headache Flashcards
what is the one year prevalence of headache disorders? what percentage do neurologists end up seeing?
50%
20% seen by docs
what are the 3 types of primary headaches?
migraine
cluster headache
tension-type headache
what is a secondary headache? i
headache cause by another condition/ disorder local or systemic. (may be serious causes: rarer than primary)
after what time frame is a headache characterised as a long lastin one?
> 4h
which headaches are long lasting?
migraine and tension type and medication overuse headache
what are the the short lastin headaches?
cluster headache
other name for cluster headache
trigeminal autonomic cephalagia
what is medication overuse headache
You have headache, you start taking a medication for 3/ week or more: you have a medication overuse headache
which patients do you give a diagnostic test to?
only the ones you suspect may have secondary headache after either
1) seeing a red flag in their history/ examination or
2) red flag after giving them preliminary primary headache diagnosis
what are the main red flag areas suggesting secondary headaches?
NOSA
neurological signs (focal neurology, swollen optic discs)
onset (abrupt really quick)
systemic symptoms (fever neck stiffness)
age (New onset or different headaches in a person >50yrs)
what do these symptoms suggest: Confusion, impaired consciousness, focal neurology (limb related neurology problem: stroke common) , swollen optic discs? (what cetgory of red flag?)
neurological, suggest intercranial pressure, encephalopathy
Fever, neck stiffness, rash, weight loss, (symptoms in lower limbs if youre a teen or young) what fo they suggest and what category are they?
meningitis, systemic
Sudden, abrupt onset of a severe headache (thunderclap headache: they feel like they have been kicked in the back of the head 10/10 pain, onset in less than a minute
brain bleed, onset
what is a headache practically (why/ how does your head hurt?)
due to activation of the trigemino-vascular system (trigeminal nerve)
where/how does the whole pathophysiology axis start?
abnormal function of some area in brainstem (hypothalamus, PAG ect) (due to some excitation)
what does this abnormal brainstem funstion lead to?
cortical spreading depression
what is happening physiologically in cortical spreading depression? what are the symptoms?
Abnormal cortical hyperexcitability
(Ca++, Glu, ¯Mg++)
you see auras
what is central sensitization and what triggers it? what is the result?
when your start being too sensitive to one/ some of your senses due to the tgvs activation, which further stimulates your headache
what is CGRP? what causes its secretion? what does it do?
It is a peptide released by the body in response to activation of TGVS.
it causes vasodilation and neurogenic inflammation
which leads to pain perpetuation and more TGVS activation.
when are migraines considered episodic and when a chronic disorder?
chronic when more than 10-15 a month
characteristics of a migraine pain- location, quality, intensity, trigger, duration
-unilateral location
- pulsating quality
- moderate to severe pain (disrupts your task at hand)
-aggrevation by routine physical activity
-last hours and sometimes days
what are the other symptoms of migraine (people usually get 1 or more of these)
one of these
nausea and/ or vomiting
photophobia and/or phonophobia/ osmophobia
+
extra
(+/- auras )
what is an aura? hoe long does it last? when does it happen usually in relation to headache onset?
complex array of symptoms reflecting focal cortical or brainstem dysfunction
5-30 mins
usually before headache
what are two specific pattern types of auras?
elemental visual distur bance (bean shape increasing over roughly 10 mins)
expanding Cs (same: incr size over 8 mins)
what are premonitory symptoms? when do they happen?
first phase, occur hours or days before migraine (yawning, polyuria, mood change, irritable, light sensitive, neck pain, concentration difficulty)
what 2 phases come after the premonitory symptoms?
aura (phase- as in, in the same phase as auras you can also get… ): visual, sensory (numbness/ paraesthesia), weakness, speech arrest
headache (same time as headache you can also get) : head and body pain, nausia, photophobia
what are the names of two final phases of headaches and when does someone move from headache to the first one?
RESOLUTION: rest and sleep
recovery: mood disturbed, food intolerance, feeling hungover can take up to 48 h
what is the first line management of migraines?
lifestyle changes: avoiding triggers such as having irregular sleeping schedules. have good diet, exercise, mindfulness,
why do lifestyle factors such as sleep affect migraines directly?
hypothalamus controls waking- sleeping phase: starts anad ends your day- hypothalamus also is the start for migraine
what are the 2 types of drugs you can give to treat migraines
1) acute/ abortive: hard/ high dose and fast
2) long term preventative: strategy: low and slow
main examples of acute/ abortive migraine treatments
paracetamol
NSAIDS (high dose and soluble)
Prokinetics
Triptans (5-HT1B/1D/1F receptor agonists)
how long does a migraine treatment need to be to be cosidered long term?
> 5 days / month
low and slow: low doses until optimal is found
what 2 types of dugs should be avoided for migraines?
opiate based and mixed analgesics
does taking you “acute” med earlier or later after migraine onset make a difference?
yes, its more effective if you take it earlier before it becomes very intense
(whatever you remember is fine) some migraine preventatives? what categories of drugs are these?
not one specific category, tehy were discovered by chance to help headaches during trials for other diseases: some are: anti depressants, anticonvulsants, calcium channel blockers, b blockers
what is a new migraine preventative tjat has been discovered and ehy is it better compared to others? what makes them more difficult to use?
CGRP antibodies - much less side effects compared to these other heavy drugs, v expensive
what is the most common type of primary headache?
tension- type headache
what do patients report tension type headaches feel like?
tight muscles around head and neck as though head is in a vice
features of tension type headache: location, intensity, and added features
bilateral, mild or moderate
typically no added features such as vomiting or phonophobia/ photophobia
are tension type headaches aggregated by movement?
no
treatment of tension type headaches
reassurance may suffice,
individual episodes : light analgesics such as aspirin or paracetamol
preventative meds rarely required
pain severity, duration and pattern over time, location of cluster headaches
severe,
unilateral,
15-(180 minutes if untreated - 30 mins average:
they come and go 1-8 times a day- same pattern every day for a specific time and then they randomly stop)
what are the features out of which at least one is usually present in cluster headaches ipsilaterally ?
Conjunctival redness and/or lacrimation: crying on one eye
Nasal congestion and/or rhinorrhoea: fluid coming out of nose
Eyelid oedema
other associated cluster headache symotms general?
Forehead and facial sweating
Miosis and/or ptosis
A sense of restlessness or agitation
Not associated with a brain lesion on MRI
usual treatment of cluster headache : acute and mechanisms of treatment + route of administr.
triptan: nasal or subcutaneous route
high flow oxygen; oxygen inhibits neuronal activation in the trigeminocervical complex
cluster headaches preventative medications
verapamil (calcium channel inhibitor)
-get an ECG first !
greater occipital verve block (procedure)
