9. Primary Headaches - Migraine, Tension, Cluster, and Trigeminal neuralgia Flashcards
What is a headache?
A headache is when pain-sensitive structures in the head and neck are stimulated (nerves, meninges, blood vessels or muscles).
Headaches are a very common presentation with a large number of differential diagnoses.
Give an example of a primary headache.
- Migraine.
- Tension headache.
- Cluster headache.
What is the most disabling and painful primary headache?
Cluster headache
What is the most common type of primary headache?
Tension headache.
Give an example of a secondary headache.
- Meningitis/Encephalitis.
- Subarachnoid haemorrhage - sentinel headache.
- Giant cell/temporal arteritis.
- Medication overuse headache.
- Systemic infection.
- Raised ICP.
What is the most common type of secondary headache?
Medication overuse headache.
Give 6 questions that are important to ask when taking a history of headache.
- Time: onset, duration, frequency, pattern.
- Pain: severity, quality, site and spread.
- Associated symptoms e.g. nausea, vomiting, photophobia, phonophobia.
- Triggers/aggravating/relieving factors.
- Response to attack: is medication useful?
- What are symptoms like between attacks?
10 red flag symptoms for a headache presentation.
- 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)
10 History of trauma (intracranial haemorrhage) - Pregnancy (pre-eclampsia)
Give 5 red flags for suspected brain tumour in a patient presenting with a headache.
- New onset headache and history of cancer.
- Cluster headache.
- Seizure.
- Significantly altered consciousness, memory, confusion.
- Papilloedema (swollen optic disc).
- Other abnormal neuro exam.
What is a migraine?
A complex neurological condition that cause recurrent throbbing headaches often preceded by an aura and associated with nausea, vomiting and visual changes.
Give 4 migraine triggers.
CHOCOLATE:
- Chocolate / caffeine
- Hangovers
- Orgasms
- Cheese
- Oral contraceptives
- Lie-ins
- Alcohol / Anxiety
- Tumult - loud noise
- Exercise
Give 3 risk factors of a migraine.
- Fx
- Strong genetic component thus family history - Female
- Age
- Can occur at any age but majority have first migraine in adolescence
How long do migraine attacks tend to last for?
Between 4 and 72 hours.
How can migraines be subdivided?
- Episodic with (20%)/without (80%) aura.
- Chronic migraine.
What are the 4 types of migraine?
- Migraine with aura
- Migraine without aura
- Silent migraine
- Hemiplagic migraine
What is a silent migraine?
Migraine with aura but no headache
What is a hemiplegic migraine?
temporary paralysis of one side of the body.
Unilateral weakness, ataxia, altered consciousness.
What is meant by an aura?
Used to describe visual changes associated with migraines.
Precedes attack & can be a variety of symptoms.
Visual disturbance e.g. lines, dots, zig-zags
Somatosensory e.g. paraesthesia, pins & needles
Types of Aura:
- Sparks in vision
- Blurring vision
- Lines across vision
- Loss of different visual fields
Give 3 possible features of a migraine aura.
Flashing lights
Tingling and weakness down one side
Visual disturbance
Ataxia
Dysphasia
Give 3 possible features of a migraine prodrome.
There may be a prodrome that precedes the headache by hours/days consisting of:
- Yawning
- Cravings
- Mood/sleep changes
Give 4 main symptoms of a migraine.
- Headache
- Severe unilateral pulsating, throbbing pain aggravated by movement - Nausea + Vomiting
- Photophobia
- Sensitivity to light - Phonophobia
- Sensitivity to sounds
Describe the pain of a migraine.
- Unilateral.
- Throbbing.
- Moderate/severe pain.
- Aggravated by physical activity.
Describe the diagnosis of migraine without aura.
> 5 attacks lasting between 4 and 72 hours
AND at least 1 of:
- Nausea/vomiting
- Photophobia/phonophobia.
And >2 of:
- Unilateral pain.
- Throbbing pain.
- Pain aggravated by physical activity (motion sensitive).
- Moderate/severe pain.
Investigations for migraines.
