Headache Flashcards
- Recurrent, severe headache which is usually unilateral and throbbing in nature
- May be be associated with aura, nausea and photosensitivity
- Aggravated by, or causes avoidance of, routine activities of daily living. Patients often describe ‘going to bed’.
- In women may be associated with menstruation
Migraine
- Recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’
- Not aggravated by routine activities of daily living
Tension headache
- Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours with clusters typically lasting 4-12 weeks
- Intense pain around one eye (recurrent attacks ‘always’ affect same side)
- Patient is restless during an attack
- Accompanied by redness, lacrimation, lid swelling
- More common in men and smokers
Cluster headache
- Typically patient > 60 years old
- Usually rapid onset (e.g. < 1 month) of unilateral headache
- Jaw claudication (65%)
- Tender, palpable temporal artery
- Raised ESR
Temporal Arteritis
- Present for 15 days or more per month
- Developed or worsened whilst taking regular symptomatic medication
- May be psychiatric co-morbidity
Medication Overuse Headache
What medciations put a patient at most risk of medication overuse headache?
Opioids and Triptans
What is the management of medication overuse headache?
Abruptly withdraw - triptans and simple analgesics
Gradually withdraw - opiod analgesics.
Describe the 15 RED FLAGS of headache.
- Compromised immunity, caused, for example, by HIV or immunosuppressive drugs
- Age under 20 years and a history of malignancy
- A history of malignancy known to metastasis to the brain
- Vomiting without other obvious cause
- Worsening headache with fever
- Sudden-onset headache reaching maximum intensity within 5 minutes
- New-onset neurological deficit
- New-onset cognitive dysfunction
- Change in personality
- Impaired level of consciousness
- Recent (typically within the past 3 months) head trauma
- Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise
- Orthostatic headache (headache that changes with posture)
- Symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
- A substantial change in the characteristics of their headache
What are some other causes of headache?
- Meningitis
- Encephalitis
- Subarachnoid haemorrhage
- Head injury
- Sinusitis
- Glaucoma (acute closed-angle)
- Tropical illness e.g. Malaria
- Chronic headache - raised ICP, Paget’s disease and psychological.
What is the definition of chronic-type headache?
A tension headache occuring on 15 or more days per month.
What are the NICE guidelines on the management of tension-type headache?
Acute: Asprin, paracetamol, NSAIDs.
Prophylais - 10 sessions of acupuncture over 5-8 weeks.
What drug is widely used for prophylaxis for headache and what does NICE recommend regarding it?
Amitriptyline
2012 NICE guidelines do not support it.
- A 74-year-old lady presents to your surgery with a four month history of headaches. She says that they occur over the right fronto-parietal area and describes them as a constant dull ache, worse at night, occasionally waking her from sleep. She has taken paracetamol which has not really helped.
- She has not experienced any nausea, vomiting, loss of consciousness, seizures, forgetfulness or tinnitus.
- Her medical history includes carcinoma of the breast at the age of 35 necessitating right mastectomy. She has hypertension well-controlled for the last ten years by amlodipine 10 mg daily.
- Clinical examination was unremarkable except for a right-sided mastectomy scar and evidence of mild osteoarthritis in several joints. Neurological examination showed no abnormality and there was no papilloedema.
- What is the next step in the management of this patient?
Refer urgently.
- Any patient with previous cancer & who develops a headache should be urgently referred.
- Also refer if they develop any of the following:
- Recent onset seizure
- Progressive neurological deficit
- New neurological signs.
- New mental or cognitive change
