Headache Flashcards
How is headache divided?
Primary Headache
- Most headache (90% GP vs 60% A+E)
- No underlying medical cause
Secondary Headache
- Has identifiable structural or biochemical cause
- Not all secondary is sinister
Give examples of primary headache
Tension Type Headache
Migraine
Cluster Headache
Give examples of secondary Headache
Tumour Meningitis Vascular disorder Systemic infection Head injury Drug-induced
What is Primary headache?
Increased sensitivity of normal intracranial pain pathways to what is going on in the environment
Describe tension-type headaches
Most frequent primary headache, but is NOT disabling and rarely presents to doctors
Lifetime prevalence of 42% in men and 49% in women
Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity
What is the difference between Infrequent ETTH, Frequent ETTH and CTTH?
Infrequent Episodic Tension-Type Headache (/= 15 days / month)
What is the treatment for tension-type headache?
Absorptive treatment:
- Aspirin or paracetamol
- NSAIDs
- Limit to approx 2 days per week to avoid the development of medication overuse headache
Preventative treatment:
-Rarely required
-Tricyclic antidepressents
(AMITRIPTYLINE, dothiepin, nortriptyline)
What is migraine?
A chronic disorder with episodic attacks
Complex charges in the brain that lead to activation and sensitisation of the trigeminal system
Most frequent DISABLING primary headache
What are the symptoms during attacks of migraine?
One of the following symptoms should be present along with headache:
- Nausea and/or vomiting
- Photophobia,
- Phonophobia
What are the symptoms between attacks of migraine?
Enduring predisposition to future attacks
Anticipatory anxiety
What is the criteria for a migraine?
Both with an without aura, headaches must last for 4 to 74 hours.
In addition the headaches must have at least 2 of the following features:
-Unilateral location
-Pulsating quality
-Moderate or severe pain
and/ or aggravation by or causing avoidance of routie physical activity (e.g. walking, climbing stairs
What are the triggers of migraines?
STRESS Hunger Sleep disturbance Dehydration Diet Environmental stimuli Changes in oestrogen levels in women
How does migraine evolve over time?
Migraine is manifested clinically as a constellation of symptoms that evolve through the various phases of a migraine attack.
Clinical experience indictaes that symptoms typically associated with each phase of an attack often recur during other pases of the attack, resulting in continuum of symptoms, rather than a succession of distinct phases.
Describe the premonitory phase of a migraine attack
70% with or without aura experience premonitory symptoms
Often seen as predictors of the headache attack
Mood alterations, muscle pain, food cravings, cognitive changes, fluid retention, yawning
What is an aura?
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve visual, sensory, motor or speech symptoms
-Show a slow evolution of symptoms from 1 area to the next (e.g. vision -> sensory -> speech)
Aura symptoms are believed to arise from an electrical disturbance called cortical spreading depression (CSD)
Describe the aura phase of migraine
Involves focal, fully reversible neurologic symptoms that often precede headache.
Visual somatosensory symptoms often described
Duration = 15-60 mins
Describe the early headache phase of migraine
Mild pain without the associated symptoms of migraine
Nasal congestion
Muscle pain
Describe the advanced headache phase of migraine
Moderate to severe unilateral throbbing pain with associated symptoms of:
-Nausea, photophobia, phonophobia or disability.
Describe the postdrome phase of migraine
Phase of migraine associated symptoms beyond the resolution of the headache (often entails significant disability that can last for 1 or 2 days)
Fatigue
Cognitive changes
Muscle pain
Summarise the phases of migraine by listing them in order
Premonitory Aura Early headache Advanced headache Postdrome
What can aura symptoms be confused with?
How do you differentiate?
TIA:
TIA differs in that it involves:
- Loss of function
- Sudden onset
- Symptoms all start at same time and can be localised to a specific vascular area
What is chronic migraine?
Headache on >/= 15 days per month, of which >/= 8 days have to be migraine, for more than 3 months
What is Medication Overuse Headache?
Headache present on >/= days/month which has developed or worsened whilst taking regular symptomatic medication
Can occur in any primary headache:
- Migraineurs are particularly prone to MOH
- Migraineurs taking pain medication for another reason can develop chronic headache
What causes Medication Overuse Headache?
