Headache Flashcards
What is meant by a primary headache?
A headache with no underlying medical cause
What is meant by a secondary headache?
A headache with an identifiable structural or biochemical cause
Name some types of primary headache
Migraine
Tension type headache
Cluster headache
Name some underlying causes of secondary headache.
Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drugs
What is the most common type of secondary headache?>
Medicine overdose headache
Describe the pathophysiology of primary headache.
Sensitisation of normal pain pathways
Which neuropeptide is released in headaches and can cause worsening of pain and increases headache length?
CGRP
(Calcitonin gene related peptide).
What are some of the factors to consider in management of primary headache?
Any modifiable lifestyle triggers
Abortive treatment
Transitional treatment
Preventative treatment
In which type of primary headache is modifying lifestyle changes particularly important?
Migraines
In which type of primary headache is transitional treatment particularly important?
Cluster headaches
If there is concern that a headache may be secondary cause, which investigation may be carried out?
MRI is more sensitive but more likely to show incidental findings
-> incidental findings are findings on investigation that were completely unexpected and potentially could lead to further unnecessary investigations
In secondary headaches, which type of investigations can be used to diagnose and guide treatment?
CT
CT angiogram
What is the most common type of primary headache?
Tension type headache
Describe the presentation of tension type headache.
Mild bilateral headache, often pressing or tight feeling.
Acute treatment for tension type headache?
Paracetamol, NSAIDs
Preventative treatment for tension type headache?
Tricyclic antidepressants e.g. amitriptyline
What are some of the symptoms of a migraine?
Headache
Nausea, vomiting
Photophobia
Phonophobia
Functional disability
What are some of the premonitory symptoms of a migraine?
Mood changes
Fatigue
Cognitive changes
Muscle pain
Food cravings
What are the symptoms of early headache in migraine and what is the treatment for this stage?
Symptoms- dull headache, nasal congestion, muscle pain
Treatment- acute treatment e.g. NSAIDs, paracetamol
What are the symptoms of advanced headache in migraine?
Symptoms- unilateral, throbbing, nausea, photophobia, phonophobia, osmophobia
What are the symptoms of the postdrome in migraine?
Fatigue
Muscle pain
Cognitive changes
A 44yo male presents with a migraine. He describes his symptoms as causing him to feel sick and needing to lie still in a dark room. What stage of migraine is he likely to be in?
Advanced headache
Aura?
Transient neurological symptoms resulting from cortical brainstem dysfunction
->affects a third of migraineurs
What may a migraine with aura affect?
Visual, sensory, motor or speech issues
What may a migraine with aura be confused with?
Transient ischaemic attack
What is the difference between a migraine with aura and a transient ischaemic attack?
TIA symptoms have a sudden onset
Aura has slow evolution of symptoms (15-60mins)
Define chronic migraine
Headache on 15 or more days/month, of which 8 or more days have to be a migraine for more than three months
What are chronic headaches commonly associated with?
Medication overuse
If a chronic migraine is caused by medication overuse, what is often the management?
Discontinue medication
Define a medication overuse headache.
Headache present on at least 15 days/month which has developed or worsened whilst taking regular symptomatic medication
Use of triptans, ergots, opioids and combination analgesics can cause a MOH. How much would cause a MOH?
Use of these drugs more than 10days/month
Use of simple analgesics can cause a MOH. How much would cause a MOH?
Use of these more than 15 days/month
Which other type of drug can cause a MOH?
Caffeine
What are some of the modifiable lifestyle triggers to try and prevent migraines?
Stress
Hunger
Dehydration
Sleep disturbance
Diet
Environment
Changes of oestrogen levels in women
Describe the acute treatment of migraines.
-Aspirin or NSAIDs
-Triptans
^(limit to 10 days/month, or two days a week to prevent MOH)
List some options for the prophylactic treatment of migraines.
-Propranolol, Candesartan
-Anti-epileptics (topiramate, valproate, but not in child bearing women).
-Tricyclic antidepressants
-Flunarizine
-Botox
-CGRP monoclonal antibodies
Treatment for MOH
Prevention better than cure so limit acute treatment to 2days/week
What can happen when there is abrupt withdrawal of overused symptomatic medication?
Headaches may get worse for 2-4 weeks.
Need to wait 2 months or longer before knowing if effective
If a women has a headache without aura, what happens in pregnancy?
Migraine gets better
If a women has a headache with aura, what happens in pregnancy?
Migraine does not change
If a women gets her first migraine during pregnancy, which type of headache is this likely to be?
Migraine with aura
Which drug is contraindicated in active migraines with aura in women and why?
Combined contraceptive pill as carries small risk of stroke
Which drug should be avoided in the treatment of migraines in women of child bearing age?
