* Headache Flashcards
What are the primary headache types?
1) Migraine
2) Tension-type
3) Cluster headache
What are the cranial nerves carrying brain fibres?
5, 7 9 & 10
What are the most common causes of headache?
1) Migraine
2) Tension-type
3) Cluster
4) Intracranial mass lesion
5) Low intracranial pressure
6) Meningitis, SAH
7) Temporal arteritis, intracranial vasculitis?
What is the mechanism of a migraine?
- Dilation and inflammation
- of intracranial and extracranial arteries
- Neurally induced
What is the mechanism of a cluster headache?
- Inflammation and edema
- in Internal carotid artery
- Neuronally induced
What is the mechanism of an intracranial mass lesion in causing a headcahe?
- eg Brain tumors, hydrocephalus
- Displaces pain-sensitive vessels
What is the mechanism of low intracranial pressure in causing a headache?
- eg Post-lumbar puncture
- Traction through brain
- Causes sagging on dural attachments
- Intracranial vasodilation
What is the mechanism of meningitis and SAH in causing a headache?
- Inflammation of vessels
- in Meninges and perivascular area
What is the mechanism of temporal arteritis and intracranial vasculitis in causing headache?
- Inflammation
- of Scalp and intracranial vessels
What are some danger signs of a headache?
- Abrupt onset that is unusually severe
- Associated with neurological symptoms
- Progressive headache over days to months
- Associated with N/V and fever
- Change in character or response to treatment of pre-existing headache
- New onset headache in adult life
- Associated with paroxysmal hypertension (episodic and volatile high blood pressure)
- Systemic symptoms of fever, weight loss and myalgia
- Associated with nocturnal occurrence and morning awakening
What are the investigations for headache and when are they done?
When presentation of the patient has atypical features
1) Blood tests
2) Imaging
- Especially for patients with high-risk features
3) Lumbar puncture
- To diagnose CNS infections and exclude SAH
4) Biopsy
- of Temporal artery and meningeal artery
How to diagnose headaches?
1) Presence of papilledema
- To rule out mass legions
2) Presence of Nuchal rigidity/neck stiffness
- Meningeal irritation seen in meningitis, SAH or intraparenchymal hemorrhage
How to diagnose a migraine Without Aura / common migraine?
> 5 attacks fulfilling these criteria
- Lasts 4-72 hours and unsuccessfully treated
- At least 2 of these:
~ Unilateral location
~ Pulsating
~ Moderate or severe intensity
~ Pain aggravated by exertion
Attack should have at least 1:
- N/V
- Photophobia
- Phonophobia
No other disease that may cause headaches
How to diagnose migraine with aura/Classic migraine?
- Typically precedes headache and lasts 20-30 min
~ Clears before headache begins - Mostly visual aura
- Criteria is the same as for common migraine BUT +++ symptoms of neurologic function occurring before/during the attack
What are the common types of migraine aura?
1) Visual
- See scintillating saw-tooth crescents of light
- Photopsias )glistening points of light)
- Shimmering heat-wave-like obscuration
2) Sensory
- Tingling/numbness
- Originates in mouth or hand
3) Others
- Mono/hemiparesis
- Dysphagia
- Cognitive changes
What are the common triggers for migraines?
1) Hormones
2) Diet
- Alcohol, MSG, chocolate, aged cheese, artificial sweetener
2) Psychological
4) Sleep
5) Drugs
- Nitroglycerine, histamine, reserpine, hydralazine, ranitidine
6) Physical-environmental
Migraine vs Tension-type vs Cluster
- Gender
- Location
- Frequency
- Severity and duration
- Pain characteristics
- Misc
- More common in females except for Cluster
- M: One side, T: Band-like, C: Peri-orbital
- M: 1-4/month, T: 1-30/month, C: 1-4/day for 3-12 months
- M: Mod-severe for 4-72 hours, T: Mild-moderate for variable time, C: Extremely severe for 15 min - 3hrs
- M: Throbbing and pulsating, T: Dull and boring, C: Sharp
- M has most family history
- M has aura
- C has autonomic features
- M has NN/V/, photopsia and exacerbation by movement
What is the treatment for migraines?
1) NSAIDs
- NAPROXEN, IBUPROFEN
2) Mixed barbiturate analgesics
- ASPIRIN, ACETAMINOPHEN, Codeine-containing compounds
3) Triptans
- SUMATRIPTAN, ZOLMITRIPTAN/Zomig
4) Anti-emetics
- PROMETHAZINE, PROCHLORPERAZINE, METOCLOPRAMIDE
What are the prophylaxis for migraines?
1) Beta-blockers
2) Calcium antagonists
- FLUNARIZINE
3) Anticonvulsants
- VALPROATE
4) NSAIDs
- NAPROXEN
5) Tricyclic antidepressants
- AMITRIPTYLLINE
What are the main side effects for each migraine prophylactic?
1) B-blocker
- Weight gain, depression, cold extremities
2) Calcium antagonists
- Sedation, weight gain, depression, constipation
3) Anticonvulsants
- Tremor, weight gain, hair loss
4) NSAIDs
- Dyspepsia, peptic ulcers
5) Tricyclic antidepressants
- Sedation, dry mouth, weight gain
When is migraine prophylaxis started?
- > 2 attacks/month
- Significant disability that lasts >3 days
- Ineffectiveness of symptomatic medications
- Use of abortive medications >2x/week
- For rare migraine variants (hemiplegic migraine, migraines producing profound disruption or neurological injury)
What is medication overuse and rebound in migraines?
- Due to regular use oof acute, symptomatic medication for headaches (>15 days/month)
- eg Simple analgesics >5 days/week, Triptans >3 days/week, Opioids >2 days /week
What is the MIDAS questionnaire?
- Self-administered Migraine Disability Assessment
- Assess headache over a 3 month period
- If score >6 days, see doc