- Clinical diagnosis - using history + physical examinations
- Eyes - for papilloedema and other eye issues using fundoscopy
- BP
- Head & neck (scalp, neck muscles and temporal arteries) - Bloods - to exclude other causes:
- CRP + ESR = normal in migraine - Imaging - to exclude other causes:
- CT/MRI = normal in migraine - Lumbar puncture - to exclude other causes:
- normal in migraine*
Indications to do a CT/MRI for a migraine.
- Worst/severe headache - thunderclap
- Change in pattern of migraine
- Abnormal neurological exam
- Onset >50yrs
- Epilepsy
- Posteriorly located headache
Indications to do a lumbar puncture for a migraine.
- Worst headache of life - thunderclap - SAH
- Severe, rapid onset headache, progressive headaches,
unresponsive headaches
-> NEUROIMAGING should PRECEDE LUMBAR PUNCTURE to rule
out mass/lesion/raised ICP!!
Treatment of patient presenting to A+E with persistent migraines.
- Rescue therapy - 1st line!
- IV Anti-emetics + Diphenhydramine
- This is for symptomatic relief of nausea
- Hydration, Oxygen, Corticosteroids can be considered
Describe the treatment for migraines.
- Ensure an accurate diagnosis.
- Lifestyle modification and trigger management.
- Psychological and behavioural treatment.
- Abortive treatment: PO triptan and NSAIDs.
- Anti-emetics.
- Preventative treatment: propranolol, acupuncture, amitriptyline.
Acute management of migraines.
- Simple analgesia - monotherapy - 1st line
- NSAIDs e..g naproxen / ibuprofen
- Apsirin
- Paracetamol - Triptans e.g. sumatriptan
- Selectively stimulate 5-hydroxytryptamine receptors in brain
- Given along with analgesia (double therapy) - Antiemetic - can choose to give alongside to other medications
- E.g. Metoclopramide
What are triptans for & how do they work?
For acute treatment of migraine.
5-HT agonist:
- Causes vasoconstriction.
- Inhibits peripheral pain receptors.
- Reduces CNS activity.
Give contraindications for triptans.
- Ischaemic heart disease
- Coronary spasm
- Uncontrolled high BP
When is sumatriptan contraindicated?
Heart disease
What drugs would you NOT give for acute treatment of migraines?
DO NOT OFFER ERGOTS
e.g.ergotamine or OPIODS
What drugs might be used to prevent migraines (prophylaxis)?
1st line - propranolol, amitriptyline, topiramate, CCBs.
2nd line - valproate, pizotifen, gabapentin, pregabalin.
Give 3 differential diagnoses of migraine.
- Cluster or tension headache
- Cervical spondylosis
- Hypertension
- Intracranial pathology
- Sinusitis/otitis media
- TIA (may mimic migraine aura)
What is a tension headache?
A form of episodic primary headaches.
- the most chronic daily & recurrent headache
Describe the epidemiology of tension headaches.
- Most common primary headache
- Onset is generally between 20-30 years old
- More common in females
How long do tension headaches usually last for?
From 30 minutes to 7 days.
What causes tension headaches?
Neurovascular irritation, referred to scalp muscles and soft tissues.
Describe the pain of a tension headache.
- Bilateral.
- Pressing/tight and non-pulsatile (“tight-band”)
- Mild/moderate pain (with pressure behind the eyes)
- +/- scalp muscle tenderness.
- Not aggravated by physical activity.
Would a patient with a tension headache experience any other symptoms?
No!
Nausea, vomiting, photo/phonophobia would not be associated.
Which symptoms are NOT associated with a tension headache?
- Vomiting
- Sensitivity to head movement
- Aura
- These are not present in a tension headache
Give some triggers for a tension headache (aetiology).
- Stress
- Sleep deprivation
- Hunger
- Eyestrain
- Anxiety
- Noise
- Bad posture
- Dehydration
- Depression
- Alcohol
Describe the pathophysiology of tension headaches.
Release & activation of inflammatory agents –> leads to sensitisation of peripheral trigeminal afferents –> ultimately in central hypersensitivity.
- e.g. of agents - substance-P or Calcitonin gene-related peptides
- Theory: the major nociceptor in tension headaches = pericranial musculature.
