Headache Flashcards
What are the primary headaches?
- Migraine
- Tension
- Cluster
What are secondary headaches?
When headache is caused by another condition/ disorder- local onset systemic
serious causes of secondary headache are uncommon
Are primary headaches short or long lasting?
Short (duration < 4 hrs):
- Cluster
Long (duration> 4 hrs):
- Migraine
- Tension
Why is further treatment sometimes needed after diagnosis of primary headache?
Can develop into a secondary headache
- look for red flags
What are the 4 key red flags suggesting secondary headaches?
Age:
- New onset or different headaches in a person >50yrs
Onset:
- Sudden, abrupt onset of a severe headache (thunderclap headache)
Systemic symptoms:
- Fever, neck stiffness, rash, weight loss
Neurological signs:
- Confusion, impaired consciousness, focal neurology (weakness concentrated on one side of the body), swollen optic discs
What causes headaches?
- Abnormal cortical hyper-excitability & excitation of the brain stem contribute to…
- Activation of the trigeminovascular system, which leads to…
- Vasodilation, neurogenic inflammation & central sensitisation = HEADACHE
What is a migraine headache?
- episodic neurological disorder that has a strong genetic component and usually presents in early-to-mid life (can be chronic)
- Primary headache characterized by recurrent episodes of unilateral, localized pain
- Can be classified as:
1. Migraine with aura (classical migraine)
2. Migraine without aura (common migraine)
3. Migraine variants (e.g. familial hemiplegic, ophthalmoplegic)
What are the risk factors for migraine headache?
- family history of migraine
- female sex
- menstruation
- stress
- obesity
- sleep disorders
- medication overuse
- COCP
- foods (caffeine, chocolate, cheese)
- exercise
- hormonal
What presenting symptoms of a migraine can be found in the history?
- Prolonged Unilateral Headache → lasts 4-72 hrs, recurrent episodes (may be up to several times per month)
- Throbbing / Pulsatile Pain
- Nausea → most common associated symptom
- May get aura beforehand → flashing lights, tingling
- Sensitivity to light (Photophobia) & sound (Phonophobia) → may have to lie down in quiet, dark room
- Headache worse with activity
- Ask about interference with daily living in history
- Decreased ability to function
- Abdominal pain is common in children with migraines
memory aid:
“POUND”:
Pulsatile headache
One-day duration
Unilateral
Nausea
Disabling.
Summarise the epidemiology of migraine
Prevalence:
Males - 6%
Females - 15-20%
-Usually occurs in adolescence and early adulthood
What signs of a migraine can be found on physical examination?
NO specific physical findings
- Exclude secondary causes with MMSE, neurological examination, fundoscopy etc.
Identify appropriate investigations for migraine
- Diagnosis is usually based on HISTORY
- Investigations may be useful for excluding other diagnoses
- Bloods, CT/MRI, lumbar puncture (abnormal in patients with SAH or Meningitis), ESR (raised in Temporal Arteritis),
How are migraines managed?
NOTE: analgesia overuse can cause headaches
1. ACUTE:
- Sumitriptan (oral triptans are first line agents for migraines- Ischaemic heart disease, hypertension and previous stroke or TIA are all contraindications) + NSAIDs + metoclopramide (antisickness if nauseus)
- the recommended advice is to take Sumatriptan only once the headache starts and not during the aura phase
2. Prophylaxis/ prevention (>2 attacks per month)
- Remove triggers
- 1st line: Beta-blockers (propranolol- unless asthma, diabetes, raynauds) or Topiramate (can cause pregnancy complications, used if pt is not getting preg)
- 2nd line: Amitriptyline
- Menstrual migraines can be controlled with the oral contraceptive pill
3. Advice
- Avoid triggers
- Rest in a quiet dark room during episodes
Identify possible complications of migraine
- Disruption of daily activities
- Can lead to analgesia-overuse headaches in people who use analgesia regularly
Summarise the prognosis for patients with migraine
- Usually CHRONIC
- Most cases can be managed well with preventative/early treatment measures
What is a tension headache?
- Tension-type headaches can be either episodic or chronic.
- They are rarely disabling or associated with any significant autonomic phenomena, thus patients do not usually seek medical care and usually successfully self-treat.
- The attacks are generalised throughout the head with a predilection for involving the frontal and occipital regions.
*Episodic - occurs on < 15 days per month
*Chronic - occurs on > 15 days per month
What are the triggers for a tension headache?
Stress/anxiety
Squinting
Poor posture
Fatigue
Dehydration
Missing meals
Bright sunlight
Noise
What presenting symptoms of a tension headache can be found in the history
- Mild-moderate in severity
- Pressure/tightness around the head like a tight band
- Pain tends to be bilateral
- Non-pulsatile
+/- scalp muscle tenderness - Often a relationship with the neck
- Can be disabling for a few hours but does not have specific associated symptoms (unlike migraines)
- Gradual onset
- Variable duration
- Usually responsive to over-the-counter medication
- IMPORTANT: check for possible triggers when taking history (e.g. stress)
- Examination is usually NORMAL
- Headache does not increase with exertion. No nausea, vomiting or aura (unlike migraines)
Summarise the epidemiology of tension headache
MOST COMMON type of headache
More common in WOMEN
Most common in YOUNG ADULTS
Most people will experience a tension headache at some point in their lives
Identify appropriate investigations for tension headaches
NO investigations necessary
Generate a management plan for tension headaches
Episodic Tension Headaches:
- Reassurance
- Address triggers (e.g. stress, anxiety)
- Advice on avoiding medications that can cause medication-induced headaches (e.g. opioids)
- Simple analgesia (e.g. ibuprofen, paracetamol, aspirin):
*1st Line (Acute) → aspirin, paracetamol or NSAIDs (ibruprofen)
*Prophylaxis → amitriptyline (not NICE recommended but widely used) or acupunture (NICE recommended) - Tricyclic antidepressants (amitriptyline) may be considered in frequently recurrent episodic tension headaches or chronic tension headaches
Identify possible complications of tension headaches
NONE
Summarise the prognosis for patients with tension headaches
GOOD
Not very severe or disabling
Recurs
What are cluster headaches?
Cluster headache refers to a type of headache that is primarily unilateral and typically more severe around the eye region. The headache episodes occur in clusters, with patients experiencing numerous attacks within a condensed timeframe.
What are the signs/ symptoms of cluster headache?
Unilateral, severe headache, often around the eye
A bloodshot or teary eye on the affected side
Vomiting
Nasal congestion
constricted pupil/ drooping eyelid
How are cluster headaches treated?
Acute treatment: Administering 100% oxygen and sumatriptan can provide relief during an acute episode.
Prophylactic treatment: Potential prophylactic treatments include verapamil and steroids, which may help reduce the frequency and severity of attacks.
In what cases is Sumatriptan contraindicated?
Sumatriptan is contraindicated in ischaemic heart disease, hypertension, peripheral vascular disease, previous strokes, and previous myocardial infarctions. This is because sumatriptan is a serotonin receptor agonist that constricts cerebral blood vessels to reduce the release and movement of substances involved in the pain pathways. Narrowing the cerebral blood vessels presents a serious risk in someone with a previous stroke as it suggests that they already have narrowed blood vessels.