Anti-epileptics
Treatment of migraine can be more difficult in pregnancy. What are some of the acute options?
Paracetamol
NSAIDs- in first two trimesters
Triptans
Treatment of migraine can be more difficult in pregnancy. What are some of the preventative options?
Propranolol
Amitriptyline (tricyclic antidepressant)
What is new daily persisting headache?
Distinct onset of headache with pain becoming continuous and unremitting for 24hrs
What is a common complication of new daily persistent headache?
Medication overdose headache
What is important about the diagnosis of new daily persistent headache?
It is a diagnosis of exclusion and secondary causes must be actively excluded
Neuralgia?
An intense burning or stabbing pain, usually brief but severe
What usually causes neuralgia?
Irritation or damage to a nerve
Which type of cranial neuralgia is the most common?
Trigeminal neuralgia
Which areas of the trigeminal nerve are usually irritated to cause trigeminal neuralgia?
Unilateral maxillary or mandibular division
Describe the pain experienced in trigeminal neuralgia.
Triggered and spontaneous lancinating (stabbing) pain
What are some of the cutaneous triggers of trigeminal neuralgia?
Wild/cold
Touch
Chewing/brushing teeth
What is a common cause of trigeminal neuralgia (pathophysiology)?
Vascular compression of trigeminal nerve
-> if an artery is pulsing, every pulse may irritate trigeminal nerve
What are some uncommon cause of trigeminal neuralgia (pathophysiology)?
MS
Intracranial arteriovenous malformation
Intracranial tumour
Brainstem lesion
List some potential medical treatments for trigeminal neuralgia.
Carbamazepine
Oxcarbazepine
Lamotrigine
Pregabalin/ gabapentin/ lacosamide
Phenytoin for severe exacerbations
List some potential surgical treatments for trigeminal neuralgia.
Glycerol ganglion injection
Stereotactic radiosurgery
Microvascular decompression
List some trigeminal autonomic cephalalgias.
Cluster headache
Paroxysmal headache
SUNCT/ SUNA
Hemicrania Continua
What are the similarities between all trigeminal autonomic cephalalgias?
Strictly unilateral head pain
Very severe pain
Cranial autonomic symptoms
Restless
What are the differences between all trigeminal autonomic cephalalgias?
Attack frequency and duration differs
List the cranial autonomic symptoms.
Conjunctival infection/ lacrimation
Nasal congestion/ rhinorrhoea
Eyelid oedema
Forehead and facial swelling
Miosis/ptosis (Horner’s)
In which regions is pain from cluster headaches felt?
Mainly orbital and temporal regions
Describe the onset of a cluster headache.
Strictly unilateral. rapid onset (maximum 9 mins)
What is experienced in cluster headaches?
Excruciatingly severe pain so patients are restless and agitated during attack
->some have committed suicide as under so much intense pain
What are some of the premonitory symptoms of cluster headaches?
Tiredness, yawning
What are some of the associated symptoms of cluster headaches?
Nausea, vomiting, photophobia, phonophobia
Describe the pattern of attacks in cluster headaches.
‘Cluster’ into bouts typically lasting 1-3 months with a period of remission after, usually a month.
Attacks may differ from 1 every other day to 8 per day.
There can be continuous background pain in remission.
Attacks occur at some time every day/ same time every year.
->loads of info but READ
What can trigger a attack during a bout of attacks but not during remission?
Alcohol
At which point of the day is it common to get a cluster headache?
Very early in the morning, during REM sleep
List some of the abortive treatments used in cluster headaches.
Triptans- injections as oral unlikely to help
Oxygen
In terms of triptans as an abortive treatment of cluster headaches, medication overdose cannot occur. However, why can only two doses a day be taken?
Any more increases risk of myocardial ischaemia
What are some of the transitional treatment options for cluster headaches?
Oral prednisolone taper
Greater occipital nerve block
What are some of the preventative treatment options for cluster headaches?
Verapamil
Lithium
Topiramate
Gabapentin
Pregabalin
Sodium Valproate
Levetiracetam
Melatonin
Which drug type should verapamil not be given alongside to treat cluster headaches?
Never at same time as beta blocker as increased risk of heart block
Those taking verapamil require ECG monitoring
The frequency of attack can help to differentiate between different trigeminal autonomic cephalgia’s.
How many times, per day, may a cluster headache occur?
1-8 x / day
The frequency of attack can help to differentiate between different trigeminal autonomic cephalgia’s.
How many times, per day, may paroxysmal hemicrania occur?
1-40 x / day
The frequency of attack can help to differentiate between different trigeminal autonomic cephalgia’s.
