Headache Flashcards
What are the types of headaches?
Primary- No underlying medical cause
Secondary- identifiable cause
What are examples of primary headaches?
- Tension type headache
- Migraine
- Cluster headache
What are examples of secondary headaches?
- Tumour
- Meningitis
- Vascular disorders
- Systemic infection
- Head injury
- Drug induced
What is the treatment basis for primary headache?
Modify lifestyle
Abortive treatment
Transitional treatment
Preventative treatment
What is tension type headache?
Most frequent primary headache
Not disabling
What is the treatment of tension type headache?
Acute: paracetamol, NSAIDs
Prevention: Tricyclic antidepressant
What does a rapid onset headache suggest?
SAH
Meningitis
Encephalitis
What does gradual onset headache suggest?
Venous sinus thrombosis
Sinusitis
Tropical illness
Intracranial hypotension
What is migraine?
Most frequent DISABLING primary headache
What are the symptoms of migraine?
- Headache
- Nausea
- Photophobia (light)
- Phonophobia (sound)
- Functional disability
What are the features of migraine?
- Premonitory
- Aura
- Early headache
- Advanced headache
- Postdrome
What is aura?
Transient neurological symptoms resulting from cortical or brainstem dysfunction
- Visual
- Somatosensory
- Motor
- Speech
What are the features of visual aura?
Chaotic distorting
Jumbling of lines
Hemianopia
What are the features of somatosensory aura?
Paraesthesia
What are the features of motor aura?
Dysarthria
Ataxia
Ophthalmoplegia
Hemiparesis
What are the causes of migraine?
CHOCOLATE
C- hocolate
H- angovers
O- rgasms
C- heese/caffeine
O- ral contraceptives
L- ie-ins
A- lcohol
T- ravel
E- xercise
What is the lifestyle treatment for migraine?
- Stress
- Hunger
- Sleep disturbance
- Dehydration
- Diet
- Environmental stimuli
- Changes in oestrogen levels in women
What is the acute treatment for migraine?
Oral triptan + paracetamol or NSAID (aspirin)
Anti emetics
What is the prophylactic treatment of migraine?
- Propranolol, Candersartan
- Anti-epileptics
- Tricyclic antidepressants
- Flunarizine
- Botox
- CGRP monoclonal antibodies
What is MOH?
Headache present on >15 days/month which has developed or worsened whist taking regular symptom meds
Can occur in any primary headache
What are the common culprits in MOH?
Mixed analgesics: paracetamol + codeine/opiates
Ergotamine
Triptans
What is cranial neuralgia?
Secondary headache caused by irritation of the nerves that mediate sensation in the head:
Intense burning or stabbing pain
What is the most common type of cranial neuralgia?
Trigeminal neuralgia
Unilateral pain in maxillary or mandibular division
What is the common cause of trigeminal neuralgia?
Vascular compression of the trigeminal nerve
What is the medical treatment of trigeminal neuralgia?
- Carbamazepine
- Oxcarbazepine
- Lamotrigine
What is the surgical treatment of trigeminal neuralgia?
- Glycerol ganglion injection
- Stereotactic radiosurgery
- Microvascular decompression
What are Trigeminal Autonomic Cephalalgias (TACs)?
Primary headaches characterized by severe unilateral head pain, typically trigeminal distribution, with ipsilateral cranial autonomic symptoms
What are the types of TACs?
Cluster headache
Paroxysmal Hemicrania/ Hemicrania continua
SUNCT/SUNA
What is SUNCT?
Short lasting unilateral neuralgiform headache with Conjunctival injection and Tearing
What is SUNA?
Short lasting Unilateral Neuralgiform headache with Autonomic Symptoms
What are the main characteristics of TACs?
Strictly unilateral pain
Predominantly V1
Excruciating pain
Cranial autonomic symptoms
- Conjunctival lacrimation
- Nasal congestion
- Eyelid oedema
- Forehead and facial swelling
- Miosis/ptosis (Horner’s)
Restless
What is the attack frequency and duration of cluster headache?
1-8 daily
15-180 mins
What is the attack frequency and duration of paroxysmal hemicrania?
1-40 daily
2-30 mins
What is the attack frequency and duration of SUNCT?
3-200
5-240 secs
Where is the pain in cluster headache?
Orbital and temporal
Where is the pain in Hemicrania?
Orbital and temporal
Where is the pain in SUNCT/SUNA?
Orbital
Supraorbital
Temporal
What is the treatment for cluster headaches?
Abortive: s/c triptans, oxygen
Transitional: oral prednisolone taper, greater occipital block
Preventative: verapamil, lithium, melatonin
What is the treatment of Hemicrania?
Absolute response to indomethacin (NSAID)
What is the treatment of SUNCT/SUNA?
Abortive: lamotrigine, carbamazepine
Transitional: GO block
Surgical: occipital nerve stimulation
What are examples of sinister secondary headaches?
- Head injury
- First or worst
- Sudden thunderclap onset
- New daily persistent headache
- Change in headache pattern or type
- Returning patient
What are specific secondary headache patterns?
Thunderclap (SAH)
Meningitis and encephalitis
High pressure
Low pressure
Giant cell arteritis
What is thunderclap headache?
High intensity headache reaching maximum intensity in less than 1 minute
Aneurysmal rupture and bleeding into subarachnoid space
What is the treatment of subarachnoid haemorrhage?
Early treatment of aneurysm: coiling/clipping
Nimodipine- CCB for vasospasm
Treat complications
HHH therapy
- Hydration
- Hyperoxia
- Hypertension
What are the symptoms of meningitis headache?
Nausea
Vomiting
Photophobia
Phonophobia
Stiff neck
What are the symptoms of encephalitis headache?
Altered mental state/consciousness, Seizures
Look for a rash
What are the symptoms of high-pressure headache?
- Headache wakens patient up
- Cough or other Valsalva headache
- Visual obscuration’s, pulsatile tinnitus
- Seizures
- Progressive focal symptoms
- Cognitive changes
- Drowsiness
- Loss of consciousness
- Papilledema
What can cause high pressure headache?
Space occupying lesion e.g. tumour
Brain swelling e.g. infection
Raised CSF pressure e.g. hydrocephalus, intracranial HTN
What are the features of low- pressure headache?
Postural
Venous enlargement
Subdural hygromas
What is giant cell arteritis?
Inflammation of large arteries
What are the features of giant cell arteritis?
Non specific headache
Scalp tenderness
Jaw claudication
Visual disturbance
Prominent, beaded or enlarged temporal arteries
Patient may be systemically unwell
Elevated ESR Raised CRP and platelet count
When should giant cell arteritis be considered?
In any patient >50 years presenting with new headache
What is the treatment of giant cell arteritis?
High dose prednisolone immediately
Temporal artery ultrasound and biopsy
What is the complication of untreated giant cell arteritis?
Complete loss of vision or stroke
