Headache Flashcards
What are primary headaches?
Headaches with no underlying medical cause
What are the three main forms of primary headache?
Tension Type Headache
Migraine
Cluster Headache
What are secondary headaches?
Headaches with an identifiable structural or biochemical cause
What are some secondary headache causes?
Tumour Meningitis Vascular disorders System Infection head injury
Describe Tension-Type headache
Mild, bilateral headache often described as pressing or tightening
No significant associated factors
Not aggravated by routine physical activity
Almost 50% lifetime prevalence in men and women
Not disabling
What is the abortive treatment for tension-type headache?
Aspirin/Paracetamol
NSAIDs
Limit to 10 days per month
What is the preventative treatment for tension-type headache?
This is rurally required but can consist of tricyclic antidepressants - amitriptyline, dothiepin, nortriptyline
What WHO classification underlines the high impact of migraine?
It is listed at number seven of the twenty most disabling conditions
What is the lifetime UK prevalence of migraine?
Men - 10%
Women - 22%
What are features of a migraine attack?
Headache
Nausea, photophobia, phonophobia, functional disability
What is the generally held principle of migraine?
That it arises from a primary brain dysfunction that leads to activation and sensitisation of the trigeminal system
Outline some triggers of migraine
Changes in oestrogen levels Stress Hunger Sleep disturbance Dehydration Diet
The brain of a migraine sufferer is said to be hypersensitive to normal stimuli
Describe the phases of onset of migraine
The premonitory phase - predictors of the attack that may include mod changes, muscle cramps, yawning
The Aura phase - This inclines focal, reversible neurological symptoms that may precede headache
They are thought to arise from an electrical disturbance known as cortical spreading depression (CSD) - 15-30% of migraines
The headache phase - This can progress through early headache that features mild pain and associated symptoms, to advanced headache which features moderate to severe pain with the more disabling symptoms of migraine
The postdrome phase - the phase of migraine associated symptoms which may continue after the headache phase has resolved for 1 to 2 days
Approximately how many migraine sufferers are affected by aura?
One third
What features of aura mean that they can be confused with an ischaemic attack?
Loss of function
Sudden onset
What are the criteria for migraine to classified as chronic?
Headache on 15 or more days of the month, of which 8 or more must be migraine, for more than 3 months
What can medicine used to combat acute migraine on a regular basis cause?
Medicine overuse-induced migraine. Often dramatically improved by cessation of medication
Outline the causes of medication overuse headache
Headache present for 15 or more days of the month which has developed or worsened whilst taking a regular symptomatic medication
Particularly in use of triptans, ergots, opiods and combination analgesics >10days/month
Can be in use of simple analgesics for more than 15days per month and in caffeine overuse such as coffee, tea, cola and irn bru
What is the abortive treatment for migraine?
Aspirin or NSAIDs
Triptans
Limit to 10 days per month
What is the preventative treatment for migraine?
Propranolol, candesartan
Anti-epileptics such as topiramate, valproate and gabapentin
What is often the affect of pregnancy on migraine without aura?
It gets better
What are some trigeminal autonomic cephalagias?
Cluster headache
Paroxysmal hemicrania
SUNCT - short-lasting unilateral neuralgiform headache with conjunctival injection and tearing
SUNA - short-lasting unilateral neuralgiform headache with autonomic symptoms
Describe cluster headaches
Strictly unilateral attacks of rapid onset that last between 15mins and 3 hours
The pain is extremely severe, often described by mothers as worse than childbirth - patients are restless and agitated
Cessation of the pain occurs rapidly
In 90% of patients alcohol is a precipitating factor in the hour before the onset of the bout
How does paroxysmal hemicrania differ from cluster headache?
Technically, the only difference is that PH responds completely to indometacin. However, PH is characterised by shorter duration and higher frequency- generally 2-40 attacks per day, and lack of connection with alcohol consumption
Describe SUNCT - short-lasting unilateral neuralgiform headache with conjunctival injection and tearing
Unilateral orbital, supraorbital or temporal pain that is stabbing or pulsating
Lasts for 10-240 seconds
Often has cutaneous triggers such as wind, cold, touch and chewing
Between 3 and 200 attacks per day
Describe trigeminal neuralgia
Unilateral maxillary or mandibular division pain - stabbing
Lasts for 5-10 seconds
Attack period 3-200
What treatment is available for paroxysmal hemicrania
Abortive - none
Prophylaxis - indometacin
What abortive treatment is available for SUNCT/SUNA?
