Headache Flashcards
Primary headache
Headache and its assocaited features that is the disorder (no underlying disorder) - tension headache, migraine, cluster headache
Secondary headache
Secondary to underlying cause e.g subarachnoid haemorrhage, space-occupying lesion, meningitis, temporal arteritis
Red flags from headache history (SNOOP)
Systemic symptoms: fever, weight loss
Neurological symptoms
Older age of onset
Onset is acute ( sudden, abrupt)
Previous headache history (worsening, increasing in frequency)
Headache history
- Age of onset
- Prodrome features
- .Pain scale
- Location and radiation
- onset (time to maximum)
- periodicity (duration and frequency)
- Associated features
- Triggers/ relieving factors
- FH in 90%
- Medication history
- Depression
General/systemic features on clinical examination
- reuced conscious level
- BP/pulse
Pyrexia
meningism
Skin rash
Cranial nerve features on clinical exam
- Pupillary responses, visual fields +/- blind spot, eye movements,
- fundoscopy
- III nerve palsy - down and out (drooping eyelid)
- VI nerve palsy - pulled in (raised ICP)
- Horners syndrome - small pupil and drooping eyelid
- Fundoscopy signs
- optic disc swelling - raised ICP (disc looks like a doughnut)
- Snuhyloid haemorrhafe (in 20% of SAH)- bleeding into lens
Neurological examination feaures
Upper motor neurone signs:
- Power - Decreased
- Tone- Increased
- Reflex- Brisk
- Fasciculations- absent
- Muscle wasting- Nil or subtle
LMN
- Power- Decreased
- Tone- Decreased
- Reflex- absent or reduced
- Fasciculations- Present
- Muscle wasting- Significant
Features of migrane
Females>males -
Most common in 25-55y/o -
Pulsatile/throbbing,
gradual onset, 4h-72hours long. -
60% are unilateral, 20% consistenyly one side
-Pain can change sides, radiate to neck
Scalp tenderness/allodynia.
Associated triggers of migraine
- nausea - 90% -vomitting - 30% - anorexia - food craving
Symptoms of migraine
photophobia- fear of bright lights
phonophobia - fear of loud noises
osmophobia - fear of odours
mood changes blurred vision, nasal stuffiness, sweating
Triggers of migraine (CHOCOLATE)
Chocolate hangovers orgasms cheese oral contraceptives lie-ins tumult exercise
The four phases of migraine
- prodrome 2. aura 3. Headache 4. postdrome
Prodrome phase
- 50% have
- 48hrs before headache
- variable symptoms
Aura phase
-recurrent reversible symptoms (visual, sensory, motor) -
develops 5-20 mins lasts for 60 -
visual aura most common (scotoma, visual field loss, flashing lights)
- sensory- starts in arms and radiates up arm
- motor–> rarer weakness most common
Scotoma definition
partial loss of vision or blind sopt in an otherwise normal visual field
Headache phase
- character commmonly throbbing/pulsatile -moderate to severe -gradual onset and can last from 4-72 hours -unilateral in 60% radiates to the neck
Postdrome phase
depressant effects: impaired concentration, lethargy
elevant effects: euphoria, heightened energy, heightened state of alertnesss
Diagnosis/ Invesitagations of migraine
Good history and normal clinical exam does not require further investigations cranial imaging advised if “red flag” symptoms are presnt or aura .24 hours
Complications of migriaine
- Medication overuse headache (MOH): headache 15+ days per month associated with frequent use of acute relief medication e.g. NSAIDs, paracetamol, opoids, triptants -
Patients advised to take acute treatments no more than 2-3 months times per week to prevent MoH
-Chronic miraine: headache on 15 days+ per month
Management of migraine
Lifestyle: avoid triggers, reduce caffeine and alcohol, encourage regular meals and sleeping patterns
Acute management: simple analgesia –paracetamol, aspirin and NSAIDs. Triptans (sumatriptan)- serotonin agonists which dilate intracranial vessels. +/- antiemetic-domperidone and metoclopramide
Prophylaxis: Beta-blocker, Tricyclic antidepressants, Anti-epilepsy drugs- topiramae and sodium valproate
Pathophysiology of migraine
- Neurovascular disorder- spreading cortical depression leads to increased sensitivity vascular changes. Overallvascular changes secondary to neural activation.
- Primary dysfunction in brainstem sensory nuclei (V, VII-X)
3, Pain results from pain sensitive cranial blood vessels and trigeminal fibres that innervate them
Features of thunderclap headache
- Abrupt onset of severe headache - reaches maximal intensity within 5 minutes, probably less than a minute. -Feels like being hit over the head). Assumed to be Subarachnoid Haemorrhage until proven otherwise
Differential diagnosis of thunderclap headache
Venous sinus thrombosis, stroke non-vascular - Spontaneous intracranial hypotension, encephalopathy, meningitis
Investigations of thunderclap headache
Primary aim is to identifif Subarachnoid haemorrhage
- Bloods: U&Es, LFTs, glucose, FBC, coagulation screen and CRP
- Blood cultures if pyrexial
- 12-lead ECG -
Urgent CT brain: Blood visible in 90% of SAH within 24 hours
-Lumbar puncture: Performed after 12 hours to look for xanthochromia- change in CSF (blood breakdown)
