Headache Flashcards
IIH
a) Presentation
b) Drug-induced causes
c) Important differentials to rule out
d) Diagnosis
e) Management (if visual impairment absent vs present)
a) - Headache with raised ICP signs
- Visual sx - grey vision on bending down, transient visual loss on standing, increased blind spots, restriction of visual fields, bilateral papilloedema, later reduced VA
- Pulsatile tinnitus
- 6th nerve palsy
b) Nitrofurantoin, oral contraceptives, tetracyclines, steroids, retinoids
c) - Chronic VST - must do a CT/MR venogram
- Other SOL
d) - Must have high pressure features including bilateral papilloedema
- Should have normal neurological exam (though can have 6th nerve palsy)
- Rule out above causes with neuroimaging
- Lumbar puncture: opening pressure >25 cm H2O (with otherwise normal CSF findings)
e) If visual impairment present:
- Lumbar drain as temporising measure (if surgery >24h)
- Surgical decompression - VP shunt or optic nerve sheath fenestration
If no visual impairment:
- During diagnostic LP, may do therapeutic LP to high-normal pressure* (18-20 cm H2O) - remove 1 mL for every 1 cm H2O reduction desired
- If BMI >30, first line is Weight loss, low sodium diet, avoid excess water
- Avoid precipitating medications (e.g. tetracyclines, COCP**, retinoids, steroids)
- Meds: acetazolamide, thiazides, furosemide, topiramate
- If resistant to weight loss/medication/threat to vision: surgical decompression/CSF diversion
*This reduces risk of post-LP headache and need for blood patch
**COCP increases risk of IIH; however, given that the medications used to treat IIH are teratogenic, you should not stop COCP if they are sexually active
Reversible cerebral vasoconstriction syndrome (RCVS)
a) What is it?
b) Causes
c) Angiography appearance
d) Diagnostic score
e) Management
a) A cause of recurrent thunderclap headaches. Classically presents as multiple headaches over period of days-weeks, with absence of SAH or other causes on imaging
- May actually cause a non-aneurysmal SAH
b) Cocaine, stress, sex hormones, orgasm, pregnancy, exercise, migraine, vasoconstricting meds (e.g. triptans, SSRIs, BBs), trauma, brain surgery, phaeochromocytoma
c) The “string of beads” appearance on angiography, consisting of segmental vasodilations and vasoconstrictions
d) RCVS2
- Thunderclap headaches, intracranial carotid involvement, gender, vasoconstricting precipitant, SAH present
e) Supportive.
- Blood pressure control
- Seizure management
- Avoidance of precipitating factor
Suspected SAH
a) Who and when to LP?
b) Who should have a CTA?
c) Differentials for thunderclap headache
a) Who to LP:
- Presenting >6 hours* of headache onset with negative CT
When to LP:
- 12h after headache onset (can be positive for xanthochromia up to 2 weeks post-SAH)
*Sensitivity of CT within 6 hours is nearly 100%
b) Once CT or LP has confirmed SAH, perform CT angiography to determine site of aneurysmal bleed (for coiling/clipping)
If CTA is negative, perform MRA or DSA
c) - Thunderclap = Peak intensity within 5 mins
- Causes include: SAH, RCVS, migraine, cough, coitus and exertion
d) - WFNS (clinical)
- Fisher (radiological)
e) - BP control: Labetalol IV to keep systolic BP <180 if unprotected aneurysm, allow uncontrolled BP if protected
- Nimodipine to prevent vasospasm (delayed cerebral ischaemia) in first 21 days (peak period 3-14 days)
- Endovascular coiling/clipping
Cluster headache vs paroxysmal hemicrania
Presentation:
- Both have severe unilateral headache with autonomic features
- Cluster worse with alcohol and at night, more common in men
- Paroxysmal hemicrania have up to 50 attacks per day of shorter duration (2 - 25 mins), vs cluster headache which have 1-8 attacks per day lasting 15 mins to 3 hours
Management:
1. Paroxysmal hemicrania
- NSAIDs e.g indomethacin
2. Cluster headache
- Acute: high flow oxygen, intranasal/SC triptans (as oral triptans too slow in action)
- Prophylaxis: with high-dose verapamil 240-960mg daily (needs ECG monitoring with each dose increase). Alternatives include valproate, lithium or steroids.
- Generally, MRI brain used to rule out structural causes.
Migraine: clinical features
a) Diagnostic criteria - (i) without aura, (ii) with aura
b) Prodromal and postdromal symptoms
c) Common triggers
d) Episodic vs chronic migraine
e) Menstrual migraine
a) For both, headache must not be better accounted for by another diagnosis.
Migraine without aura - 5 attacks needed with:
1. Headache lasting 4–72 hours in adults or 2–72 hours in adolescents
2. Headache with at least two of the following characteristics:
- Unilateral location (more commonly bilateral in children).
- Pulsating quality — may be described as ‘throbbing’ or ‘banging’ in young people.
- Moderate or severe pain intensity.
- Aggravation by, or causing avoidance of, routine activities of daily life (for example walking or climbing stairs).
3. With at least one of the following associated symptoms:
- Nausea and/or vomiting.
- Photophobia (sensitivity to light) and phonophobia (sensitivity to sound).
Migraine with aura - 2 attacks needed with:
1. One or more typical fully reversible aura symptoms including:
- Visual symptoms such as zigzag lines and/or scotoma — visual aura is the most common type of aura.
- Sensory symptoms such as unilateral pins and needles or numbness.
- Speech and/or language symptoms such as dysphasia.
2. Plus at least three of the following:
- At least one aura symptom spreads gradually over at least 5 minutes.
- Two or more aura symptoms occur in succession.
