Disorders of the Somatosensory Function - Headache Flashcards
what causes a primary headache?
No underlying medical cause
what causes a secondary headache?
has an identifiable structural or biochemical cause
what are three types of primary headaches?
Tension Type Headache
Migraine
Cluster Headache
what are examples of causes of secondary headache?
Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced
what can result from taking medication too often to releive a migraine?
Medication Overuse Headache
describe the physiology of primary headache?
Sensitisation of normal pain pathways
Involves brainstem and cortical structures and trigeminovascular system
Calcitonin gene related peptide a key transmitter
CGRP is known to be involved in the brain processes which cause pain during the attack.
how can a primary headache be managed?
Modifiable lifestyle triggers
especially important in migraine
Abortive treatment
Transitional treatment
more important in cluster headache
Preventative treatment
are all secondary headaches sinister?
no
0.18% of patients with stable migraine
13-18% of patients presenting to A+E with headache
how may a secondary headache present?
Headache occurring for the first time in close temporal relation to another disorder known to cause headache
Pre-existing primary headache becoming significantly worse in close temporal relationship another disorder known to cause headache
what is the definition of a secondary headache?
Defined by headache in the context of a condition known to cause headache
what specific headache features may give clues to diagnosis of a secondary headache?
Thunderclap in SAH
Postural headache in low pressure headache
what would investigation of primary headache involve?
For most patients investigation is not required
MRI is more sensitive than CT, but is more likely to show incidental findings
what investigations are done for a secondary headache?
CT and CT angiogram in Subarachnoid Haemorrhage
what is a tension type headache?
Most frequent primary headache, but is NOT disabling and rarely presents to doctors
how would a tesnsion type headache be characterised?
Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity
what is the treatment for acute tension type headache?
Paracetamol, NSAIDs
what preventative treatment can be taken for tension type headaches?
Tricyclic Antidepressants (Amitriptyline)
what is the most frequent disabling primary headache?
migraine
what is a migraine?
neurologic chronic disorder with episodic manifestation (CDEM), characterized by recurrent and reversible attacks of pain and associated symptoms.1
Migraine is no longer thought to be caused by a primary vascular event.2 It involves integrated brain mechanisms among a number of central nervous system (CNS) structures (cortex, brainstem, trigeminal system, meninges) and has a complex pathophysiology. It is generally recognized that migraine arises from a primary brain dysfunction that leads to activation and sensitization of the trigeminal system.3
what symptoms are experienced during a migraine?
Headache
Nausea, photophobia, phonophobia
Functional disability
what is experience between migraine attacks?
Enduring predisposition to future attacks
Anticipatory anxiety
what are the different components which make up a migraine?
premonitory
aura
early headache
advanced headache
postdrome
what symptoms are experienced during a premonitory migraine?
mood changes
fatigue
cognitive changes
muscle pain
food craving
what symptoms are experienced during a aura migraine?
fully reversible
neurological
visual somatosensory
what symptoms are experienced during an early headache?
dull headache
nasal congestion
muscle pain
advanced headache
post-drome
describe the premonitory phase?
Seventy percent of patients suffering from migraine with or without aura experience premonitory symptoms.1
Premonitory symptoms are often seen as predictors of the headache attack. 1
Mood alterations, muscle pain, food cravings, cognitive changes, fluid retention, and yawning are common premonitory symptoms.1
Eighty-three percent of subjects with premonitory symptoms could predict over 50% of their attacks.1
describe the aura phase?
An aura involves focal, reversible neurologic symptoms that often precede the headache.1
Aura symptoms are believed to arise from an electrical disturbance called cortical spreading depression (CSD); it occurs in approximately was 15-32% of migraine attacks.1,2,3
Auras are not always followed by headache pain; such auras are called acephalgic migraine or migraine aura without headache
describe the early and advanced headache phase?
The headache phase is subdivided according to headache pain intensity into an early phase and an advanced phase.1
Early headache: mild pain without the associated symptoms of migraine1
Advanced headache: moderate to severe pain with the associated symptoms of nausea, photophobia, phonophobia, or disability; used to confirm a migraine diagnosis1
describe the postdrome phase?
Phase of migraine-associated symptoms beyond the resolution of the headache; often entails significant disability that can last for 1 or 2 days.1
how long does an aura last for?
15-60 minutes
who does aura affect?
33% of migraineurs
what is the aura phase often confused with?
Can be confused with transient ischaemic attack
Loss of function
Sudden onset
Symptoms all start at same time and can be localised to a specific vascular area
what is the definition of a chronic migraine?
Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months
what is a tranformed migraine (association with chronic migraine)?
migraine that begins to manifest in regular episodes of migraine attacks, and they typically begin to increase in frequency and may change characteristics. Headaches may become less severe, but they may start occurring nearly daily.
can medication use cause transformed migraines?
yes but transformation can occur with or without escalation in medication use
In patients with medication overuse, discontinuing the overused medication often (but not always) dramatically improves headache frequency
what is the definition of a medication overuse headache?
Headache present on ≥15 days / month which has developed or worsened whilst taking regular symptomatic medication
how frequent does use of triptans, ergots, opiods and combination analgesics for a medication use headache?
> 10 days / month
how frequent does use of simple analgesics for a medication use headache?
> 15 days per month
what else can a medication overuse headache be caused by?
Caffeine overuse: coffee, tea, cola, irn brew
how is a migraine managed?
Modifiable lifestyle triggers
Abortive treatment
Preventative treatment
what are some modifyable lifestyle triggers for migraine?
stress
hunger
sleep disturbance
dehydration
diet
environmental stimuli
changes in oestrogen levels in women
what are acute treatments for migraine?
Aspirin or NSAIDs
Triptans
what should acute treatment for migraine be limited to?
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
what are prophalactic treatments for migraine?
Propranolol, Candesartan
Anti-epileptics
Topiramate, Valproate (not childbearing women)
Tricyclic antidepressants
Amitriptyline, nortriptyline
Flunarizine
Botox
CGRP Monoclonal Antibodies
how is medication overuse headache treated?
Limit acute treatment to 2 days per week in patients with TTH and Migraine
Abrupt withdrawal of the overused symptomatic medication:
Headaches may become worse for 2-4 weeks (sometimes longer)
Need to wait for 2 months before know if effective or not
More likely to be effective for triptans, than opioids and combination painkillers
what are specific issues for pregnant women and headaches?
Migraine without aura gets better in pregnancy
Migraine with aura usually does not change
First migraine can occur during pregnancy
Particularly migraine with aura
what is contra-indicated in active migraine?
The combined OCP is contraindicated in active migraine with aura
ok if no attacks for > 5 years, but stop if aura recurrs
when should anti-epileptics be avoided?
in women of child bearing age
If have to use counsel about teratogenicity and ensure adequate contraception
what is acute treatment for migraines in pregnant women?
Acute attack: Paracetamol, NSAID (1st two trimesters), Triptans
Preventative: Propranolol or Amitriptyline
what is preventative treatment for migraines in pregnant women?
Preventative: Propranolol or Amitriptyline
what must actively be exluded in new daily persisten headache?
Spontaneous Intracranial Hypertension
Raised intracranial pressure, etc
Covered in secondary headache section
what is neuralgia?
An intense burning or stabbing pain
The pain is usually brief but may be severe.
Pain extends along the course of the affected nerve.
Usually caused by irritation of or damage to a nerve
what are cranial neuralgia caused by?
irritation of nerves that mediate sensation in the head:
Trigeminal
Glossopharyngeal and Vagus
Nervus intermedius
Occipital
what pain does trigeminal neuralgia cause?
Unilateral maxillary or mandibular division pain > ophthalmic division
Triggered and spontaneous stabbing (lancinating) pain
how long does each triggered and spontaneous stabbing (lancinating) pain last in trigeminal neuralgia?
5 - 10 seconds duration
what are cutaneous triggers for trigeminal neuralgia?
Wind, cold
Touch
Chewing
what is a common cause of trigemial neuralgia?
Vascular compression of the
trigeminal nerve
what are uncommon causes of trigeminal neuralgia?
Multiple sclerosis
Intracranial arteriovenous malformation
Intracranial tumour
Brainstem lesions
how is trigeminal neuralgia medically treated?
Carbamazepine
Oxcarbazepine
Lamotrigine
Pregabalin / Gabapentin / Lacosamide
Phenytoin can be useful for severe exacerbations
how is trigeminal neuralgia surgically treated?
Glycerol ganglion injection
Stereotactic radiosurgery
Microvascular decompression
where is the pain located in a cluster headache?
mainly orbital and temporal
Attacks are strictly unilateral
describe the onset and duration of a cluster headache?
Rapid onset (max within 9 mins in 86%)
Duration: 15 mins to 3 hours (majority 45-90 mins)
Rapid cessation of pain
how do patients present with a cluster headache?
Excruciatingly severe (“suicide headache”)
Patients are restless and agitated during an attack
Premonitory symptoms: tiredness, yawning
Associated symptoms: nausea, vomiting, photophobia, phonophobia
Typical aura (often under recognised)
are cluster headaches often episodic?
in 80-90%
Attacks “cluster” into bouts typically lasting 1-3 months with periods of remission lasting at least 1 month
Attack frequency: 1 every other day to 8 per day
May be continuous background pain between attacks
Alcohol triggers attacks during a bout, but not in remission
what is striking circadian rhythm?
attacks occur at the same time each day
bouts occur at the same time each year
what do 10-20% of cluster headache patients experience?
