9.2 Headache Flashcards
what are secondary headaches?
headaches that occur because of another condition
what are some of the differential diagnosis of acute headache?
Vascular
• Haemorrhage - Subarachnoid, Subdural, Extradural
• Thrombosis - Venous sinus thrombosis
Infective/inflammatory
- Meningitis, Encephalitis, Abscess, Temporal arteritis
Ophthalmic - Glaucoma
Situational (exacerbating factors)
- Cough, Exertion, coitus
what are some of the differential diagnosis of chronic headaches?
- Migraine
- Cluster headaches
- Drug side effects - Analgesics, Caffeine (particularly withdrawal), Vasodilators
- Tension headaches
- Trigeminal neuralgia (difficult to classify but probably secondary due to a vascular anomaly)
- Raised intracranial pressure (e.g. tumours)
- Temporal / giant cell arteritis
- Systemic - Hypertension, Pre-eclampsia, Phaemochromocytoma – rare
what taking a history for headaches, what should we be asking about?
Full history of presenting complaint using SOCRATES/SQITARS
What might be causing /triggering the headache?
PMH of headache?
Drug history - Analgesics, Side effects causing headache (e.g. vasodilators)
FH - E.g. migraine with aura has some heritability
social history - Stress, Diet (some foods can trigger migraine), Hydration
what do we look for on examination of a patient with headaches?
Vital signs / obs - E.g. raised ICP can cause bradycardia / hypotension. Hypertension itself can cause headache
Neurological examination - Full peripheral and cranial nerve
Other relevant systems as guided by history (e.g. if associated feelings of faintness then examine CVS)
what are the red flag features of headaches?
Systemic signs and disorders (e.g. of meningitis or
hypertension)
Neurological symptoms
Onset new or changed and patient >50 yo (can be suggestive of malignancy e.g. brain metastases)
Onset in thunderclap presentation (suggests vascular cause such as SAH)
Papilloedema (suggests raised ICP
what are the symptoms associated with a headache that is being caused by a space occupying lesion?
Gradual onset Progressive Associated neurological features E.g. visual disturbance or focal signs Additional features of raised ICP - Early morning headache - Nausea and vomiting - Worse on coughing and bending
what population is most at risk of developing migraines?
females under 30 (most have first attack when young)
what are the clinical features of a migraine?
unilateral and often frontal
onset can be sudden or gradual
quality is throbbing or pulsing
moderate intensity
lasts between 4 to 72 hours , possibly cyclical character
photophobia and phonophobia - bright lights and loud noises are aggravating factors
relieving factors are sleep and medications such as triptans
may have aura and nausea and vomiting
what is a migraine aura?
Migraine aura symptoms include temporary visual or other disturbances that usually strike before other migraine symptoms — such as intense head pain, nausea, and sensitivity to light and sound. Migraine aura usually occurs within an hour before head pain begins and generally lasts less than 60 minutes.30 M
what are triggers for migraines?
Certain foods - Cheese, Chocolate
Lack of sleep
Stress
what is the pathophysiology of a migraine?
Unclear, but a number of ideas have been put forward from vasodilatation to ‘spreading depression’ in the cerebral cortex
Often clear family history
what is the epidemiology of tension headaches?
most common primary headache
more common in females
more common in younger patients
first onset in over 50s is unusual and should possibly be thinking of malignancy
what are the clinical features of a tension headache?
bilateral frontal
can radiate to the neck
quality is squeezing, band like constriction
non-pulsatile
intensity is mild to moderate
worse at the end of the day as stress builds up
worsen when stressed, poor posture and lack of sleep
simple analgesics can help
sometimes some mild nausea
what are chronic tension headaches?
tension headaches that occur more than 15 times a month
what are episodic tension headaches?
tension headaches that occur less than 15 times a month
what is the pathophysiology of tension headaches?
Maybe tension in muscles of head and neck (e.g. occipito-frontalis)
Usually no family history
what is the epidemiology of medication overuse headache?
