General Headaches Notes Flashcards
What are the classifications of headaches?
Primary headache - NO secondary underlying pathology
Secondary headache - there IS underlying cause
What are examples of primary headaches?
Tension headache
Migraine
Cluster headache
What are examples of secondary headaches?
Space occupying lesion
Intracranial hypertension
Vasculitis/arteritis (inflammation of blood vessels)
Signs not to miss on examination?
Papilloedema - raised ICP (need emergency imaging)
Peripheral field loss or enlarged blind spot - raised ICP
6th (abducens) nerve palsy
- Due to raised ICP (CN VI is stretched)
- Giant cell arteritis causing infarction of nerve
Extensor plantar - toes goes UP (not normal)
Ataxia - loss of controlled movement (potential lesion in posterior fossa affecting the cerebellum)
Oral hairy leukoplakia
Purpuric rash - Non-blanching/Meningococcal sepsis
Livedo reticularis - at risk of venous clot in sinuses of brain - leading to headaches
Investigations that can be done for a headache?
Typically done on patients who we know will likely have an abnormality
CT
MRI
CSF manometry - looking at pressure
Lumbar puncture - subarachnoid haemorrhage has xanthochromia in CSF
- CSF should NOT contain any polymorphs-nuclear cells e.g. neutrophils - evidence of bacterial infection e.g. meningitis
What are RED FLAGS for headaches?
Sudden ‘thunderclap’ onset = subarachnoid haemorrhage
Sudden neurological deficit
Seizure
Jaw claudication + tender temporal region + over 50 = Giant Cell Arteritis
Photophobia + neck stiffness + fever (+ petechial rash) = Meningitis
Loss of/reduced conscousness
History of trauma
Sudden red, painful eye
Suspected malignancy (SoL)
Worse on coughing or straining (raised intracranial pressure)
How does a tension-type headache present?
Bilateral
Pressing/tightening (non-pulsating) - pain
Mild or moderate
How long does tension-type headache last and how does it effect activities?
30 mins -> continuous
Not aggravated by routine activities of daily living (ADL)
NO - other symptoms
What is the difference between episodic and chronic tension-type headache?
Episodic - LESS than 15 days per month
Chronic - MORE than 15 days per month for more than 3 months
What is the treatment of tension-type headaches?
Acute treatment
- Aspirin, paracetamol, NSAIDs but NOT opioids
Prophylactic treatment
- 10 series of acupuncture over 5-8 weeks for chronic tension-type headache
How does migraine present?
Unilateral or bilateral
Pulsating/throbbing/banging
Moderate or severe
How long does migraine headache last and how does it effect activities?
4-72 hours in adults
1-72 hours in young people (12-17 years)
Aggravated by or causes avoidance of routine ADLs
What other symptoms can be caused due to migraine?
Unusual sensitivity to light and/or sound or nausea and/or vomiting
• Aura - symptoms can occur with/without headache and:
◦ Are fully reversible
◦ Develop over at least 5 minutes
◦ Last 5-60 minutes
• Typical aura symptoms include:
◦ Visual symptoms - flickering lights, spots or line and/or partial loss of vision
◦ Sensory symptoms - numbness and/or pins and needles
◦ Speech disturbances
What is the difference between episodic and chronic migraine (with/without aura) headache?
Episodic - LESS than 15 days per month
Chronic - MORE than 15 days per month for more than 3 months
What is the acute treatment of migraines?
Combination therapy: oral triptan (e.g. 50 mg sumatriptan) + NSAID/paracetamol
If ineffective/not-tolerated:
- Offer non-oral metoclopramide (anti-emetic) or prochlorperazine
- Consider non-oral triptan or NSAID
DO NOT GIVE opioids or ergots
What is the prophylactic treatment of migraines?
First line :
- Beta-blockers - propranolol (if unsuitable offer 10 acupuncture sessions)
- Low-dose amitriptyline
Second line: Topiramate (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant)
Riboflavin (vitamin B2) may reduce frequency and severity
What can trigger migraines?
Jet lag Cheese Menstruation Relaxing after stress Contraceptive pills Flickering lights on a TV screen
What time frame does menstrual-related migraine occur around?
2 days before and 3 days after start of menstruation - in at least 2 or 3 consecutive menstrual cycles
How is menstrual-related migraine treated?
Frovatriptan/zolmitriptan (2.5 mg twice daily) on days migraine is expected
How does a triptan work?
Triptans are used to abort migraines when they start to develop. They are 5HT receptors agonists (serotonin receptor agonists). They act on:
- Smooth muscle in arteries to cause vasoconstriction
- Peripheral pain receptors to inhibit activation of pain receptors
- Reduce neuronal activity in the central nervous system
How does a cluster headache present?
Unilateral (around eye, above eye and along side of head/face)
Quality - can be sharp, boring, burning, throbbing, tightening
Intensity - severe or very severe
How long does cluster headache last and how does it effect activities?
15-180 minutes
Effects on activities - restless or agitation
What other symptoms can be caused due to cluster headache?
On same side as headache:
- Red and/or watery eye
- Nasal congestion and/or runny nose
- Swollen eyelid
- Forehead and facial sweating
- Constricted pupil and/or drooping eyelid
What is the difference between episodic and cluster headache?
Episodic - 1 every other day to 8 per day, with remission more than 1 month
Chronic - 1 every other day to 8 per day with a continuous remission less than 1 month in a 12 month period
What is the acute treatment of cluster headache?
Triptans (e.g. sumatriptan 5mg injected subcutaneously)
High flow 100% oxygen for 15-20 minutes (can be given at home) - at least 12L/min via non-rebreathe mask
DO NOT give paracetamol, NSAID, opioids, or oral triptans
What is prophylactic treatment of cluster headache?
Verapamil 360mg (CCB) Corticosteroids - prednisolone (a short course for 2-3 weeks to break the cycle during clusters) Lithium
What may be the cause of rapid onset headaches?
Need to rule out: subarachnoid haemorrhage (SAH, sudden-onset, ‘worst ever’ headache
Other differentials: meningitis, encephalitis
What may cause gradual onset headaches?
Venous sinus thrombosis
Sinusitis
Intracranial hypotension