- Each individual aura symptom lasts 5-60 minutes.
- At least one aura symptom is unilateral.
- At least one aura symptom is positive*.
- The aura is accompanied, or followed within 60 minutes, by headache
*Migraine/seizure symptoms tend to be ‘positive’ (e.g. flashing lights, spectra, paraesthesia, pain, jerking).
In contrast, TIA symptoms tend to be ‘negative’ (e.g. weakness, sensory loss, vision loss)
b) - Prodromal symptoms (such as fatigue, poor concentration, neck stiffness, and yawning) may occur hours or 1–2 days before onset of other symptoms of migraine.
- Postdromal symptoms (such as fatigue and elated or depressed mood) may occur after resolution of the headache and last up to 48 hours.
c) - Stress
- Poor sleep hygiene
- Dehydration, poor diet, caffeine, alcohol, certain foods
- Exercise
- Menstruation
d) - Episodic: headache occurs less than 15 days per month
- Chronic: headache occurs >15 days per month (with features of migraine headache on at least 8 days per month) for more than 3 months.
e) Migraine occurring predominantly between 2 days before and 3 days after the start of menstruation for at least 2 out of 3 consecutive menstrual cycles.
Migraine: management
a) Lifestyle factors
b) Acute episodes
c) Prophylaxis
d) Indications for admission/urgent referral
e) Management of status migrainosus
a) - Good sleep hygiene
- Good diet, avoid dehydration, avoid caffeine and alcohol
- Maintain healthy weight
- Stop all regular painkillers (advised headaches may become worse for 2-3 weeks before getting better)
b) - Choice of:
1. Aspirin 600mg + 10mg metoclopramide*/50mg cyclizine
2. Naproxen 500mg + antiemetic
3. Ibuprofen 400mg + antiemetic
4. Paracetamol 1g + antiemetic
- May wish to add/substitute a triptan to this
- Avoid opiates
- Avoid using acute treatment more than 2-3 times per week or more than 12 times per month to prevent MOH
*Beware extra-pyramidal symptoms. Should be given as max dose 10mg TDS for 5 days.
c) For patients with 2+ migraines per month*, choice of:
1. Propranolol 20mg OD, titrated up by 40mg each week as needed to max dose 240mg daily (beware asthma/ hypotension/ bradycardia/ heart block)
2. Candesartan 2mg OD, titrated up 2-4mg each week to max dose 16mg daily (beware hypotension, renal dx)
- Trial of preventative for 3 months. If no effect on maximum tolerated dose (migraine frequency reduced by <50%), try new therapy
- Can also trial amitriptyline/nortriptyline, topiramate** or sodium valproate
- In females with purely menstrual migraine, can trial triptans only, taken around time of headaches starting for 2-3 days
- If <2 migraines per month, generally just use acute Rx
** Advise females on risk of foetal malformations, ensure contraceptive use (not COCP in migraine, especially with aura)
d) - Status migrainosus - migraine lasting >72h despite treatment
- Atypical features - e.g. motor weakness, balance issues
- Secondary headache features
e) If usual acute management fails, trial:
- IV fluids
- High flow oxygen
- IV magnesium sulphate
- Steroids
- Local anaesthetic/nerve blocks
Headache red flags: SNOOP 5 mnemonic
Systemic features - fever, weight loss, etc.
Neurological signs or symptoms
Onset - thunderclap, severe and sudden
Onset - age >50
Progressive/pattern change
Precipitated by cough/valsalva
Postural - worse on lying down/early morning/bending forward
Papilloedema
Pregnancy
Trigeminal neuralgia
a) Classic presentation
b) Red flags
c) Management
a) - Unilateral electric shock sensation in trigeminal nerve distribution, lasting seconds to 2 mins, with rapid offset
- Triggered by cold air, touching, shaving, talking, eating, etc.
- Most common >50 years old
b) - Age of onset <40 years old
- Sensory changes, CN palsies, deafness
- FHx MS
- Skin or oral lesions
- Bilateral pain, or only ophthalmic division
- Optic neuritis
- If any red flags present, consider structural lesion (e.g. posterior fossa tumour, cavernous sinus lesion), or MS. Need MR brain.
c) - Carbamazepine 1st line. Initiate therapy at 100 mg up to twice daily, and titrate in steps of 100–200 mg every 2 weeks, until pain has been relieved up to 1600mg max daily dose. MR preparations may have better SE profile
- If Chinese/Thai –> MUST check HLA-B1502 status before starting carbamazepine due to risk of SJS
- Note also - Carbamazepine has several contraindications and side effects (read these before prescribing). Do not prescribe in pregnancy
- If carbamazepine inadequate, refer to specialist - other anticonvulsants tried, then nerve blocks/Botox
Medication overuse headache (MOH)
a) diagnostic criteria
b) management
a) In someone with TTH or migraine headache with no red flags…
- Headache is present on 15 days or more each month.
- Symptomatic treatment has been overused regularly for more than 3
months.
- Overuse is considered to be occurring when ergotamine, triptans, opioids, or combined analgesic medications are taken on 10 days or more each month; simple analgesics are taken on 15 days or more each month; or any combination of ergotamine, triptans, or opioids is taken on 15 days or more each month without overuse of any single drug alone.
- Headache develops, or is markedly worsened, during medication overuse
b) - Withdrawal of all acute medication (abrupt if simple, tapered if opioid)
- Symptoms should worsen over a few days but resolve fully in 1-3 weeks if MOH is only cause, or improve if MOH is an aggravating factor
- If headache severe during withdrawal, can use NSAID/paracetamol for up to 2 days
- If headaches still present 4 weeks later, consider prophylaxis eg propranolol