-> helps explain why patients frequently report both migraine and tension-type headaches.
The band-like pattern may be due to muscle ache in the frontalis, temporalis and occipitalis muscles.
Investigations for a tension headache.
Clinical diagnosis from history + clinical presentation
- Based on a typical headache without associated features such as nausea + vomiting and aura, with a normal neurological examination.
Management of a patient with tension headaches.
- Reassurance and lifestyle advice e.g. regular exercise, avoidance of triggers
- Relaxation techniques
- Stress relief
- e.g. massage or acupuncture - Hot towels to local area
- Symptomatic relief for episodes occurring >2 days a week:
- Simple analgesics - 1st line:- Aspirin, Paracetamol, NSAIDs e.g. Ibuprofen
- No opioids!
Note: Limit analgesics to no more than 6 days per months to reduce the risk of medication-overuse headaches!!
Management of chronic tension headaches.
- 1st line -> Antidepressants
- e.g. Amitriptyline
- 2nd line -> Muscle relaxants
- e.g. Tizanidine
- Non-drug therapies
- Relaxation training, electromyographic (EMG) biofeedback, cognitive behavioural therapy, and myofascial trigger point-focused massage
Name a type of headache that is accompanied with cranial autonomic features.
Cluster headache.
Define a cluster headache.
- Come in clusters of attacks and then disappear for a while.
- One of the most painful conditions.
- Severe and unbearable unilateral headaches, usually around the eye.
How long does a cluster headache last?
15 min - 3 hrs
Describe the epidemiology of a cluster headache.
- Male
- 20-50
- smoker
Describe the pathophysiology of cluster headaches.
- Trigeminal autonomic reflex arc
-> responsible for trigeminal pain and cranial autonomoic features - Nociceptive information from pain-sensitive structures in the face, and particularly the dura mater and cerebral blood vessels, is carried to the brainstem via the trigeminal nerve.
- Within the brainstem, these trigeminal fibres synapse in the area known as the trigeminocervical complex (TCC).
- Information is then sent to the hypothalamus, thalamus, and cortex via the painprocessing pathways.
- Afferent trigeminal signals arriving at the TCC activate the cranial parasympathetic system.
- This results in increased firing of the parasympathetic fibres innervating facial structures, and causes the autonomic features seen in an attack.
- Each ‘cluster’ can last minutes to hours and has autonomic symptoms like: swollen eyelid, red eye, runny nose and tearing
In summary:
1. Hyperactivity of trigeminal-autonomic reflex arc
2. Vasodilation and trigeminal stimulation
3. Histamine & mast cells
4. Autonomic nervous system activated
Describe the clinical presentation of cluster headaches.
- Rapid onset of EXCRUCIATING pain AROUND ONE EYE, TEMPLE or FOREHEAD
- Ipsilateral cranial autonomic features:
1) Eye may become watery and bloodshot with lid swelling,
lacrimation (red, swollen + watery eye)
2) Facial flushing
3) Rhinorrhea (blocked nose) - nasal discharge
4) Miosis (excessive pupil constriction) +/- ptosis (drooping or
falling of upper eyelid) - seen in 20% of attacks
Describe the pain of a cluster headache.
- Severe/very severe pain.
- Pain around the eye/temporal area.
- Unilateral.
- Headache is accompanied by cranial autonomic features.
Describe the ipsilateral cranial autonomic clinical features that affect the eye in cluster headaches.
Horner’s syndrome:
1. Miosis - constricted pupil
2. Ptosis - droopy eyelid
3. Anhidrosis - decreased sweating
Cranial autonomic symptoms:
1. Eye may become watery and bloodshot with lid swelling, lacrimation (red, swollen + watery eye)
2. Facial flushing
3. Rhinorrhea (blocked nose) - nasal discharge
4. Miosis (excessive pupil constriction) +/- ptosis (drooping or falling of upper eyelid) - seen in 20% of attacks
Describe the timeline of cluster headaches.
Recurrent bouts of the headache a couple of times a day, coming on a few times a month, then disappears for a few months and then returns unexpectedly.
What is the difference between episodic vs chronic cluster headaches?
