Headache Flashcards

1
Q

If the brain does not have pain receptors, what causes the pain?

A
  1. meninges - inflammation due to meningitis.
  2. blood vessels - stretching/traction or distension of arteries.
  3. skull - sinusitis or dental problems
  4. muscles - the head and neck (e.g. increased muscle tension d/t TMJ)
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2
Q

Which nerve transmits most pain signals in the head and where does it synapse?

A

The trigeminal nerve.

Synapse at the brainstem.

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3
Q

Pain signals from the back of the head and the posterior fossa (base) of the skull are transmitted by the…

A

First three cervical spinal nerves.

Synapse at the brainstem.

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4
Q

Describe the role of second and third order neurons.

A

2nd order neurons = project to the thalamus then…

3rd order neurons = to the somatosensory cortex

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5
Q

Define primary and secondary headaches.

A

Primary = not caused by another disorder. Chronic and recurring.:
- migraine
- tension-type headache
- cluster-type headache
- other

Secondary = caused by another disorder so headache is a symptom:
- trauma/injury
- vascular disorder
- substance use/withdrawal etc.

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6
Q

What are temporomandibular disorders (TMD)?

A
  • Caused by teeth grinding, trauma, disc displacement, degeneration (arthritis)
  • headache increases with jaw movement (chewing, grinding, clenching)
  • joint inflammation spreads to affect nearby muscles and fascia
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7
Q

Describe the pathopysiology of secondary headache.

A
  • irritation, ischemia or stretching of pain-sensitive structures around the brain (meninges and vessels)
  • or pain-sensitive structures around the head (muscle, bone, peripheral nerve, join, sinus)
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8
Q

What could a sudden onset (thunderclap - max intensity <1 min) headache signal?

A

Subarachnoid hemorrhage.

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9
Q

What could a new onset headache in >50 year old signal?

A

Brain tumor

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10
Q

What could focal neurological deficits lasting >1 hour signal?

A

CVA

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11
Q

What could new headache with stiff neck, fever, or rash indicate?

A

meningitis

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12
Q

What could headache with papilledema or decreased LOS indicate?

A

Increased ICP

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13
Q

What could headache triggered by sneezing, coughing or straining indicate?

A

Chiari malformation (the cerebellum bulges through a normal opening in the skull where it joins the spinal canal).

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14
Q

Describe the characteristics of a tension headache.

A
  • most common
  • bilateral
  • steady pressing, tightening, bandlike quality
  • mild to moderate severity
  • duration: 30 mins - several days
  • photophobia OR phonophobia NOT both
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15
Q

Pericranial and/or nuchal muscle tenderness (detected by palpation) often accompanies what type of headache?

A

Tension type headaches. (TTH)

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16
Q

Episodic vs chronic tension type headaches headaches.

A

Episodic = occurs < 15 days/month

Chronic = occurs 15 or >15 days/month for >3 months

17
Q

Describe the pathophysiology of tension type headaches.

A
  • exact mechanism unknown
  • attributed to activation of myofascial nociceptors (head, neck shoulders) = could be triggered by stress, poor posture, and sleep disturbances
18
Q

What is the role of peripheral sensitization in tension type headaches?

A

Peripheral sensitization of myofascial nociceptors contributes to muscular hypersensitivity in TTH.

Neuropeptides act on nociceptors to move the membrane potential closer to threshold.

Increased excitability leads to hyperalgesia or allodynia.

19
Q

Describe the characteristics of cluster headaches.

A
  • unilateral
  • severe
  • pain occurs around one eye (orbital or supraorbital) and may extend back toward the ear (temporal)
  • one or more autonomic symptom on the affected side: eye redness/lacrimation, eyelid edema, nasal congestion/rhinorrhea, forehead/facial sweating, miosis (pupil restriction) /ptosis (upper eyelid droops)
  • sense of restlessness or agitation
  • Attacks are sudden and last 15-180 min
20
Q

What is involved in the acute treatment of cluster headaches?

