Headache Flashcards
Migraine (with/without aura)
Recurrent disorder, Family history increases risk.
- Are UNI or BILATERAL
- Lasts 4 to 72 hours in adults
- Lasts 1 to 72 hours aged 12 to 17
- Moderate to severe pain
Signs and Symptoms:
Numbness/Pins and needles
Aura is mainly visual issues like: scotomata (dark patches), photophobia, scintillating scotomata, visual scintillations (zig zag lines).
Aetiology: Neurovascular theory: cerebral blood flow changes, inconsistent blood flow in the brain.
Migraines can become chronic by:
- Food triggers (sweets, chocolate, alcohol, caffeine, meat etc),
- Symptomatic drugs (barbiturates, NSAID, opiates).
COCP not advised for contraception for women with migraine with aura.
Suspect menstruation migraine if they have migraine 2 days b4 or 3 days after menstruation for 2 out of 3 consecutive cycles.
Treatment and prophylaxis:
Non pharmacological:
- Eat regular meals
- Maintain hydration
- Avoid triggers
Pharmacological:
- acute to be restricted to 2/7 - avoids medication overuse headache
Acute migraine
1st line acute migraine - Monotherapy aspirin, ibuprofen or Triptan (5HT agonist) (Sumatriptan 1st choice ALT almo, ele, frova, nara, riza, zolmi, Tolfenamic acid.
- Soluble aspirin/Paracetamol better
- If using triptan take at start of headache not start of aura.
- Can SC suma or nasal zolmi for early vomiting or severe migraine attacks.
- Severe N+V = suppository diclofenac is a option
- Mefenamic acid for menstrual migraine if already taking for dysmenorrhea or menorrhagia.
IF unable to take all above try paracetamol.
2ND LINE
- Monotherapy FAIL then give Sumatriptan + Naproxen
N+V:
- Metoclopramide/prochlorperazine can be tried as single dose Metoclopramide AVOID regular use - risk of EPS.
ALT domperidone
PREVENTION:
Propranolol - 1st line prevention
ALT
Metoprolol, atenolol, nadolol, timolol, bisoprolol.
- Topiramate IF beta blocker unsuitable. Topiramate take with contraception, risky for pregnancy.
EPISODIC OR CHRONIC prophylaxis= Amitriptyline ALT less sedative TCA. OR Candesartan (avoid in P/Child bearing age)
Sodium valproate for >55 OR
Flunarizine
ALT Botulinum toxin type A (specialist) where medication overuse been treated and 3 or more oral prophylactic failed.
Menstrual migraine prophylaxis =
Frovatriptan ALT zolmitriptan
- Given 2 days before and 3 days after menstruation
Cluster headache
Severe condition. Unilateral, retro or peri orbital, short lasting.
Signs and symptoms:
- Drooping eyelid,
- Redness of conjunctiva,
- Pupil constriction,
- Runny nose,
- Tear formation.
less common: facial blushing, swelling, sweating, stabbing, sharp pain
Last 5 min to 3 hours. can happen once every other day to 8 a day. Occur mainly in sleep or early morning. Can go to cheek and jaw.
Increase risk of suicide, alcohol use, smoking, peptic ulcer disease.
Trigger: Alcoholic products and tobacco, hot weather, extreme temperatures, watching television, GTN, stress or relaxation, glare, allergic rhinitis and sexual activity.
Episodic - 7 day to 1 year pain free intervals of 2 weeks
Chronic - >1 year with/without remission of <2weeks.
Can get chronic from episodic/onset
Treatment:
SC injection Sumatriptan FAIL then nasal spray of suma or zolmi
ALT oxygen 100% at 10 to 15 L/min for 10 to 20 min.
Prophylaxis:
Only if attacks are frequent and last >3weeks or they cant be treated. Verapamil or lithium.
Prednisolone short term episodic either monotherapy or + verapamil.
Tension headache
Chronic reoccurring, Bilateral,
Can be acute or chronic.
Acute - come by stress its moderate intensity, self limiting or OTC analgesics
Chronic - Recurs daily, comes from contracted muscles of neck and scalp, bilateral)
Mild or moderate pain
Categories:
- Infrequent episodic - <1day of headache/month
- Frequent episodic - at least 10 eps of headache occurring on <15 days/month on average for +3 months
- Chronic- >15 days of headache/month for 3+ months in absence of medication overuse
Triggers:
Stress (physical or psychological), contraction of neck and poor posture.
Treatment:
NON pharmacological:
- hot or cold packs,
- ultrasound,
- TENS,
- improvement of posture,
- trigger point injections,
- occipital nerve blocks,
- stretching and relaxation techniques
PHARMACOLOGICAL:
- OTC for episodic,
- Amitriptyline (TCA) for prophylaxis, - Frequent eps = acupuncture.
Medication overuse headache
Stop taking overused acute headache medications for 1 month. STOP ABRUPTLY. Short term symptoms get worse but long term better.
RED FLAGS/ medical emergencies
RED FLAGS:
* Fever, photophobia or neck stiffness (meningitis, encephalitis or brain abscess)
* New neurological symptoms (haemorrhage or tumours)
* Visual disturbance (giant cell arteritis, glaucoma or tumours)
* Sudden-onset occipital headache (subarachnoid haemorrhage)
* Worse on coughing or straining (raised intracranial pressure)
* Postural, worse on standing, lying or bending over (raised intracranial pressure)
* Vomiting (raised intracranial pressure or carbon monoxide poisoning)
* History of trauma (intracranial haemorrhage)
* History of cancer (brain metastasis)
* Pregnancy (pre-eclampsia)
Temporal arteritis: Inflamed arteries. Biopsy to diagnose. Treatment with rapid corticosteroid.
Trigeminal neuralgia: Facial pain syndrome, recurrent and chronic.
Unilateral pain on the nerve. Facial spasm,
Triggered by chewing, or touching affected area of face
Treatment:
1st line Carbamazepine
Surgery can be done too. surgery will decompress/intentionally damage the nerve.
Drugs extra info PRSC
5HT 3 agonists
- Triptans. Can help induce serotonin syndrome. Used in migraines, Suma/Zolmi can be used in cluster headaches.
Migraine - Ergot alkaloids.
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