Abortive - none
Prophylactic - lamotrigine, topiramate, gabapentin, carbamazepine/oxcarbazepine
What treatment is available for trigeminal neuralgia?
Abortive - none
Prophylactic - carbamazepine, oxcarbazepine
Surgical - glycerol ganglion injection, stereotactic radio surgery, decompressive surgery
What preventative treatment is available for cluster headache?
High dose verapamil
Lithium
Methysergide
Topiramate
Give some associating factors which can suggest a more sinister cause of headaches
Associated head trauma First or worst headache Sudden thunderclap onset New persistent daily headache change in headache pattern or type
Give some red flags indicative of serious secondary headaches
New onset headache
New or change in headache - aged over 50, immunosuppression or cancer
Change in frequency, characteristics or associated symptoms
Focal neurological symptoms
Non-focal neurological symptoms
Abnormal neurological examination
Neck stiffness/fever
High pressure
- worse when lying down
- wakening the patient up
- precipitated by physical exam
- precipatated by valsalva
- risk factors for cerebral venous sinus thrombosis
Low pressure
-headache caused by sitting/standing up
GCA
- jaw claudication or visual disturbance
- prominent or beaded temporal arteries
What is the definition of a thunderclap headache?
A high intensity headache reaching maximum intensity in less than one minute - the majority peak instantaneously
Give some likely differential diagnoses for thunderclap headaches
Primary - migraine/primary thunderclap
Subarachnoid haemorrhage
Intracerebral haemorrhage
TIA/stroke
What proportion of patients with a thunderclap headache will have a subarachnoid haemorrhage?
10%
85% of the SAHs are aneurysmal
What are key factors in management of patients who may have a SAH?
Never consider them too well, examination is often normal
At the time of the thunderclap headache, they must have a same day hospital assessment to determine cause
CT and LP must be done
What is an early treatment for SAH which can save lives if caught?
Coiling
What is it important to consider in any patient presenting with headache and fever?
CNS infection
What are the characteristics of meningitis?
Nausea with or without vomiting, photo/phonophobia, stiff neck
Look for rash
What are the characteristics of encephalitis?
Altered mental state or consciousness, focal symptoms or signs, seizures
Look for rash
Give some cases of raised intracranial pressure
Glioblastoma multiforme Cerebral abscess Venous infarct with focal area of haemorrhage Meningioma Hydrocephalus Pappilloedema
What are features suggestive of a space occupying lesion and or raised intracranial pressure?
A progressive headache with associated symptoms and signs
Warning signs include headaches waking the patient up, positional changes to headache and focal neurological signs
What causes intracranial hypotension?
A dural CSF leak that may be spontaneous or iatrogenic
How will intracranial hypotension due to a dural CSF least manifest in headache?
There will be a clear postural component to the headache, developing or worsening soon after assuming an upright position and lessens or resolves upon lying down
Once the headache becomes chronic it may lose its postural component
What is the Ix for suspected intracranial hypotension?
MRI brain and spine
What it the management for intracranial hypotension?
Bed rest, fluids, analgesia, caffeine
I.v. caffeine
Epidural blood patch
What is giant cell arteritis?
Arteritis of the large arteries in the brain
Should be suspected in any patient over the age of 50 presenting with new headache
What are the characteristics of headache and the patient in general that is suffering from giant cell arteritis?
Usually diffuse, persistent and may be severe
The patient may be systemically unwell
Specific features include scalp tenderness, jaw claudication and visual disturbance
Prominent, beaded or enlarged temporal arteries may also be present
What investigative indicators are suggestive of giant cell arteritis?
An elevated ESR - usually more than 50 often much higher
Raised CRP
Raised platelet count
What is the immediate management for suspected giant cell arteritis?
High dose prednisolone should be started
Temporal artery biopsy arranged
