Headache Flashcards
what is a primary headache?
Most common headache
No underlying medical cause
name a few primary headaches
Tension Type Headache
Migraine
Cluster Headache
what is a secondary headache?
has an identifiable structural or biochemical cause
give some causes of secondary headaches
Tumour Meningitis Vascular disorders Systemic infection Head injury Drug-induced
what is a tension-type headache?
Most frequent primary headache, but is NOT disabling and rarely presents to doctors
Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity
how often are infrequent ETTH?
< 1 day / month
how often are frequent ETTH?
1-14 days / month
how often are CTTH?
≥15 days/ month
what is the treatment for tension-type headache?
Abortive treatment
Aspirin or paracetamol
NSAIDs
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
what is a migraine?
most frequent disabling primary headache
Most sufferers aged 20 to 50
A chronic disorder with episodic attacks
Complex changes in the brain
what are the symptoms during the attacks?
Headache
Nausea, photophobia, phonophobia
Functional disability
what are the symptoms in-between attacks?
Enduring predisposition to future attacks
Anticipatory anxiety
name some migraine triggers
stress sleep disturbance changes in oestrogen level in women hunger dehydration environmental stimuli diet
what are the 5 phases of a migraine attack?
Premonitory Phase Aura Phase Early headache Advanced headache Postdrome
how long do migraine attacks last?
4 to 72 hours
what is the Premonitory Phase?
predictors of the headache attack
Mood changes, muscle pain, food cravings, cognitive changes, fatigue
what is aura?
Affects 33% of migraineurs
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve visual, sensory, motor or speech systems
15-60 minutes
what are the symptoms of early headache?
Dull headache
Nasal congestion
Muscle pain
what are the symptoms of advanced headache?
Unilateral Throbbing Nausea Photophobia Phonophobia Osmophobia
what is the Postdrome phase?
migraine-associated symptoms beyond the resolution of the headache
can last 1-2 days
what is a chronic migraine?
Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months
what is the treatment for medication overuse headaches?
discontinuing the overused medication often (but not always) dramatically improves headache frequency
what is a transformed migraine?
History of episodic migraine
Increasing frequency of headaches
Migrainous symptoms become less frequent and less severe
what is medication overuse headache?
Headache present on ≥15 days / month which has developed or worsened whilst taking regular symptomatic medication
when does medication overuse headache occur?
Migraineurs are particularly prone
Migraineurs taking pain medication for another reason can develop chronic headache
what causes medication overuse headache?
triptans, ergots, opiods and combination analgesics >10 days / month
simple analgesics > 15 days per month
Caffeine overuse: coffee, tea, cola, irn brew
what is abortive migraine treatment?
Aspirin or NSAIDs
Triptans
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
what is prophylactic migraine treatment?
Propranolol, Candesartan
Anti-epileptics
Tricyclic antidepressants
Venlafaxine
how does pregnancy affect migraine frequency?
Migraine without aura gets better in pregnancy
Migraine with aura usually does not change
what is Trigeminal Autonomic Cephalalgias?
type of primary headache that occurs with unilateral head pain in the trigeminal nerve area
describe a cluster headache attack
Pain: mainly orbital and temporal
Attacks unilateral
Rapid onset
15 mins to 3 hours
Rapid cessation of pain
Excruciatingly severe (“suicide headache”)
Prominent ipsilateral autonomic symptoms Migrainous symptoms often present
describe the cluster headache bout
Episodic in 80-90%
Attacks “cluster” into bouts typically lasting 1-3 months with periods of remission lasting at least 1 month
Attack frequency: 1 every other day to 8 per day
Striking circadian rhythmicity-same time every day
10-20% have chronic cluster
what is chronic cluster?
Bouts last >1 year without remission or
Remissions last <1 month
describe a Paroxysmal Hemicrania attack
Pain: mainly orbital and temporal Attacks unilateral Rapid onset 2-30 mins Rapid cessation of pain Excruciatingly severe Prominent ipsilateral autonomic symptoms Migrainous symptoms may be present Background continuous pain can be present Absolute response to indometacin
describe the Paroxysmal Hemicrania frequency
80% have chronic PH, 20% have episodic PH
Frequency: 2-40 attacks per day (no circadian rhythm)
Absolute response to indometacin
describe a SUNCT attack
Unilateral orbital, supraorbital or temporal pain
Stabbing or pulsating pain
10-240 seconds duration
Cutaneous triggers eg Wind
Pain is accompanied by conjunctival injection and lacrimation
describe SUNCT frequency
3-200/day, no refractory period
describe Trigeminal Neuralgia attack
Unilateral maxillary or mandibular division pain > ophthalmic division Stabbing pain 5 - 10 seconds duration Cutaneous triggers eg cold Autonomic features are uncommon
describe Trigeminal Neuralgia frequency
3-200/day-similar to SUNCT, has a refractory period
What features predict sinister headache?
Serious intracranial pathology is very unlikely in longstanding episodic headache
Presentations more likely to have a sinister cause
Associated head trauma
First or worst
Sudden (thunderclap) onset
New daily persistent headache
Change in headache pattern or type
what are red flags of a sinister headache?
new onset headache new or change in headache aged over 50 abnormal neurological examination neck stiffness / fever high/low pressure GCA
what indicates high pressure headache
headache worse lying down
headache wakening the patient up
headache precipitated by physical exertion
headache precipitated by valsalva manoeuvre
risk factors for cerebral venous sinus thrombosis
what indicates low pressure headache
headache precipitated by sitting / standing up
what indicates Giant Cell Arteritis headache
Headache is usually diffuse, persistent and may be severe systemically unwell scalp tenderness jaw claudication visual disturbance beaded temporal arteries
what is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than 1 minute
Majority peak instantaneously
what must be tested for in patients with a thunderclap headache?
Subarachnoid Haemorrhage
1 in 10 patients with thunderclap headache will have a SAH
85% aneurysmal
50% mortality, 20% of survivors remain dependant
Early coiling (or clipping) of the aneurysm saves lives
how is thunderclap headache investigated?
SAME DAY hospital assessment
Does the patient have SAH or another secondary cause
CT brain (3% negative at 12 hrs, 7% negative at 24 hrs)
LP (must be done >12hrs after headache onset)
CT +/- LP is unreliable beyond 2 weeks and angiography is required beyond this time
what should be considered in any patient presenting with headache and fever?
CNS infection
Meningitis and Encephalitis
Look for a rash!
what are the symptoms of Meningitis?
nausea +/- vomiting, photo/phono phobia, stiff neck
what are the symptoms of Encephalitis?
altered mental state / consciousness, focal symptoms / signs, seizures
what features suggest a space occupying lesion and/or raised intracranial pressure?
Progressive headache with associated symptoms and signs
Headache worse in morning/lying flat or brought on by valsalva
Focal symptoms or signs
Non-focal symptoms e.g. cognitive or personality change, drowsiness
Seizures- due to underlying structural causes
Visual obscurations and pulsatile tinnitus
what causes Intracranial hypotension?
Dural CSF leak
Spontaneous or iatrogenic (post lumbar puncture)
what features suggest Intracranial hypotension?
headache precipitated by sitting / standing up
Once the headache becomes chronic it often loses its postural component
what supports the diagnosis of Giant cell arteritis?
An elevated ESR (usually >50, often much higher, rarely normal)
Raised CRP and platelet count are other useful markers