10-20% have chronic cluster
Bouts last >1 year without remission or
Remissions last <1 month
what is peak time for headache during circadian periodicity?
REM sleep
what are the treatment groups for cluster headache?
Abortive
Transitional
Abort cluster bout
Allow time for preventative treatments to take effect
Preventative
what are abortive treatments for cluster headaches?
Triptans
6mg s/c Sumatriptan treatment of choice
Safe to use up to 2x / day
No Medication Overuse Headache
Nasal Zolmatriptan alternative
Oral triptans not effective
Oxygen
10-15ltrs 100% Oxygen for 15-20 mins
May delay rather than abort attack
when is oxygen a good abortive treatment for cluster headaches?
Useful if >2 attacks per day or
contraindications to triptans
how often is it safe to use triptans?
twice a day
are oral triptans effective?
no
what are transtional treatments for cluster headache?
Oral prednisolone taper
1mg/kg up to 60mg daily for 1 week
Taper by 10mg every 2 days till stopped
Very effective, but headaches may recur
as prednisolone is tapered
Introduce preventative at same time
Greater Occipital Nerve block
Depomedrone (80mg) + Lidocaine (20mg)
Complete response in ~60%
Effect usually lasts 4-6 weeks
May completely abort cluster avoiding
need for preventative treatment or
allow time for preventative to take effect
what are preventatove treatments for cluster headache?
Verapamil - Greatest evidence base, 240-960mg /day
requires ECG monitoring
Lithium - Chronic Cluster Headache, 400mg – 2g /day
requires level monitoring (0.8-1mM)
Methysergide - Episodic Cluster Headache, 3-12mg / day
NO LONGER AVAILABLE Very effective, but short term only because of risk of retroperitoneal fibrosis
Topiramate - 50 – 800mg /day
Probably 2nd line after Verapamil for most patients
Gabapentin - 900 – 3600mg / day
Pregabalin - 100 – 600mg / day
Sodium Valproate - 600mg – 2g / day
Leveteracetam - 2 – 4g / day
Melatonin - 9 – 15mg / day
Usually used as an adjunct treatment
which preventative treatment is no longer available for cluster headaches?
Methysergide - Episodic Cluster Headache, 3-12mg / day
NO LONGER AVAILABLE Very effective, but short term only because of risk of retroperitoneal fibrosis
what are different types of trigeminal autonomic cephalagias?
Cluster Headache
Paroxysmal Hemicrania
SUNCT
Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing
SUNA
Short-lasting Unilateral Neuralgiform headache with Autonomic Symptoms
Hemicrania Continua
where are paroxysmal hemicranias mainly located?
mainly orbital and temporal
Attacks are strictly unilateral
describe the onset and duration of paroxysmal hemicrania?
Duration: 2-30 mins
Rapid cessation of pain
Excruciatingly severe
50% are restless and agitated during an attack
how will a patient with paroxysmal hemicrania present?
Prominent ipsilateral autonomic symptoms
Migrainous symptoms may be present
In 10% attacks may be precipitated by bending or rotating the head
Background continuous pain can be present
what does paroxysmal hemicrainia have an absolute response to?
indometacin
how is hemicrania continue described?
Strictly unilateral continuous headache
Episodic (lasting weeks – months) or chronic (unremitting)
moderately-severe continuous background headache
superimposed exacerbations of more severe pain lasting 20 minutes to several days
where is the location of hemicrania continua?
orbital and temporal, but can involve any part of the head, including the face
where is SUNCT located and how is the pain described?
Unilateral orbital, supraorbital or temporal pain
Stabbing or pulsating pain
Pain is accompanied by conjunctival injection and lacrimation
how long does SUNCT/ SUNA last?
10-240 seconds duration
attack frequency from 3-200/day, no refractory period
what are cutaneous triggers for SUNCT/SUNA?
Wind , cold
Touch
Chewing
what is the medical treatment for SUNCT/SUNA?
Lamotrigine
Topiramate
Oxcarbazepine
Carbamazepine
Duloxetine
Pregabalin / Gabapentin
what is transitional treatment for SUNCT/SUNA?
GON block
what is surgical treatment for SUNCT/SUNA?
Occipital Nerve Stimulation
Deep Brain Stimulation
What features predict sinister headache?
