Headache Flashcards by Adam Davie

What are primary headaches?

Headaches with no underlying medical cause

How well did you know this?

Not at all

Perfectly

What are the three main forms of primary headache?

Tension Type Headache
Migraine
Cluster Headache

How well did you know this?

Not at all

Perfectly

What are secondary headaches?

Headaches with an identifiable structural or biochemical cause

How well did you know this?

Not at all

Perfectly

What are some secondary headache causes?

Tumour
Meningitis
Vascular disorders
System Infection
head injury

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What is the abortive treatment for tension-type headache?

Aspirin/Paracetamol
NSAIDs
Limit to 10 days per month

How well did you know this?

Not at all

Perfectly

What is the preventative treatment for tension-type headache?

This is rurally required but can consist of tricyclic antidepressants - amitriptyline, dothiepin, nortriptyline

How well did you know this?

Not at all

Perfectly

What WHO classification underlines the high impact of migraine?

It is listed at number seven of the twenty most disabling conditions

How well did you know this?

Not at all

Perfectly

What is the lifetime UK prevalence of migraine?

Men - 10%

Women - 22%

How well did you know this?

Not at all

Perfectly

What are features of a migraine attack?

Headache

Nausea, photophobia, phonophobia, functional disability

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Approximately how many migraine sufferers are affected by aura?

One third

How well did you know this?

Not at all

Perfectly

What features of aura mean that they can be confused with an ischaemic attack?

Loss of function

Sudden onset

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What can medicine used to combat acute migraine on a regular basis cause?

Medicine overuse-induced migraine. Often dramatically improved by cessation of medication

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What is the abortive treatment for migraine?

Aspirin or NSAIDs
Triptans
Limit to 10 days per month

How well did you know this?

Not at all

Perfectly

What is the preventative treatment for migraine?

Propranolol, candesartan

Anti-epileptics such as topiramate, valproate and gabapentin

How well did you know this?

Not at all

Perfectly

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