Headache Flashcards
What is a primary headache and secondary headache
Primary: Headache with no underlying medical cause (90% of headaches)
Secondary: identifiable structural or biochemical cause
What are types of primary headache (3)
Tension type headache
Migraine (most common)
Cluster headache
What are causes of secondary headaches (4)
Tumour
Meningitis
Sub-arachnoid haemorrhage
Medication overuse headache (migraine)
What is the management of primary headache (4)
Modifiable lifestyle triggers (e.g. sleep, dehydration, stress - important in migraine)
Abortive treatment (stopping headache that’s already started)
Transitional treatment (important in cluster headache - series of headaches over months)
Preventative treatment (reduce amount of triggers)
What is the aim preventative treatment
To reduce the threshold (sensitivity) for developing headache e.g. if only have 1 trigger to develop a headache going to have more headaches than if you have 3 triggers
Give examples of how the features of secondary headaches indicate what the diagnosis is (thunderclap + postural)
Thunderclap headache associated with subarachnoid haemorrhage
Postural headache in low pressure headache (headache when upright which resolves when lying flat)
What is the investigation of primary headaches
For most patients investigation not required…
Look for an underlying secondary cause triggering the primary headache
MRI more sensitive than CT but more likely to show incidental findings (complicates management and lead to further unnecessary investigation)
What is the investigation in secondary headaches
Specific investigations can help confirm diagnosis and guide treatment (e.g. CT and CT angiogram in SAH)
What is a tension-type headache
Most frequent primary headache
Mild, bilateral headache which is often pressing or tightening in quality - no associated features and not aggravated by physical activity
Not disabling and rarely presents to doctors
What is the treatment for tension-type headaches (acute and preventative)
Acute: paracetamol, NSAIDs
Preventative: tricyclic antidepressants (amitriptyline)
What is a migraine
Most frequent disabling primary headache
Chronic disorder with episodic attacks, leads to complex changes in the brain
What are the symptoms during a migraine attack (4)
Headache
Nausea
Photophobia
Functional disability (more you move around the worse it gets - desire to lie down in a dark room)
What are the symptoms in-between migraine attacks (1)
Enduring pre-disposition to future attacks —> anticipatory anxiety
What are the criteria for chronic migraines
Headache on more than 15 days per month, of which more than 8 days have to be a migraine for more than 3 months
How do migraines lead to medication overuse migraines
Associated with the anticipatory anxiety
Think headache is gonna start so take medication for it —> desensitisation of the system leading to medication overuse headaches
How are medication overuse headaches treated (2 strategies)
Preventative: Limit acute treatment to 2 days per week
Abrupt withdrawal: headaches may become worse for 2-4weeks, need to wait for 2 months to determine whether treatment was successful or not
What is the management strategy for migraines (3)
Consider:
Modifiable lifestyle triggers
Abortive treatment
Preventative treatment
What is the acute treatment for migraines (2)
Aspirin or NSAIDs
Triptans (specific for migraines)
(Limit this to 10 days per month to avoid development of medication overuse headache)
What is the aim of prophylactic treatment for migraines (what are the options (3))
Preventative treatment to reduce incidence
Propanalol
Anti-epileptics (valproate)
Botox
What presentations of a headache are more likely to have a sinister cause (6)
Head injury (bleed)
First or worst
Sudden (thunderclap) onset
New daily persistent headache
Change in headache pattern or type
Returning patient
Red flag features that should make you consider secondary headache (6)
New onset
Change in frequency and associated symptoms
Neck stiffness/fever (meningitis)
High pressure (e.g. worse lying down, wakening patient up, precipitated by physical exertion)
Low pressure
GCA (jaw claudication, prominent or beaded temporal arteries)
What are the features of a thunderclap headache
High intensity headache reaching maximum intensity in less than 1 minute
Affects the whole head (worst occipitally)
(MUST exclude SAH)
What is a SAH
Subarachnoid haemorrhage
Aneurysmal rupture and bleeding into subarachnoid space
What are the complication of SAH (5)
Vasospasm
Hydrocephalus (blood in ventricular system)
Seizure
Infection
Re-bleeding
What is the investigation for SAH
CT head ASAP
LP > 12hrs after headache onset
CT angiogram if SAH confirmed
What is the treatment for SAH (4)
Early treatment of aneurysm (coiling of aneurysm = very effective)
Nimodipine (reduce vasospasm)
Treat complications
HHH therapy (hydration, hyperoxia, hypertension)
When would meningitis and encephalitis be considered?
Any patient presenting with headache and fever
What are the symptoms of meningitis (3)
Nausea +/- vomiting
photo/phono phobia
stiff neck
what are the symptoms of encephalitis (3)
Altered mental state/consciousness
Focal symptoms/signs
Seizures
