Headache Flashcards
What does a headache with scalp tenderness indicate?
Giant cell arteritis
What does a headache that is abrupt and sudden onset indicate?
Subarachnoid haemorrhage
What does a headache with changes in vision (+/- papilloedema) indicate?
Glaucoma
What does a headache that wakes you up at night indicate?
Raised ICP
What does a headache that is worse in the morning/lying down indicate?
Raised ICP
What does a headache with fever, neck stiffness, photophobia indicate?
Meningitis
What does a headache with focal neurological signs (numbness, tingling, weakness, drowsiness) indicate?
Raised ICP
What does a headache with nausea, vomiting indicate?
Raised ICP
What features of a headache would indicate raised ICP?
Wakes you up at night
Worse in the morning/when lying down
Focal neurological signs (numbness, tingling, weakness, drowsiness)
Nausea, vomiting
Who are more likely to get migraines?
Females
Teens to early 20s
Obesity
What proportion of migraines occur with and without aura?
With aura - 20%
Without aura - 80%
What are triggers for migraines?
Travel Exercise Stress/anxiety Hormonal changes (pre-menstrual period) Food (chocolate, cheese, caffeine, alcohol) May not be one
What is the prodrome phase of a migraine?
Early signs that indicate the onset of a migraine that can precede the headache by hours to days
What are examples of symptoms that can occur in the prodrome phase of a migraine?
Yawning
Food cravings
Changes in sleep, appetite and mood
What is the aura phase of a migraine?
Stereotyped focal neurological symptoms in a migraine that precede the headache by minutes to an hour
What are examples of symptoms that can occur in the aura phase of a migraine?
Visual: flashes, distortion, hemianopia
Somatosensory: paraesthesia
Motor: weakness, ataxia, dysarthria
What are the features of the headache in a migraine?
Unilateral Throbbing and pulsating Lasts 4-72 hours Made worse by movement Associated with at least 2 of: photophobia, phonophobia, or osmophobia (aversion to odours)
What features make a diagnosis of migraine without aura?
Unilateral pushing headache
Made worse by movement
Associated with photophobia, phonophobia and nausea/vomiting
What are the 3 strategies of management of migraines?
Acute relief
Prophylaxis
Lifestyle
What is the management for acute relief of migraines?
1st - NSAIDs (aspirin, naproxen, ibuprofen) + paracetamol
2nd - higher dose of aspirin or triptan (sumatriptan/rizatriptin)
What is the problem with triptans, and what is the guidance to prevent this?
Can cause dependency and rebound headaches
Shouldn’t be taken more than twice a week
What can be done for prophylaxis of migraines?
Avoid triggers
Medication if >3 attacks per months that are associated with considerable disability
Options: propranolol, amitriptyline, topiramate, gabapentin, valproate
What lifestyle measures can be taken to avoid migraines?
Diet - avoid triggers, keep healthy and balanced
Hydration - lots of water, avoid caffeine
Decrease stress
Regular exercise
What are examples of triggers for tension headaches?
Stress
Tiredness
Noise
Excessive concentration or staring at screen for too long
What is the presentation of tension headaches?
Either episodic or chronic
Bilateral pressure or tightness in the head
Mild to moderate in severity
Lasts between 30 mins and a week
What features are absent in tension headaches?
Nausea, vomiting
Photophobia, phonophobia
Not made worse by movement or activity
What is the management for tension headaches?
Acute - paracetamol/NSAIDs
Antidepressants - dothiepin or amitriptyline
What is the management for chronic tension headaches?
Discourage regular analgesia (not more than 3 times a week)
Relaxation therapies
What are cluster headaches?
Clusters of headaches where multiple attacks happen most days over a 1-3 month period
How many attacks need to have occurred for a diagnosis of cluster headaches to be made?
At least 5
What is the presentation of cluster headaches?
Commonly at night
Severe
Unilateral - always on the same side of the head
Around the orbit, supraorbital or temporal areas
Last 30 mins to 3 hours
Associated ipsilateral autonomic symptoms
Associated restlessness, agitation and relief is sought by wandering
What are the ipsilateral autonomic symptoms associated with cluster headaches
Lacrimation
Miosis and ptosis
Conjunctival injection and swelling
Facial flushing and rhinorrhoea
What is the management of acute attacks of cluster headaches?
