Headache Flashcards
What are some red flags in a headache presentation?
New onset >55yo Known/previous malignancy Immuno-suppressed Early morning headache Exacerbation by Valsalva (coughing, sneezing-raised ICP)
What is the migraine M:F ratio?
1:2.5
How many migraines present with aura?
20%
What is the IHS criteria for migraine without aura?
At least 5 attacks
Duration 4-72hrs
2 of: moderate/severe, unilateral, throbbing pain, worst movement
1 of: autonomic features, photophobia/phonophobia
What is the pathophysiology of migraine?
Both vascular and neural influences cause migraines in susceptible individuals
Stress triggers changes in brain, these cause serotonin to be released
Blood vessels constrict and dilate
Chemicals including substance P irritate nerves and blood vessels causing pain
What is the neurophysiology behind migraine with aura?
Cortical spreading depolarisation
Activation trigeminal vascular system-dilatation cranial blood vessels
Release of substance P, neurokinin A, CGRP
Describe migraine with aura
Aura fully reversible-visual, sensory, motor or language symptom
Duration 20-60mins
Headache follows
What are some migraine triggers?
Sleep Dietary Stress Hormonal Physical exertion
What is the non-pharmacological treatment of migraine?
Realistic goals
Education
Headache diary
Relaxation/stress management
What is the pharmacological treatment of migraine?
Abortive-NSAID (aspirin, naproxen, ibuprofen) (if gastroparesis consider anti-emetic) Triptans-5HT agonist Treat at start of headache Rizatriptain=eletriptain > sumatriptan Frovatriptan for sustained relief
When should headache prophylaxis be considered?
More than 3 attacks/month or very severe
Must trial for 4 month minimum
What pharmacological options are there in migraine prophylaxis?
Propranolol-reduction in freq of around 60-80% (avoid asthma, PVD, HF) Topiramate (CAI)- poor S/E profile Amitriptyline Gabapentin Pizotifen Sodium valproate
What are some adverse effects of topiramate?
Wt loss
Paraesthesia
Impaired concentration
Enzyme inducer
What Ix should be considered in migraine?
Typically none required
Consider imaging if >55yo, known malignancy or acephalgic migraine
What are the different types of migraines?
Acephalgic Basilar Retinal Ophthalmic Hemiplegic (familial/sporadic) Abdominal
What are the trigeminal autonomic cephalgias (TAC)?
A group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features
What are ipsilateral cranial autonomic features?
Ptosis Miosis Nasal stuffiness Nausea/vomiting Tearing Eye lid oedema
What are the 4 main types of TAC?
Cluster
Paroxysmal hemicranias
Hemicrania continua
SUNCT
Describe a cluster headache
30-40s
M>F
Striking circadian (around sleep) and seasonal variation
Severe unilateral, duration 45-90mins
Freq 1-8/day
Cluster bout may last from a few weeks to months
What is the treatment for a cluster headache?
High flow O2 100% for 20 mins
SC sumatriptan 6mg
Steroids-reducing course over 2 weeks
Verapamil for prophylaxis
Describe a paroxysmal hemicrania headache
50-60s F>M Unilateral headache/autonomic features Duration 10-30mins Freq 1-40/day
What is the treatment for a paroxysmal hemicrania headache
Indomethicin
What is a SUNCT headache
Short lived (15-120s) Unilateral Neuralgiaform headache Conjunctival injections Tearing
What is the treatment for a SUNCT headache
Lamotrigine
Gabapentin
What do patients with new onset unilateral cranial autonomic features require?
Imaging-MRI brain and MR angiogram
Describe trigeminal neuralgia
>60yo F>M Triggered by touch, usually V2/3 Severe stabbing unilateral pain Duration: 1s-90s Freq: 10-100/day Bouts of pain may last from a few weeks to months before remission
What is the treatment of trigeminal neuralgia?
Medical- carbamazepine, gabapentin, phenytoin, baclofen
Surgical- ablation vs decompression
When should trigeminal neuralgia patients get a brain MRI?
If any signs on examination, atypical features, a poor response to medical treatment or if surgical treatment is being considered