Head injury
First or worst
Sudden (thunderclap) onset
New daily persistent headache
Change in headache pattern or type
Returning patient
Are there features (red flags) that should make us consider secondary headache?
new onset headache
new or change in headache
aged over 50
Immunosupression or cancer
change in headache frequency, characteristics or associated symptoms
focal neurological symptoms
non-focal neurological symptoms
abnormal neurological examination
neck stiffness / fever
high pressure
headache worse lying down
headache wakening the patient up
headache precipitated by physical exertion
headache precipitated by valsalva manoeuvre
low pressure
headache precipitated by sitting / standing up
GCA
jaw claudication
prominent or beaded temporal arteries
what is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than 1 minute
Majority peak instantaneously
Whole head (worst occipitally)
what must be excluded with a thunderclap headache?
MUST exclude Subarachnoid Haemorrhage
what are differential diagnosis for a thunderclap headache?
Primary (migraine, primary thunderclap headache, primary exertional headache, primary headache associated with sexual activity)
Subarachnoid haemorrhage
Intracerebral haemorrhage
TIA / stroke
Carotid / vertebral dissection
Cerebral venous sinus thrombosis
Meningitis / encephalitis
Pituitary apoplexy
Spontaneous intracranial hypotension
what is a subarachnoid haemorrhage?
Aneurysmal rupture and bleeding into subarachnoid space
what is the incidence and prognosis of a subarachnoid haemorrhage?
rupture 6-12/100,000/year
30% die within 24 hrs (15% before hospital)
Further 30% die within first 2 months
25% 2 yr survival (conservative management)
what is the risk of rebleeding with a subarachnoid haemorrhage?
6% in first 24 hours
30% in first 1/12
Risk falls to 3.5% per year after that
Those that re-bleed have a 70% mortality
what are complications of a subarachnoid haemorrhage?
Vasospasm (from day 4-5)
Hydrocephalus (blood in ventricular system)
Seizure
Infection
Re-bleeding
what investigations are done for a subarachnoid haemorrage?
CT Head as soon as possible
LP > 12 hours after headache onset
CT angiogram if SAH confirmed
what is the treatment for a subarachnoid haemorrhage?
Early treatment of aneurysm
Coiling of aneurysms
Clipping of aneurysms
Nimodipine
(Ca2+ channel blocker for vasospasm)
Treat complications
‘HHH’ therapy
Hydration
Hyperoxia
Hypertension
what should be considered in any patient presenting with a headache and fever?
CNS infection
what symptoms present with meningism?
nausea +/- vomiting, photo/phono phobia, stiff neck
what symptoms present with encephalitis?
altered mental state / consciousness, focal symptoms / signs, seizures
what may raise intracranial ressure?
Space Occupying Lesion
eg Tumour
Brain swelling
eg Infection
Raised CSF pressure
Hydrocephalus
Intracranial Hypertension
what are symptoms of a high pressure headache?
Headache wakens patient up
Cough or other valsalva headache
Visual obscurations / pulsatile tinnitus
Seizures
Progressive focal symptoms
Cognitive change / drowsiness
Headache associated with loss of consiousness
Consider 3rd ventricular colloid cyst in patient with headache and loss of consciousness
what are signs of a high pressure headache?
Papilloedema
New abnormal neurological examination
how does intrancranial hypertension clinically present?
Progressive episodic or persistent headache
Visual obscuration’s and / or pulsatile tinitus
Papilloedema, often with enlarged blind spot
what is a differential diagnosis for intracranial hypertension?
Idiopathic intracranial hypertension
Drug induced (tetracycline, retinoids)
Pregnancy induced
Cerebral Venous Sinus Thrombosis
Meningitis: infective, inflammatory, malignant
After SAH due to poor CSF drainage
what causes intracranial hypotension?
spontaneous or post lumbar puncture
what type of headache is associated with intrancranial hypotension?
postural headache
Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down
Due to “brain sink”
what MRI features are characteristic of intracranial hypotension?
Venous engorgement
Subdural hygromas
what is treatment of intrecranial hypotension?
Bed rest, fluids, analgesia, caffeine (e.g. 1 can red bull qds)
i.v. caffeine
Epidural blood patch
what is giant cell arteritis?
Inflammation (arteritis) of large arteries
how would a patient with giant cell arteritis present?
Headache is non-specific
Specific features include scalp
tenderness, jaw claudication and visual disturbance
Prominent, beaded or enlarged temporal arteries may be present
The patient may be systemically unwell
what findings would be supportive of a diagnosis of giant cell arteritis?
Should be considered in any patient over the age of 50 years presenting with new headache
An elevated ESR (blood test) supports the diagnosis
(usually >50, often much higher, rarely normal)
Raised CRP and platelet count are other useful markers
how is giant cell arteritis treated?
Treatment is with high dose prednisolone
If GCA is considered prednisolone should be started immediately and a temporal artery biopsy arranged
