Headache Flashcards
What is important to ask in a headache history in terms of onset?
Onset: Acute (seconds to minutes) SAH/Intra-cerebral haemorrhage/coital/thunderclap Evolving (hours to days) Infection/inflammatory/↑ICP Chronic (weeks to months) Chronic daily headache/ ↑ICP
What are sinister symptoms of headaches/along with headaches?
Cognitive effects Seizures Fever Visual disturbance Vomiting Weight loss
During examination of a patient with a headache, what would you look out for?
Fever/rash/neck stiffness/↑BP/organomegaly Fundal changes (papilloedema) Cranial nerve signs/Horners Syndrome Focal abnormalities Long tract signs
What are the characteristic features of sub-arachnoid haemorrhage?
Awoken with severe, sudden onset (seconds) head pains
Back of head, severity 10/10
Vomiting and confused
Clinically apyrexial, refusing fundoscopy and globally hyper-reflexic
Ocular movements appear impaired
What drugs can cause drug induced migraine?
mn
What is important to ask in a headache history in terms of periodicity?
Periodicity
Episodic (at least a few days free between attacks)
Migraine /Cluster headache
Chronic (headache most days)
Medication overuse/chronic migraine/hemicrania continua
What is important to ask in a headache history in terms of Associated features?
Associated features: Diurnal variation/postural element Nausea and vomiting Photophobia/ phonophobia Autonomic features (lacrimation/Horners/red eye)
What is important to ask in a headache history in terms of behaviour, family history, medication, concerns?
Behaviour
Lies down in dark room (Migraine)
Agitation/pacing (Cluster)
Family History
Migraine is often familial
Medication/ self medication
Analgesia (what? And how often?)
What is the patient concerned about?
What are the signs and symptoms of Raised Intracranial pressure?
Headache (worse on lying or awakening) Vomiting Seizures Papilloedema lateralising signs
What causes Raised Intracranial pressure?
Mass Effect (brain tumour, abscess)
Brain swelling (Hypertensive encephalopathy)
Increased venous pressure
CSF outflow obstruction (hydrocephalus)
Increased CSF production (meningitis/SAH)
What is the treatment of brain abscesses?
Resuscitation
Broad spectrum IV antibiotics (cefotaxime)
Steroids (dexamethasone) in patients with streptococcus pneumoniae meningitis
Neurosurgical consultation (craniotomy and drainage)
What are the signs and symptoms of temporal arteritis?
Signs/symptoms Weight loss Myalgia Transient loss of vision Jaw claudication Tender non-pulsatile temporal artery
What is the treatment of temporal arteritis?
Commence immediate high dose steroids
Prednisolone 60mg od for 1st week
Slow taper over 6 weeks to 15-20mg od
Arrange temporal artery biopsy
What are associated features with a migraine headache?
Nausea photophobia dizziness Focal migraine: Cranial neuropathies/cerebellar signs (basilar arteries involved) Hemiplegic (frontal lobe) Visual aura: black and white flashes/straight lines occipital seizure: coloured dots
How does migraines arise?
Neurovascular headache
Brain waves slow down
Cortical depression from occipital lobes = visual defects
then may spread to the parietal/frontal lobe = sensory loss/hemiparesis
What are triggers for migraines?
sleep deprivation
hunger
stress
oestrogens
What is the management for migraines?
Brain imaging:
Focal symptoms/signs lasting 24 hours or more
New onset daily migraine
Conservative measures:
Avoid caffeine/ increase water intake
Avoid tyramine foods (cheese/chocolate/red wine)
Sleep hygiene and regular meals
Analgesia:
Triptans/naproxen/paracetomol
Preventative treatment:
Propranolol/pizotifen/topiramate/valproate/amitriptiline/botox
What are the characteristics of Trigeminal autonomic cephalgias?
gradual onset unilateral right orbital pain
short-lasting headaches
variable autonomic features - red eye, eyelid droop
What is the management of Trigeminal autonomic cephalgias?
Pain relief
Sumatriptan (Class A)
High flow 100% oxygen
Prevention (start at beginning of cluster):
Prednisolone
Verapamil
Indomethacin
What are the characteristics of tension headache?
Intermittent BILATERAL headache
Described as tight band around head lasting several hours
normally just headache and no other symptoms
What is the management of tension headache?
Relaxation and massage
amitriptyline (if frequent)
Acupuncture
Ensure patient has recently had optician check - eye strain
Low intercranial pressure can be caused by what procedure causing a headache?
Lumber punture
Who commonly suffers with Idiopathic Intracranial Hypertension with what symptoms?
woman of child bearing age
Visual problems - papilledema
What is the definition of a chronic daily headache?
headache lasting over 4 hours on over 15 days per month for over 3 months
What are the treatment options for a chronic daily headache?
Withdraw analgesia if history of overuse
Consider amitriptyline/topiramate for transformed migraine