Use of triptans, ergots, opioids and combination analgesics >10days/month
Use of simple analgesics >15 days per month
Caffeine overuse: coffee, tea, cola etc
What is the abortive treatment for migraine?
- Aspirin or NSAIDs
- Triptans
- Limit to approx 2 days per week to avoid medication overdose headache
What is the prophylactic treatment for migraine?
- Propranolol, Candesartan
- Anti-epileptics (Topiramate, Valproate, Gabapectin)
- Tricyclic andtidepressents (amitriptyline, dothiepin, nortiptyline)
- Venlafaxine
How is migraine effected in pregnancy?
Migraine without aura gets better in pregnancy
Migraine with aura usually doesnt change
First migraine can occur during pregnancy
-Particularly migraine with aura
Why should you avoid anti-epileptics in a woman of child bearing age?
Teratogenicity of medication
Ensure adequate contraception
How is the treatment of migraine different in pregnancy?
Treatment is more difficult
Acute attack: Paracetamol
Preventative: Propanolol or Amitriptyline
No anti-epileptics
What are the Trigeminal Autonomic Cephalalgias?
Cluster Headache
Paroxysmal Hemicrania
SUNCT = Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing
SUNA = Short-lasting Unilateral Neuralgiform headache with Autonomic symptoms
What is the attack in Cluster Headache like?
Pain = mainly orbital and temporal
Attacks are UNILATERAL Radip onset (
What migrainous symptoms are often present in cluster headache?
Premonitory: tiredness, yawning
Associated symptoms: nausea, vomiting, photo- and phonophobia
Typical aura
What autonomic symptoms may be present in Trigeminal Autonomic Cephalalgias?
Conjunctival injection Nasal congestion Eyelid oedema Forehead and facial swelling Miosis/ ptosis
Describe the bouts in Cluster Headaches?
Episodic in 80-90%
-Attacks cluster into bouts lasting about 1-3 months with periods of remision lasting at least a month
- Frequency: 1 every day to 8 per day
- May be continuous backgorund pain between attacks
Alcohol triggers attacks during a bout but not in remission
How does circadian rhythm play a role in cluster headache?
Attacks occur at the same time each day
Bouts occur at the same time each year
10-20% of patients who have cluster headaches have chronic cluster headache.
What is this?
Bouts last >1 year without remission or…
Remission last
Describe Paroxysmal hemicrania
Attack frequency: 1-40 per day
-(1-8 in Cluster)
Duration of attack: 2-30mins
(15-180mins in Cluster
Pain quality: Sharp throbbing
(Cluster = same)
Pain intensity: very severe
(Cluster = same)
Circadian periodicity = 45%
(70% in cluster)
Describe SUNCT
Attack frequency:
-3-200
(1-8 in cluster)
Duration: 5-240 seconds
(15-180 mins in cluster)
Pain quality:
-stabbing, burning
(sharp, throbbing in cluster)
Pain intensity: very severe
(same as cluster)
No circadian periodicity
What is paroxysmal hemicrania?
Pain = mainly orbital and temporal, UNILATERAL, rapid onset, 2-20 mins, rapid cessation of pain
Prominent ipsilateral autonomic symptoms
10% attacks can be preceiptated by BENDING OR ROTATING HEAD
What is the treatment for Paroxysmal hemicrania?
Absolute response to indometacin as a prophylactic treatment
Describe SUNCT
Unilateral orbital, supraorbital or temporal pain which is stabbing or pulsating
10-240 seconds duration
Attack frequency = 3-200 per day, no refractory period
Pain accompanied by conjunctival injection and lacrimation
How does the pain differ in SUNCT?
Stabbing or pulsating pain may be single stabs, group of stabs or have a sawtooth pattern
What are the cutaneous triggers for SUNCT?
Wind, cold
Touch
Chewing
What is trigeminal neuralgia?
Unilateral maxillary or mandibular division pain > opthalmic division
Stabbing pain of a single or multiple stabs
5-10 sec duration
Attack frequency similar to SUNCT, has refractory period
Autonomic features uncommon
What is the abortive treatment for a cluster headache?