3rd most common type of headache
20% of headaches are due to medication overuse
30-40 years old
Females > males
what are the clinical features of medication overuse headaches?
Present on at least 15 days per month
No improvement after OTC medication (e.g. paracetamol)
Using analgesics on at least 10 days per month
Taking analgesia for headache in the first place
Can get a variety of symptoms Often co-exists with depression and sleep disturbance
what is the management of medication overuse headache?
Discontinuation of medication (following this will get worse before getting better)
what is the pathophysiology of medication overuse headache?
related to upregulation of pain receptors in the meninges
what is the epidemiology of cluster headaches?
1/1000 people
Males > females
Usual onset 20-40 years old
what are the clinical features of cluster headaches?
around or behind one eye
no radiation
quality is sharp and penetration
intensity is severe and constant
rapid onset
attacks last 15mins to 3 hours and occur 1-2 times a day
usually occur at night
clusters of attacks last 2 to 12 weeks
remissions between clusters can last 3 months to 3 years
aggravating factors are head injury, alcohol and smoking
simple analgesics can help
associated with decreased sympathetic activity
- red, watery eye
- nasal congestion
- ptosis
what are some of the triggers for cluster headaches?
Alcohol Histamine (hayfever) GTN Heat Exercise Solvent inhalation Lack of sleep
what is the incidence of trigeminal neuralgia?
Peak incidence 50-60, increasing with age
25/100,000 UK population
Females > males
what are the clinical features of trigeminal neuralgia?
unilateral, often over one eye
radiates to eyes, lips, nose and scalp (CN V)
quality is sharp and stabbing
electric shock feeling
intensity is severe
sudden onset
lasts a few seconds to 2 minutes
aggravating factors include a light touch to the face, eating, cold wind, vibration
can have numbness or tingling proceeding an attack
what is the pathophysiology of trigeminal neuralgia?
Most cases caused by compression of trigeminal nerve by a vascular malformation
A few cases can be found to be caused by tumours, MS or skull base anomalies
More common in those with a history of chronic pain (central sensitisation?)
what investigations are used in headaches?
Clearly, dependent on cause (e.g. if subarachnoid haemorrhage then investigate accordingly
Headache diary can be useful for chronic headaches
Imaging may be indicated if red flags
vital signs
neurological examination - cranial and peripheral nerve examination, Glasgow-come scale)
what is the main treatment for migraines?
triptans
what is the treatment of cluster headaches?
simple analgesia
high flow oxygen
when do headaches need to be referred?
Suspicion of a tumour Suspicion of raised ICP Recent onset seizures Previous cancer Unexplained focal deficit Unexplained cognitive /personality changes
what are the majority of headaches caused by?
majority are benign due to primary headache disorder - usually tension headaches.
give some examples of primary headache disorders
tension headache
migraine
cluster headache
give some examples of secondary headaches due to another condition?
trigeminal neuralgia space occupying lesion tumour haemorrhage meningitis medication overuse medication related hypertension pre-eclampsia
what headaches might be sight threatening?
giant cell (temporal) arteritis acute glaucoma
describe the headache caused due to a space occupying lesion?
gradual, progressive mild in severity worse in the mornings early-morning on waking worsened with posture, couch, valsalva manoeuvre, straining simple analgesics may be effective in early stage focal neurological signs nausea and vomiting visual symptoms
what is temporal arteritis?
vasculitis of large and medium sized arteries of the head, often branched of the external carotid artery.
what is the epidemiology of temporal arteritis?
more common in females
>50 years, most common in over 75yrs
when should temporal arteritis be considered?
Consider in any >50 year old with abrupt onset of headache + visual disturbance or jaw claudication
what artery is commonly involved in temporal arteritis?
superficial temporal
why is temporal arteritis a medical emergency?
Risk of irreversible loss of vision due to involvement of blood vessels supplying CN II (optic)