How many times, per day, may SUNCT occur?
3-200 x / day
so daily attack frequency SUNCT > Paroxysmal Hemicrania > Cluster Headache
In which type of trigeminal autonomic cephalalgias is the duration of attack the-
1. Longest
2. Shortest
- Longest= cluster headache, 15-180 mins
- Shortest= SUNCT 2-240 secs
Describe the pain felt in cluster headaches and paroxysmal hemicrania.
Sharp and throbbing
Describe the pain felt in SUNCT.
Stabbing and burning
What is the only NSAID which works for paroxysmal hemicrania and hemicrania continua?
Indometacin
Indomethacin is a NSAID and works on COX-1 and COX-2 receptors, like other NSAIDs. However, it does not work through these receptors in paroxysmal hemicrania. What does it act on instead?
Nitric oxide
Paroxysmal hemicrania is very similar to cluster headaches in terms of pain, rapid onset and offset. How does it differ?
More frequent and shorter than cluster headaches.
Pain still felt in unilateral orbital and temporal areas
Describe pain felt in SUNCT.
Unilateral orbital, supraorbital or temporal region
Stabbing or pulsating pain
What are some of the triggers of SUNCT?
Wind, cold
Touch
Chewing
How long does SUNCT last?
10-240 second duration
List some of the medical treatment options for SUNCT/SUNA.
Lamotrigine
Topiramate
Oxcarbazeprine
Carnazeprine
Duloxetine
pregabalin/gabapentin
What is a transitional treatment for SUNCT/SUNA?
GON block (greater occipital nerve)
What are some surgical options for treatment for SUNCT/SUNA?
Occipital nerve stimulation
Deep brain stimulation
Which features would predict a more serious type of headache?
More likely to have a sinister cause:
-Head injury
-First or worst
-Sudden, thunderclap onset
-New daily persistent headache
-Change in headache pattern or type
-Returning patient
List some red flags which should make us consider secondary headache.
New onset headache, without preceding history
New or change in headache
Aged over 50
Immunosuppression or cancer
Neck stiffness
Fever
High/LOW PRESSURE
GCA- giant cell arteritis
What is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than a minute
What must be considered if a patient presents with a thunderclap headache?
Subarachnoid haemorrhage
What is a subarachnoid haemorrhage?
Aneurysmal rupture and bleeding into subarachnoid space
What are some complications of a subarachnoid haemorrhage?
Vasospasm
Hydrocephalus
Seizure
Infection
Re-bleeding
->those who rebleed have high mortality rate
Which investigations should be done if subarachnoid is suspected?
CT Head asap
Lumbar puncture
When should a lumbar puncture be carried out in someone with suspected subarachnoid haemorrhage?
12 hours after headache onset to allow blood breakdown products to develop
Which investigation should be carried out after conformation of subarachnoid haemorrhage.
CT angiogram
What is the treatment of a subarachnoid haemorrhage?
Early treatment essential, clipping of aneurysm
Nimodipine ( type of Ca channel blocker for vasospasm)
HHH treatment- hydration, hyperoxia, hypertension- keep high hydration, BP and oxygen levels
What can cause high pressure in brain?
Tumour/ brain occupying lesion
Brain swelling
What are some symptoms suggestive of a high pressure headache?
Headache wakes patient up
Cough
Visual obscurations/pulsatile tinnitus
Seizures
Progressive focal symptoms
Cognitive change or drowsiness
What are some signs suggestive of a high pressure headache?
Papilledema
New abnormal neuro examination
What is the clinical presentation of intracranial hypertension?
Progressive episodic or persistent headache
Visual obscuration’s and/or pulsatile tinnitus
Papilledema, often with enlarged blind spot
What is the commonest cause of intracranial hypotension?
Lumbar puncture
What name is given to a headache which develops or worsens soon after assuming an upright position and lessens shortly after lying down?
Postural headache
What would be seen on MRI in someone with intracranial hypotension?
Less CSF, more blood so venous engorgement
Subdural hygromas (increased space between skull and brain)
What is the treatment for intracranial hypotension?
Bed rest, fluids, analgesia, caffeine
IV caffeine
Epidural blood test
When is a high pressure headache worse?
When lying flat
When is a low pressure headache worse?
When standing upright
What is giant cell arteritis?
Inflammation of large arteries
Headache is a non-specific feature of giant cell arteritis. What are some specific features?
Scalp tenderness
Jaw claudication
Visual disturbances
Systemically unwell
Enlarged temporal arteries may be present
What is the treatment of giant cell arteritis?
High dose prednisolone
Which blood tests supports diagnosis of giant cell arteritis?
Elevated ESR
->Raised CRP and platelet count are other useful markers
