Approach to Headache Flashcards
How common is migraine?
20% of women
5-10% of men
What is migraine?
Idiopathic headache syndrome (genetic)
May be preceded by aura but over 2/3 are not
What is the typical presentation of migraine?
Recurrent, episodic headache
Really bad pain (moderate to severe, building over minutes)
Unilateral
Pulsating
Aggravated by exercise
+ one or both of N+V, and photo- or phono-phobia
Sometimes accompanied by vertigo
Patient just “doesn’t feel right” (distracted, confused, irritable)
What changes of brain activity occur during migraine aura?
Slowly spreading wave of reduced activity (cortical spreading depression of Leao; measured in cm/min)
Probably glial rather than neuronal
Often with occipital onset
What visual disturbances are often reported with migraine aura?
Scintillating scotoma
Monochromatic patterns (e.g. wavy lines, fortification spectra, water effects)
Creeping hemi or quandrantanopia
Monocular changes rare (but retinal migraine does exist)
What kinds of phenomena can be seen with a migraine aura?
Visual
Sensory (e.g. parasthesia)
Motor (e.g. weakness)
Speech centre (e.g. dysphasia)
Brainstem (e.g. in basilar migraine)
What causes headache in migraine?
Much less clear
Trigeminal pain (meningeal and facial innervation, serotonin receptors involved)
Almost certainly a brainstem event, but there are secondary meningeal vessel changes, and pain amplification occurs in scalp and head (allodynia; this feedback loop can be broken by botullinum toxin)
Describe the typical presentation of tension-type headache
Mild to moderate
Band-like: bilateral, pressing
Not associated with exercise induction, N+V, photo- or phono-phobia
I.e. a “normal headache”
What is chronic daily headache? What are the different types?
Headache on most days, most of the day
Chronic migraine (evolves from migraine without aura) or chronic tension-type (individually mild headaches but persistence distressing)
What can make a headache chronic?
Bad luck: severe migraine, chronic daily headache as a primary headache
Bad treatment: medication overuse headache
Bad neck: cervicogenic
What medications can cause chronic headache?
Opiates
Triptans
Ergots
Possibly paracetamol but probably not NSAIDs
Describe the typical pattern of medication overuse headache
More than 10 days a month (twice a week)
What is the mechanism of medication overuse headache?
Chronic changes rather than just tolerance; upregulation of pain receptors
Mx of medication overuse headache
Medication withdrawal (but have withdrawal headaches for weeks; however patients are often surprisingly compliant with stopping medication)
What clinical feature may accompany a cervicogenic headache?
Muscular neck pain (nearly ubiquitous)
What features may accompany the thunderclap headache characteristic of SAH?
May have neurological Sx/signs, e.g. weakness/sensory loss, impairment of consciousness (common; depth of coma marks prognosis)
Photo- or phono-phobia
N+V
Can be unilateral headache (headache is meningeal)
How can SAH be distinguished from migraine?
Onset is extremely abrupt in SAH
DDx for primary thunderclap headache
SAH
Sexual and exertional headaches
Vasospastic headache
Primary thunderclap headache (although not well-described entity)
Dx of SAH
Plain CT
Lumbar puncture if CT normal but there is a good story (will be more accurate once xanthochromia develops)
Signs/Sx of raised ICP
Diffuse headache, variable in severity but often progressive
Prominent nausea
Papilloedema (peripheral visual loss or transient blindness)
Diplopia (CNVI palsy)
Worsening of Sx with increases in ICP (e.g. valsalva - cough or straining, morning headache) and better with reduced ICP (e.g. when standing)
May also have Sx of underlying lesion
26 year old woman with transient, objective L sided weakness and sensory disturbance makes acute presentation to ED, but her sensory and motor Sx then fully resolved
DDx?
Migraine aura (high prior probability)
TIA
Focal seizure
Hypoglycaemia
Vasospastic headache
Functional eurological disorder
Others: non-seizure tumour Sx, periodic paralysis, paroxysmal dyskinesia, mitochondrial disorder, etc
Does EEG diagnose seizure?
No, just predicts recurrence (sometimes)
Distinguish between migraine, TIA and focal seizure in terms of the typical pattern of involvement
Migraine: cortical, brainstem
TIA: cortical, brainstem
Focal seizure: cortical, mesial temporal (invokes memory phenomena)
Distinguish between migraine, TIA and focal seizure in terms of the typical onset
Migraine: acute with sensorimotor march over minutes
TIA: acute, immediate
Focal seizure: acute with sensorimotor march over seconds
Distinguish between migraine, TIA and focal seizure in terms of the typical offset
Migraine: gradual, often stepwise, intermixed with new Sx
TIA: gradual
Focal seizure: distinct (Todd’s paresis)
Todd’s paresis
Focal weakness in a part of the body after a seizure
Distinguish between migraine, TIA and focal seizure in terms of the typical Sx character
Migraine: often active parasthesia, weakness usually varies
TIA: usually negative Sx (e.g. weakness, numbness)
Focal seizure: often active parasthesia, clonus or dystonia prior to weakness
Outline some distinguishing clinical features of migraine, TIA and focal seizure
Migraine: N+V, headache (may be mild with fronto-parietal aura), photo- or phono-phobia, more likely in young
TIA: CV Hx (CV RFs, PHx of MI/stroke/PVD), very common in those >65
Focal seizure: dyscognitive phase, previous stereotyped events
