Q

Are migraines common?

A

Yes (15 in every 100)

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17
Q

Describe the pathophysiology of a migraine

A
  • Pathophysiology unclear
  • Possible theories proposed e.g. vasodilation of meningeal vessels
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18
Q

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
A
  • 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
19
Q

Who are medication over-use headaches more common in; males or females?

How often do medication over-use headaches ofen present?

A
  • Females
  • Present at least 15 days a month (constant)
20
Q

Who do medication over-use headaches occur in?

A

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

21
Q

What is a medication over-use headache?

What does it often co-exist with?

A
  • 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
22
Q

What analgesic is the most common cause/commonly used to create medication-over use headaches?

A

Co-codamol

23
Q

How do you treat medication over-use headaches?

A

Discontinue medication (headache worsens before improves. Typically completely resolved by 2 months)

24
Q

Describe the pathophysiology of medication over-use headaches

A

Up-regulation of pain receptors in meninges

25
Q

Generaly what happens to the severity of migraines with age?

A

Severity generally decreases with age

26
Q

Who are cluster headaches more common in; males or females?

What is the usual age of onset/presentation of cluster headaches?

A
  • MALES
  • 20-40yrs
27
Q

Describe the pathophysiology of cluster headaches

A

Unknown but its questions whether this is hypothalamic activation with secondary trigeminal and autonomic involvement

28
Q

Describe cluster headaches, include:

  • Where the headache is
  • Quality of headache
  • Severity
  • Duration
  • Remission
  • Triggers
  • Effect of simple analgesia
  • Associated symptoms
  • Clinical examination findings
A
  • 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
    *
29
Q

If a headache is due to a space occupying lesion it often has other suspicous historical or examination findings; true or false?

A

True

30
Q

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
A
  • 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
31
Q

Describe the pathophysiology of headaches caused by space-occupying lesions

A

Raises ICP (could also compress structures)

32
Q

Who is trigeminal neuralgia more common in; males or females?

At what age is the peak incidence?

A
  • Females
  • 50-60yrs
33
Q

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
A
  • 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
34
Q

Describe the pathophysiology of trigeminal neuralgia

A

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.

35
Q

Who is temporal arteritis more common in; males or females?

At what age is temproal arteritis most common in?

A
  • Females
  • >50yrs, common in >75yrs
36
Q

Describe the pathophysiology of temporal arteritis include whcih artery is often invovled

A
  • Vasculitis involving small & medium sized arteries of head
  • Superficial temporal artery
37
Q

Who must you consider temporal arteritis in? HINT: 4 identifaible features

A

Consider in anyone >50yrs with abrupt onset of headache + visual disturbance or jaw claudication

38
Q

Why is it VITAL that you don’t miss a headache due to temporal arteritis?

A

It is sight threatening

39
Q

How would you treat someone who has suspected temporal arteritis?

A

Immediate high dose steroids (don’t wait for biopsy results)

40
Q

State some symptoms, other then headaches and loss of vision, of temporal arteritis

A
41
Q

State some ways we can investigate causes of headaches

A
  • Headache diary for chronic headaches
  • Imaging may be indicated if red flags
  • THOROUGH history
42
Q

Discuss how we treat headaches

A

Depends on underlying cause:

  • Simple analgesia
  • Triptans for migraines
  • Cluster headaches may respond to high flow oxygen
  • Remove aggravating factors
43
Q

Suggest some circumstances in which you may refer soemone with a headache to be investigated by specialists

A
  • Suspicion of tumour
  • Suspicion of raised ICP
  • Recent onset seizures
  • Previous cancer
  • Unexplained focal deficit
  • Unexplained cognitive or personality changes
44
Q

How do you determine if tension headaches are:

  • Chronic
  • Episodic
A
  • Chronic: >15 times per month
  • Episodic: <15 times per month

Sem 4: Nervous System (21 decks)

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