Headache Flashcards
Secondary headaches causes
Meningitis
Subarachnoid haemorrhage
Intracranial pressure
Giant cell arteritis
Venous sinus thrombosis
Pituitary apoplexy
Carotid dissection
Primary headache causes
Tension headache
Migraine
Cluster headaches
Trigeminal neuralgia
Headaches red flags
new
worst ever
thunderclap onset
systemically unwell
symptoms of raised ICP
symptoms of cancer (B symptoms)
meningism
focal signs
Does your brain hurt?
no
brain has no sensory neurons
pain from secondary headaches comes from outside the brain
When is a headache from raised ICP worse?
lying down
when doing valsalva manoeuvres (eg. straining)
What sign on ophthalmoscopy rules out raised ICP?
flickering of veins
rules out raised ICP but not seeing them does not mean there is raised ICP
When can a swollen optic disc be called papilloedema?
when you know disc swelling is caused by raised ICP
Describe the head CT of a subarachnoid haemorrhage
subarachnoid hyperdensity (blood) (blood in sylvian fissures)
blood obstructed normal CSF flow, causes obstructive hydrocephalus
diffuse swelling
What does thunderclap onset mean?
peak intensity straight away
Subarachnoid haemorrhage symptoms
thunderclap onset worst ever headache
memingitic
Subarachnoid haemorrhage investigations
CT - fantastic early, rubbish late
Lumbar puncture - fantastic within 2 weeks, useless afterwards (looking for xanthrochromia)
look for cause (aneurysms) = CT angiogram or digital subtraction angiography
Subarachnoid haemorrhage treatment
bedrest
fluids (normal saline, 3L over 24h)
nimodipine (decreases risk of vasospasm in Berry aneurysms)
look for and secure aneurysms
What can cause angiogram negative subarachnoid haemorrhage?
generally less dangerous
eg. RCVS (reversible cranial vasoconstriction syndrome), amyloid angiopathy
What cause of headache is notifiable?
meningitis (esp neisseria meningitidis)
How does meningitis headache differ from subarachnoid haemorrhage?
meningitis = same headache but slower start
Meningitis treatment
antibiotics
elderly/immunocompromised = cover listeria
steroids for pneumococcus
GCA symptoms
jaw claudication
amaurosis fugax
scalp tenderness
palpable pulseless temporal arteries
What can virtually exclude GCA in a patient?
normal ESR/CRP/Platelets
How is GCA confirmed?
temporal artery biopsy
can have skip lesions though
GCA treatment
steroids
What can cause neck pain and headache in a rollercoaster enthusiast?
carotid artery dissection
can present as Horner’s syndrome
traumatic injury to sympathetic chain
can cause acute, sudden onset headache
Carotid artery dissection treatment
aspirin
due to high risk of stroke because of thrombi
Thunderclap headache and history of galactorrhea condition
pituitary adenoma, presses on optic chiasm
causing pituitary apoplexy
presents also with bitemporal hemianopia
risk of Addisonian crisis
How is pituitary apoplexy treated?
steroids
risk of Addisonian crisis due to pituitary failure
Headache in woman on the pill with headache and haemorrhage cause?
venous sinus thrombosis
Venous sinus thrombosis treatment
heparin
Describe a tension headache
commonest headache
end of the day, not severe, like a band
no signs on examination
Describe a migraine headache
very common
genetic predisposition
recurrent unilateral throbbing gradual onset (hours), nausea, vomiting, photo and motion sensitivity
painkillers do not work
Migraine treatment options
Holistic
Acute/abortive
Preventative
Keep a diary
Sleep hygiene
Neck stretching
Supplements = Riboflavin 400mg OD, magnesium >600mg OD
What abortive medicines can be used for migraines?
at start of attack, with or without anti-emetic
Triptan (PO, SC, Nasal)
2nd dose 1-2 hours later
NSAID (aspirin 600-900mg dispersible)
then ride it out
What constitutes medication overuse in migraines?
10 days/month for opiates/triptans
15 days/month any other analgesic
most guidelines suggest withdrawal before starting preventatives
can feel worse before better
Preventative medicines used for chronic migraines
Supplements (riboflavin 400mg OD, magnesium)
Tricyclics (amitriptyline)
SNRIs (duloxetine, venlafaxine, mirtazepine)
Beta blockers (propranolol, metoprolol)
Serotonergic modulators (pizotifen)
Neuromodulators (topiramate, valproate)
Calcium channel antagonists (verapamil)
ACE-I/ARB (lisinopril, candesartan)
GON-B/MCNBs
Botox
Chronic cluster headache treatment
verapamil - main drug used
lithium
topiramate
gabapentin/pregabalin
sodium valproate
baclofen/tizanidine
levetiracetam
corticosteroids
GON-B
Gammacore
Trigeminal neuralgia treatment
Carbamazepine/Oxcarbazepine
gabapentin/pregabalin
baclofen
tizanidine
lamotrigine
topiramate
duloxetine
lacosamide
