Headache Flashcards
Are most headaches primary or secondary?
Primary
What percentage of headaches are primary and secondary?
Primary - 90%
Secondary - 10%
What are primary headaches?
Ones with no underlying medical cause
What are secondary headaches?
Ones with an identifiable structural or biochemical cause
What are examples of causes of secondary headaches?
- Tumour
- Meningitis
- Vascular disorder
- Systemic infection
- Head injury
- Drug induced
What are examples of primary headaches?
- Tension type headache
- Migraine
- Trigeminal autonomic cephalalgias
- Cluster headache
- Paroxysmal hemicrania
- SUNCT
What is a migraine?
A migraine is a chronic disorder with episodic attacks where complex changes occur in the brain:
- During attacks
- Headaches
- Nausea, photophobia, phonophobia
- Functional disability
- In-between attacks
- Enduring predisposition to future attacks
- Anticipatory anxiety
What is the most frequent primary headache?
Tension type headache
What is a tension type headache?
Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity
What are the different kinds of tension type headache?
- Infrequent ETTH
- <1 day/month
- Frequent ETTH
- 1-14 days/month
- CTTH
- Equal to or more than 15 days/month
When is a tension type headache an infrequent ETTH?
<1day/month
When is a tension type headache a frequent ETTH?
1-14 days/month
When is a tension type headache a CTTH?
Equal to or more than 15 days/month
What is the treatment for tension type headache?
- Abortive treatment
- Aspirin or paracetamol
- NSAIDs
- Limit to 10 days per month (about 2 days per week) to avoid the development of medication overuse headache
- Preventative treatment
- Rarely required
- Tricyclic antidepressants
- Amitrptyline, dothiopin, nortriptyline
What is the most common disabling primary headache?
What changes occur in the between during a migraine attack?
- Headaches
- Nausea, photophobia, phonophobia
- Functional disability
What changes occur in the brain between migraine attacks?
- Enduring predisposition to future attacks
- Anticipatory anxiety
What are examples of migraine triggers?
- Stress
- Hunger
- Sleep disturbances
- Dehydration
- Diet
- Environmental stimuli
- Changes in oestrogen level in woman
How are migraines manifested clinically?
Migraine is manifested clinically as a constellation of symptoms that evolve through the various phases of a migraine attack, the clinical phases of a migraine:
What are the clinical phases of a migraine?
- Premonitory phase
- 70% of patients experience this
- Aura phase
- Involves focal, reversible neurologic symptoms that often precede the headache
- Believed to be due to electrical disturbances called cortical spreading depression (CSD)
- Occurs in 15-30% of migraine attacks
- May involve visual, sensory, motor or speech systems
- Duration is 15-60 minutes
- Slow evolution of symptoms
- Moves from area to the next, for example vision then sensory then speech
- Can be confused with transient ischaemic attack
- Loss of function
- Sudden onset
- Symptoms all start at the same time and can be localised to a specific vascular area
- Headache phase
- Subdivided according to headache pain intensity
- Early headache
- Advanced headache
- Subdivided according to headache pain intensity
- Postdrome
What is the aura phase of a migraine believed to be due to?
- Believed to be due to electrical disturbances called cortical spreading depression (CSD)
Why does the aura phase of a migraine have slow evolution of symptoms?
Moves from one area of the brain to the next
Why can the aura phase of a migraine be confused with a TIA?
- Loss of function
- Sudden onset
- Symptoms all start at the same time and can be localised to a specific vascular area
What can the headache phase of a migraine be divided into?
- Early headache
- Advanced headache
What is a chronic migraine?
Chronic migraine is a headache on 15 or more days per month, of which 8 or more days have to be migraine, for a total of more than 3 months:
What is a transformed migraine?
Migraine condition that initially began as episodic migraine attacks, which then increase in frequency over a period of month to years
What is the clinical presentation of transformed migraine?
- History of episodic migraine
- Increasing frequency of headaches over weeks/months/years
- Migranious symptoms become less frequent and less severe
- Can occur with or without escalation in medication use
What is a medication overuse headache?
- Headache present on 15 or more days/month which has developed or worsened whilst taking regular symptomatic medication
In what kinds of headaches can medication overuse headaches occur in?
- Can occur in any primary headache
- Migraineurs are particular prone to MOH
- Migraineurs taking pain medication for another reason can develop chronic headache
What are medication overuse headaches often caused by?
- Use of triptans, ergots, opiods and combination analgesics more than 10 days/month
- Use of simple analgesics more than 15 days per month
- Caffeine overuse
What is the treatment for migraine?
- Abortive treatment
- Aspirin or NSAIDs
- Triptans
- Limit to 10 days per month (about 2 per week) to avoid the development of medication overuse headache
- Prophylactic treatment
- Propranolol, candesartan
- Anti-epileptics
- Topiramate, valproate, gabapentin
- Tricyclic antidepressants
- Amitryptyline, dothiepin, nortriptyline
- Venlafaxine
What are some specific migraine issues in woman?
- Migraine without aura gets better in pregnancy
- Migraine with aura usually does not change
- First migraine can occur during pregnancy
- The combined OCP is contraindicated in active migraine with aura
- Avoid if anti-epileptics in woman of child bearing age
- Treatment is more difficult in pregnancy
- Acute attack is paracetamol
- Preventative is propranolol or amitriptyline
What is the acute attack and preventative medication for migraine in pregnant woman?
Acute attack - paracetamol
Preventative - propranolol or amitriptyline
What are different kinds of trigeminal autonomic cephalalgias?
Cluster headache
Paroxysmal hemicrania
SUNCT
SUNA
Trigeminal neuralgia
What can cluster headaches be seperated into?
- The attack
- Pain, mainly orbital and temporal
- Strictly unilateral
- Rapid onset
- Duration is 15 mins to 3 hours
- Rapid cessation of pain
- Excruciatingly severe (known as suicide headache)
- Migrainous symptoms often present
- Tiredness, yawning, nausea, vomiting, photophobia, phonophobia
- The bout
- Episodic in 80-90%
- Attacks cluster into bouts typically lasting 1 to 3 months with periods of remission lasting at least 1 month
- Attack frequency is 1 every other day to 8 per day
- May be continuous background pain between attacks
- Alcohol triggers attacks during a bout, but not in remission
- Striking circadian rhythmicity
- Attacks occur at the same time every day
- Bouts occur at the same time each year
- 10-20% have chronic cluster
- Bouts last >1 year without remission or remission lasts <1 month
- Episodic in 80-90%
What occurs during the attack of a cluster headache?
- Pain, mainly orbital and temporal
- Strictly unilateral
- Rapid onset
- Duration is 15 mins to 3 hours
- Rapid cessation of pain
- Excruciatingly severe (known as suicide headache)
- Migrainous symptoms often present
- Tiredness, yawning, nausea, vomiting, photophobia, phonophobia