A
  • Triptans and 100% O2 by mask
  • Verapamil is most commonly used for prevention
  • a CGRP antagonist or corticosteriod can be used to decrease frequency or severity during a cluster period
21
Q

Describe the ‘cluster’ component of cluster headaches.

A
  • Occur in ‘clusters’ then disappear for months/years
  • cluster periods last 7 - 365 days
  • frequency during cluster period: once every other day to 8 per day
  • triggers during cluster period can include alcohol, nicotine, nitro etc.
22
Q

What are circadian periodicity and Circannual peridocity in cluster headaches?

A

Circadian periodicity = single attacks often occur at the same time of day. Most common (50%) occur at night, 2-3 hours after falling asleep (known as the alarm clock headache).

Circannual periodicity = cluster periods often occur during a certain season

23
Q

Describe episodic vs chronic cluster periods.

A

Episodic (80-90%) = separated by pain-free remission period of 3 or > 3 months

Chronic (10-15%) = occur without remission or remission periods last < 3 months.

24
Q

Who is affected by cluster headaches?

A
  • 0.1% of the population
  • typically males (3:1)
  • mean onset of 30 years
25
Q

Describe the pathophysiology of cluster headaches

A

Classified as a trigeminal autonomic cephalalgia.

The opthalmic branch (sensory) of the trigeminal nerve is activated causing pain.

26
Q

What is responsible for the autonomic (parasympathetic) symptoms in cluster headaches?

A

A trigeminal autonomic reflex (e.g lacrimation, rhinorrhea).

27
Q

What is thought to contribute to the clockwise and seasonal regularity of cluster headaches?

A

Dysfunction of the hypothalamus (the biological clock)

28
Q

Describe the characteristics of a migraine?

A
  • unilateral, pulsating, throbbing
  • can be bilateral and non-throbbing
  • moderate to severe
  • 4-72 hours
  • associated symptoms: nausea and vomiting, photophobia and phonophobia
  • aggravated by routine physical activity or head movement
  • relieved by sleep
29
Q

Describe episodic vs chronic migraines.

A

Episodic = 1-2/month - 1/year or several times a week.

Chronic = 15 or >15 days/month for 2 or >3 months

30
Q

What is the second most common type of headache?

A

Migraines - 12 % of the population affected

31
Q

Typical age of onset for migraines?

A

Can occur in childhood. 80% report first migraine before the age of 30. New onset rare after age 50.

32
Q

Which headaches are more common in females then males?

A

migraines = 2-3x more for females

for males 3:1 ratio for cluster headaches

33
Q

Describe the three classifications of migraines.

A
  1. migraine with aura (warning signs - visual, sensory, speech and/or language, motor, brainstem, retinal)
  2. migraine without aura
  3. chronic migraine
34
Q

What is a retinal migraine?

A

Different from a visual aura.
Rare.
Visual symptoms are monocular
Headache typically occurs within an hour of symptom onset
Need to r/o hemianopia

35
Q

Describe migraine pathophysiology.

A

A neurologic disorder resulting form dysfunction of the trigeminovascular system.

A neurovascular disorder causing hypersensitivity to the peripheral trigeminal nerve fibres that innervate blood vessels for the meninges.

36
Q

What is cortical spreading depression (CSD)?

A

A spontaneous wave of electrical activity and hyperemia spreads forward across the cerebral cortex from the occipital region resulting in hypersensitivity.

Electrical activity is depressed (including blood flow) in the area behind for up to 30 mins after wave passes.

Can be clinically silent of manifest as the aura.

37
Q

What is responsible for migraine pain?

A

Activation of the trigeminal nerve by the CSD (cortical spreading depression) and the release of nuerotransmitters and neuropeptides.

38
Q

The trigeminal nerve innervates…

A
  • meningeal blood vessels and dura mater (detects stretch)
  • muscles of the face
  • the nasal cavity and sinuses