Headache Flashcards
Red flag head ache features
New or unexpected headache
New headache in over 50
New headache in under 10
Thunderclap headache
Atypical aura (over an hour) with headache
Aura occurring for first time during use of COCP
Persistent morning headache with nausea
Progressive headache over weeks
Headache with postural change
New headache in pt with cancer history
New headache in pt with HIV history
What is a migraine
Neurological disorder characterised by recurrent, unilateral, throbbing headaches preceded by aura
Symptoms and clinical signs of migraine
Aura (visual or sensory) prior to migraine
Photophobia / phonophobia
Unilateral throbbing / pulsating headache - lasts hours (4-72hrs)
Nausea / vomitting
Worsened by activity
Ix for migraines
Clinical diagnosis
Rule out secondary cause first (even with prev migraine history)
Neuro exam - for raised intracranial pressure
MRI
Blood tests - ESR/CRP for giant cell arteritis
How to differentiate between migraine and tension headache
Migraine - unilateral, aggravated by activity, nausea / vomiting, aura
Tension headache - bilateral, not worsened by activity, no nausea or vomiting
How to differentiate between migraine and cluster headaches
Migraine - unilateral, pain lasts hours to days
Cluster headache - unilateral, pain lasts 15-180 mins, up to 8 times a day, autonomic symptoms e.g. lacrimation, ptosis, miosis
Migraine treatment outline
Acute management
Prophylactic management
Avoid triggers
Don’t take COCP
Headache diary
Refer if management fails in primary care
Migraine acute management
Analgesia (aspirin, paracetamol, ibuprofen) with an antiemetic (metaclopramide - helps absorb painkiller) and a triptan (sumatriptan)
Take above all together at once at start of migraine
Prophylactic migraine treatment and when is it given
If more than 8 episodes within a month or if acute treatment is contraindicated / ineffective, risk of frequent use of acute treatment
Depends on contraindications
Amitriptyline
Propranolol
Candesartan
Topiramate
Pizotifen
Sodium valproate
Signs and symptoms of tension type headache
Bilateral non pulsatile headache with no neurological symptoms - no aura or photophobia
“Tight band like pressure” headache
Tension headache investigations
Clinical diagnosis from history
Tension headache management
Analgesia acutely
Amitriptyline is effective only if debilitating
How does cluster headaches present
Episodic, severe unilateral headaches in periorbital area around eye
Side locked
Autonomic symptoms on one side same as headache side e.g. lacrimation, blood shot eye, nasal discharge, conjunctival infection, periorbital oedema, ptosis, miosis
Cluster headache investigation
Angiogram if pt has cluster headache symptoms and Horner’s syndrome and pulsatile tinnitus - to rule out carotid dissection
Imaging to rule out secondary causes
Cluster headache acute management
100% Oxygen
Sub cut sumatriptan
Cluster headache preventive management
Veramapil
Steroids - prednisolone
Topiramate / sodium valproate - sometimes
Lithium - rare
SUNCT / SUNA - presentation
Short lasting unilateral headache - rare
Autonomic symptoms with sharp shooting pains
Side locked
Lasts minutes to seconds
Trigeminal neuralgia symptoms and treatment
May have autonomic features
Sharp shooting pain lasting seconds
Always triggered
Carbamazepine - 1st line
Neurosurgical vascular decompression - definitive
Paroxysmal hemicrania presentation
Side locked headache
Resolves with indomethacin
Rare
Hemicrania continua presentation
Side locked headache - resolves with indomethacin
Non remitting , continuous headache until treatment
Causes of vascular headaches
Cerebral venous sinus thrombosis (VST)
Haemorrhage
Temporal arteritis / GCA
Vascular headache caused by Cerebral venous sinus thrombosis presentation and investigation
Headache
Seizures
Reduced consciousness
Pro ptosis
Facial oedema
Computed tomography head or magnetic resonance venography
Vascular headache caused by Haemorrhage presentation and investigation
Vomiting
Thunder clap headache
Reduced level of consciousness
Pre retinal haemorrhage
Meningism
Computed tomography head and lumbar puncture
Vascular headache caused by Temporal arteritis presentation and investigations
Jaw claudication, temporal headache, vision loss, hard non pulsating temporal artery
USS and biopsy
Cerebral venous sinus thrombosis treatment
Warfarin / heparin
Neurosurgical / ENT intervention
Vascular headache caused by Haemorrhage treatment
Neurosurgical
Blood pressure management
Temporal arteritis management
Steroids
Presentation of headache secondary to intracranial neoplasm
Progressive
Worse in morning or when lying down
Nausea or vomiting
Certain movements aggravate it
Headache due to intracranial neoplasm Ix and management
Genetic testing of tumour
MRI brain
Neurosurgical intervention
Steroid / immunosuppression
Chemo / radiotherapy