1st - high flow oxygen
2nd - triptan
Prednisolone can be given to try to minimise the cluster and should be started along with a prophylaxis
What is the prophylactic management of cluster headaches?
1st - verapamil
2nd - topiramate
Others are gabapentin, pregabalin, lithium, valproate
What are the primary headache disorders?
Migraine
Tension
Cluster
Paroxysmal Hemicrania / Hemicrania Continua
Short Lasting Uniform Neuralgiform Headache
Post Coital
Idiopathic Intracranial Hypertension
What are causes of secondary headaches?
Meningitis GCA Sinusitis Acute glaucoma Medication overuse (opiates, triptans, paracetamol, benzodiazepines)
What are paroxysmal hemicrania and hemicrania continua?
Primary headache disorders that have similar types of headache and associated autonomic features as cluster headaches
But do not occur in clusters, and they are paroxysmal - lasting 2-30 mins, 5 headaches per day experienced
Continua - present for 3 months with attacks of greater intensity
Show definite response to indomethacin
What are short-lasting uniform neuralgiform headaches?
Unilateral stabbing type headaches similar to cluster headaches
Attacks last seconds - 10 mins, numerous (50-60) attacks can be experienced in a single day
What is a SUNCT?
Short-lasting Uniform Neuralgiform headache with Conjunctival injection and Tearing
What is a SUNA?
Short-lasting Uniform Neuralgiform headache with cranial nerve Autonomic symptoms
What is a post-coital headache?
One that builds during sexual excitement and is associated with a burst of intensity just before or during orgasm
Who gets idiopathic intracranial hypertension?
Females
Obesity
What are red flags for idiopathic intracranial hypertension?
Headache with diurnal variation and morning nausea and vomiting
Visual loss - blurred visual disc with haemorrhages
What is idiopathic intracranial hypertension?
Unexplained raised ICP causing symptoms
What investigations are done for idiopathic intracranial hypertension?
MRI brain - normal
CSF - elevated pressure
Visual fields
Fundoscopy - flattened optic disc
What is the treatment for idiopathic intracranial hypertension?
Weight loss
Acetazolamide
Ventricular atrial/lumbar peritoneal shunt
Monitor visual fields and CSF pressure
What are symptoms of secondary headache caused by GCA?
Scalp tenderness
Jaw claudication
Absent temporal pulses
What are symptoms of secondary headache caused by sinusitis?
Facial fullness or pain
Worse on bending over
Associated with URTI and postnasal drip
What are symptoms of secondary headache caused by acute glaucoma?
Older patients with severe pain around the eye
Nausea, vomiting
Reduced visual acuity and visual halos
What are symptoms of secondary headache caused by medication overuse?
Similar to tension headache
Typical history - someone experiencing episodic headaches so began regularly using analgesics and headache has now become chronic
What drugs can cause headache in overuse?
Opiates
Triptans
Paracetamol
Benzodiazepines
What are causes of facial pain?
Trigeminal neuralgia
TMJ dysfunction
What is trigeminal neuralgia?
Facial pain due to blood dilation and compression of the trigeminal nerve as it leaves the cranium
What is the presentation of trigeminal neuralgia?
Sudden onset unilateral intense, stabbing pain in the distribution of the trigeminal nerve
Attacks tend to last seconds to minutes
Can be caused by triggers
What are triggers for trigeminal neuralgia?
Washing
Shaving
Eating
Talking
What is the management of trigeminal neuralgia?
1st - anticonvulsants (carbamazepine, oxcarbazepine, lamotrigine)
2nd - surgical intervention
Who are more commonly affected by the causes of facial pain?
Trigeminal neuralgia - men
TMJ dysfunction - women 20-40
What is the presentation of TMJ dysfunction?
Cyclical or constant facial pain upon using the jaw
Noise from and abnormal movements of the TMJ
Tenderness over the muscles of mastication
What is the management of TMJ dysfunction?
Rest
Physiotherapy
NSAIDs if it continues after period of rest