- Episodic = clusters last 4-12 weeks and are followed by pain-free periods of months or even 1-2 yrs before the next cluster.
- Chronic = attacks for more than 1 year without remission.
Investigations of cluster headaches.
Clinical diagnosis based on history + clinical presentation.
- At least: 5 headache attacks fulfilling the criteria.
Treatment of an acute attack of a cluster headache.
- Triptans - e.g. SC Sumatriptan 6mg
- Selective serotonin (5HT) receptor agonist = reduces vascular
inflammation - High flow 100% 15L Oxygen for 15-20 minutes
- Via non-rebreathable mask
How is sumatriptan given in acute cluster headache?
Subcutaneous
What are triptans used to treat?
Migraines and cluster headaches - not preventative/curing though.
e.g. Sumatriptan, Rizatripan.
How do triptans work?
Agonist effects on serotonin 5-HT-1b and d receptors in cranial blood vessels
-> Causes their constriction, and subsequent inhibition of pro-inflammatory neuro-peptide release.
May also work on serotonin receptors in nerve endings to relieve pain through decrease in levels of substance P.
Preventative prophylaxis for cluster headaches.
- CCBs - 1st line
- Verapamil - Corticosteroids
- Prednisolone
- A short course for 2-3 weeks to break the cycle during clusters - Avoid alcohol + stop smoking during cluster period
- Lithium
- If other medications are contraindicated
Define trigeminal neuralgia.
A facial pain syndrome in the distribution of ≥1 divisions of the
trigeminal nerve.
The trigeminal nerve is which cranial nerve?
CN V
How many divisions does the trigeminal nerve have and what are they?
3 branches:
V1 - Opthalmic
V2 - Maxillary
V3 - Mandibular
What areas are the 3 branches of the trigeminal nerve responsible for?
- Opthalamic branch - Superior region of the head; meninges and cornea
- Maxillary branch - Upper lip, maxillary teeth and mucosa
- Mandibular branch - Mandibula, lower lip, mucosa and mandibular teeth
What are the trigeminal nerve fibres?
Nnociceptive fibres (Aδ and C fibres) and low threshold mechanoreceptors
Describe the epidemiology of trigeminal neuralgia.
- Peak incidence between 50-60 YO
- More common in FEMALES than males
- Prevalence increases with age
Give 2 examples of triggers of trigeminal neuralgia.
- Washing affected area
- Shaving
- Eating
- Talking
- Dental prostheses
List 3 secondary causes of trigeminal neuralgia.
- Compression of trigeminal root by anomalous/aneurysmal intracranial vessels or a tumour
- Chronic meningeal inflammation.
- MS.
- Herpes zoster.
- Skull base malformation.
Briefly describe the pathophysiology of trigeminal neuralgia.
Compression of the trigeminal nerve results in demyelination and excitation of the nerve resulting in erratic pain signalling.
Describe the clinical features of trigeminal neuralgia.
- Paroxysms of intense, stabbing facial pain that is electric-shock like, lasting seconds in the trigeminal nerve distribution.
- Unilateral, affecting mandibular or maxillary divisions.
- Face screwed up in pain.
Describe the pain of trigeminal neuralgia.
- Unilateral face pain.
- Pain commonly in V3 distribution.
- Very severe.
- Electric shock like/shooting/sharp.
How long does the pain associated with trigeminal neuralgia usually last for?
A few seconds.
Diagnosis of trigeminal neuralgia.
- Clinical diagnosis based on criteria and based on history.
- Need at least 3 attacks with unilateral facial pain
- Not attributed to another disorder - MRI of the brain
- To exclude secondary causes or other pathologies
Management of trigeminal neuralgia.
- Anticonvulsants - 1st line
- Oral Carbamazepine
- Less effective options: Lamotrigine, Phenytoin, Gabapentin - Surgery options
- Microvascular decompression
(Anomalous vessels are separated from the trigeminal root)
- Ablative surgery - gamma knife surgery
(Directly at trigeminal nerve ganglion or nerve root)
Differential diagnosis of trigeminal neuralgia.
- Giant cell arteritis/temporal arteritis should be excluded.
- Dental pathology, temporo-mandibular joint dysfunction, migraine, cluster headaches.