SC Sumatriptan 6mg or nasal zolmatriptan 5mg
100% oxygen
What is the abortive treatment for a bout of cluster headaches?
Occipital depomedrone injection (same side as the headache)
Or tapering course of oral prednisolone
What is the preventative medication in cluster headache?
- Verapamil (high doses possibly)
- Lithium
- Methysergide (risk of retroperitoneal fibrosis)
- Topiramate
What is the abortive treatment in paroxysmal hemicrania?
No abortive treatment only prophylactic
What is the treatment for SUNCT/SUNA?
No abortive treatment
Prophylaxis
- Lamotrigine
- Topiramate
- Gabapentin
- Carbamazepine
What is the treatment in Trigeminal Neuralgia?
No abortive
Prophylaxis:
- Carbamazepine
- Oxcarbazepine
Surgical Intervention:
- Glycerol ganglion injection
- Steriotactic radiosurgery
- Decompressive surgery
What presentations of headache are more likely to have a sinister cause?
- Associated head trauma
- First or worst headache
- Sudden (thunderclap) onset
- New daily persistent headache
- Change in headache pattern or type
- Returning patient (keeps getting worse)
What are some of the red flags in headache?
New onset headache
New or change in headache:
- aged over 50
- Immunosupression or cancer
Change in headache frequency, characteristics or associated symptoms
- Focal neurological symptoms
- Non-focal neurological symptoms
- Abnormal neurological examination
Neck stiffness/ fever
high pressure
Low pressure
Giant cell arthritis
What are the signs of high intracranial pressure in headache?
- Headache worse when lying down
- Headache wakening patient up
- Headache precipitated by physical exertion
- Headache precipitated by valsalva manoeuvre
- Risk factors for cerebral venous sinus thrombosis
What are the signs of low intracranial pressure in headache?
Headache precipitated by sitting/standing up
What are the signs of Giant Cell Artiritis
Jaw claudication or visual disturbance
Prominent or beaded temporal arteries
More common in 70’s/80’s
What is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than 1 minute
Majority are peak intensity
May be primary or secondary although no differentiating features
What is the differential diagnosis of thunderclas headache?
- Subarachnoid haemorrhage
- Intracerebral haemorrhage
- TIA/Stroke
- Carotid/ vertebral dissection
- Cerebral venous sinus thrombosis
- Meningitis/ encephalitis
- Pituitary apoplexy
- Spontaneous intracranial hypotension
How many patients with a thunderclap headache are having a subarachnoid haemorrhage?
1 in 10
Who should you act on when especially suspect a SAH in?
All patients presenting with a sudden severe headache that peaks within a few minutes and lasts for at least 1 hour
Examination is often normal
Never consider a patient “too well” for SAH
How do you treat someone with suspected SAH?
SAME DAY hospital assessment
CT brain
Lumbar Puncture (must be done >12 hours after headache onset)
CT +/- LP is unreliable beyond 2 weeks and angiography is required beyond this time
When should CNS infection be considered?
Any patient presenting with headache and fever
How to spot meningism?
Nausea +/- vomiting, photo/phono-phobia, stiff neck
look for a rash
How to spot encephalitis?
Altered mental state/ consciousness
Focal symptoms/ signs
Seizures
Look for a rash
How do you investigate Intracranial Hypotension?
MRI brain and spine
WHat is the treatment for Intracranial hypotension?
Bed rest, fluids, analgesia, caffeine (red bull)
IV caffeine
EPIDURAL BLOOD PATCH
What is giant cell arteritis?
Arteritis of large arteries (on spectrum with polymyalgia rheumatica)
Should be considered in any patient over the age of 50 presenting with new headache
What are the symptoms and signs of giant cell arteritis?
Headache usually diffuse, persistant and may be severe.
Patient mey be systemically unwell.
Specific features include scalp tenderness, jaw claudication and visual disturbance.
Prominent, beaded or enlarged temporal arteries may be present
What investigations can you perform to confirm Giant Cell Artiritis?
An elevated ESR supports diagnosis (usually >50, often much higher, rarely normal)
Raised CRP and platelet count are other useful markers
What is the course of action if giant cell arteritis is the likely diagnosis?
High dose prednisolone should be started and a temporal artery biopsy arranged
