Headache Flashcards
What are the primary headaches?
- Migraine
* Trigeminal autonomic cephalgias
What are the secondary headaches?
- Thunderclap - subarachnoid haemorrhage
- High pressure headaches - SOL
- Low pressure headache
- Neuralgias - vascular compression
Describe what you should ask when taking history of the presenting complaint of headache
•Personal history of migraine or tendency
•How many different headache types
•For each headache type:
- age of onset
- chronic headache, episodic, constant or new type of headache
- premonitory symptoms
- onset, time to peak
- progression
•impact, personal concerns, expectations
What should you ask about regarding past medical history of someone presenting with headache?
- Immunosuppression
- Cancer
- Foreign travel
- Cardiac, cerebrovascular, renal, hepatic, psychiatric, gastric disease
Which medication classically causes headache?
Nitrates
What should you ask about in a social history of someone presenting with headache?
- Sleep
- Meals
- Exercise
- Caffeine
- illicit drugs, alcohol
What examinations should you carry out in someone presenting with headache?
- Blood pressure, urine dipstick, pregnancy test, temperature, weight
- GCS and mental status examination
- Palpation of the skull, neck, greater occipital nerves, TMJ, temporal arteries, nuchal rigidity?]
- Eyes: acuity, visual fields, fund, papilloedema, presence or absence of horners/3rd/6th nerve palsy
- Facial sensation
- Autonomic features if during an attack
- Cranial nerves, routine neurological examination
- Skin exam
What investigations should you consider for a patient presenting with headache?
- Blood pressure
- ECG
- Urinalysis
- Bloods, ESR/CRP for temporal arteritis, UEs, thyroid function
- CT Brain/MRI brain
- Lumbar puncture
- CT angiogram
- CT venogram
When should you image someone?
- Systemic symptoms
- Secondary risk factors
- Seizure
- Neurological symptoms
- Onset
- Older than 50
- Progression (including a change in attack frequency, nature)
- Papilloedema
- Precipitated by cough, exertion, sleep or valsalva
- If you cannot diagnose a primary headache then image the
When should you lumbar puncture someone with headache?
- Change in nature of headache
- Systemic symptoms of signs
- Focal neurological deficit
What is the diagnostic criteria for tension type headache?
•At least 10 episodes of headache occurring on <1 day per month on average and:
•Lasting 30 minutes to 7 days
•And at least 2 of the following:
- Bilateral
- mild or moderate intensity
- Not aggravated by routine physical activity such as walking or climbing stairs
- pressing or tightening (non-pulsating) quality
•No vomiting and no more than one of photophobia or phonophobia
•Not better accounted for by another ICHD-3 diagnosis
What is the pathophysiology of migraine?
- Interaction between primary afferent nociceptive neurones, trigeminovascualr system, brainstem, thalamus, hypothalamus and cortex
- Calcitonin gene related peptide
Describe the ICHD-3 criteria for a diagnosis of migraine
•At least 5 attacks and:
•Attacks lasting 4-72 hours
•Headache must have two of the following:
- unilateral
- pulsating
- moderate or severe pain
- aggravation by or causing avoidance of routine physical activity
•During the attack at least one of:
- nausea and/or vomiting
- photophobia and phonophobia
•Not better accounted for by another ICHD-3 diagnosis
What should be determined in the diagnosis of migraine?
- high or low frequency?
- Episodic or chronic
- With or without aura
What are the phases of headache?
- Prodrome: hours or days before
- Aura: 5-60mins
- Headache 4-72 hours
- Postdrome 24-48 hours
Describe the prodromal phase of migriane
- Yawning
- Polyuria
- Depression/irritability/poor concentration
- Food cravings
- Sensitivity to light
- poor sleep
Describe the postdrome phase of migraine
- Depression
- Euphoria
- Poor concentration
- Fatigue
Describe the aura phase of migraine
- Can be visual (99%), sensory, language or motor related
- Evolves
- Fully reversible
What is the acute treatment of migraine?
- Avoid opiates, restrict acute medication to 2 days a week
- Simple analgesics: aspirin or ibuprofen
- Triptans: sumatriptan is first choice (gastrically absorbed so won’t work if vomiting)
- Add antiemetic if persistent vomiting: metoclopramide
- If no response then try other triptans or triptan and NSAID combination
What is the strategy for prophylactic therapy of migraines?
- Lifestyle advice and triggers
- Identify and treat medication overuse
- Prophylaxis if 4-5+ disabling headaches per month
- Use headache diaries
- For each medication determine efficacy at 3 months, if ineffective went medication and try another
What are the prophylaxis options for migraine you could try first?
- Propranolol (beta blocker) start at 20mg bd, target 80mg bd
- Topiramate (anti-epileptic) start at 15 or 25mg daily, target 50mg bd
- Amitriptyline (tricyclic anti-depressant) start at 10mg, target 50mg
- Candesartan (ARB) start at 4mg, target 16mg
- Flunarazine (selective calcium try blocker)
What are the second line prophylaxis options for migraine?
- Onabotulinumtoxin A for chronic migraine >/15 headache days per month, 8 of which are migraine days, MOH previously addressed, failed on at least 3 prophylactics
- CGRP inhibitors (monoclonal antibodies) once a month
What is the diagnostic criteria for cluster headaches?
•At least 5 attacks
•Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes
•Either or both of the following:
1. At least one of:
- conjunctival injection and/or lacrimation
- nasal congestion and/or rhinorrhoea
- eyelid oedema
- forehead and facial sweating or flushing
- sensation of fullness in the ear
- miosis and/or ptosis
2. a sense of restlessness or agitation
•Occurring with a frequency between one every other day and 8 per day
What is the classical presentation of trigeminal neuralgia?
- Sharp shooting pain
- Can be triggered by something e.g. chewing
- MRI shows distorted/compressed trigeminal nerve (superior cerebellar artery)
What is the typical history of someone with a raised pressure headache?
- Worse on lying flat, improved on sitting or standing up
- Worse in the morning
- Persistent nausea/vomiting
- Worse on valsalva
- Worse with physical exertion
- Transient visual obscurations with change in posture
What are the typical examination findings in someone with raised pressure headaches?
- Optic disc swelling - papilloedema
- Impaired visual acuity/colour vision
- Restricted visual fields
- 3rd nerve palsy
- 6th nerve palsy
- Focal neurological signs
What are the SIGN 107 guidelines for thunderclap headache?
- Treat as a medical emergency
- No contrast CT asap, preferably within 12 hours of onset
- If CT is normal, lumbar puncture (oxybilirubin)
In someone with a suspected thunderclap headache, with normal CT/lumbar puncture, what other investigations can you carry out?
- MRI
* MRI/CT venogram or angiogram
What are the causes of thunderclap headache?
- Subarachnoid haemorrhage approx 15%
- Intracerebral haemorrhage
- Arterial dissection
- Cerebral venous sinus thrombosis
- Ischaemic stroke
- Bacterial meningitis
- Spontaneous intracranial hypotension
- Pituitary apoplexy
