Headache Flashcards
What is the most frequent disabling primary headache?
Migraine
When is migraine incidence higher?
In women during puberty and menopause
What is a migraine
Neurological chronic disorder with episodic attacks, characterised by recurrent and reversible attacks of pain and associated symptoms
Symptoms of migraine
Headache
Functional disability
Anticipatory anxiety
Associated symptoms
Triggers of migraine
Stress Hunger Sleep disturbance Dehydration Diet Environmental stimuli Changes in oestrogen levels in women
Premonitory features of migraine
Mood changes Fatigue Cognitive changes Muscle pain Food craving
Features of migraine
Premonitory features Aura Early headache Advanced headache Postdrome features
Features of early headache in migraine
Dull headache
Nasal congestion
Muscle pain
Features of advanced headache in migraine
Unilateral Throbbing Nausea Photophobia Phonophobia Osmophobia
Postdrome features of migraine
Fatigue
Cognitive changes
Muscle pain
What percentage of those who experience migraines will experience aura?
33%
What is aura?
Transient neurological symptom resulting from cortical or brainstem dysfunction which may involve visual, sensory, motor or speech symptoms
Duration of aura
15-60 minutes
What might an aura be confused with?
Transient ischaemic attack - loss of function, sudden onset, symptoms start at same time, can be localised to particular vascular area
What is a chronic migraine?
Headache on 15 or more days per month, of which 8 days have to be a migraine, for more than 3 months
Presenting features of transformed migraine
History of episodic migraine
Increasing frequency of headaches over weeks/months/years
Migraine symptoms become less frequent and less severe
Episodes of severe migraine on background of less severe featureless frequent/daily headache
Most common cause of chronic migraine
Medication overuse
What is a medication overuse headache?
Headache present on 15 or more days/month which has developed or worsened whilst taking regular symptomatic medication
Most common primary headache in which medication overuse headache occurs
Migraine
What can cause a medication overuse headache?
Use of; Triptans Ergots Opioids Combination analgesics for > 10 days/month
or use of simple analgesics for > 15 days/month
or caffeine overuse e.g. coffee
What is the most frequent primary headache?
Tension-type headache
Lifetime prevalence of tension-type headache
42% in men
49% in women
Features of tension-type headache
Mild, bilateral headache which is often pressing or tightening in quality but has no significant associated features and is not aggravated by routine physical activity
What might be felt on manual palpation of a patient with a tension-type headache?
Peri-cranial tenderness
What is a new daily persistent headache?
Daily and unremitting headache from soon after onset (3 or less days)
Diagnostic criteria for primary new daily persistent headache
Must have the headache for > 3 months and exclude secondary causes
What are the forms of primary new daily persistent headache?
Self-limiting
Unremitting
Cause of primary new daily persistent headache
40-60% no precipitating event
Can be associated with viral illness, trauma, surgery, stressful life event
Examples of secondary causes of heterogenous headache disorder
Subarachnoid haemorrhage Cerebral venous sinus thrombosis Subdural haematoma Giant cell arteritis Infective/malignant meningitis
What is hemicrania continua?
Strictly unilateral continuous headache that has an absolute response to indomethacin
Features of hemicrania continua
Continuous moderately severe headache that waxes and wanes in intensity
Episodic or chronic
Strictly hemicranial
Superimposed exacerbations of more severe pain
Associated symptoms of hemicrania continua
Occur with exacerbations of pain
Ipsilateral cranial autonomic features e.g. rhinorrhoea, eyelid oedema
Idiopathic stabbing headache
Migrainous features
Examples of trigeminal autonomic cephalalgias
Cluster headache
Paroxysmal hemicranias
Short-lasting unilateral neuralgiform headache with conjunctival injection (SUNCT)
Short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA)
Features of trigeminal autonomic cephalalgias
Unilateral head pain
Very severe/excruciating
Varied attack frequency, duration and response to treatment
Cranial autonomic symptoms
Conjuctival injection/lacrimation Nasal congestion/rhinorrhoea Eyelid oedema Forehead and facial sweating Miosis/ptosis
Features of cluster headache
Mainly orbital and temporal pain Attacks strictly unilateral Rapid onset Rapid cessation of pain Excruciatingly severe pain
Duration of cluster headache
15mins - 3 hours
Onset of cluster headache
9 mins max
Associated symptoms of cluster headache
Restlessness Agitated Prominent ipsilateral autonomic symptoms Migrainous symptoms Premonitory symptoms e.g. tiredness Nausea Vomiting Photophobia Phonophobia Aura
In what percentage of people are cluster headaches episodic?
80-90%
How long do bouts of cluster headache attacks typically last?
1-3 months with periods of remission lasting at least 1 month
Attack frequency of cluster headaches
1 every second day - 8 per day
When does alcohol trigger a cluster headache attack?
During a bout, but not during remission
What percentage of people have chronic cluster headaches?
10-20%
Frequency of chronic cluster headaches
Bouts last > 1 year without remission
or remissions last < 1 month
Features of paroxysmal hemicrania
Pain mainly orbital and temporal Attacks strictly unilateral Rapid onset Rapid cessation of pain Excruciatingly severe Prominent ipsilateral ANS symptoms Restless and agitated (50%)
Duration of paroxysmal hemicrania
2-30 mins
Features of SUNCT
Unilateral orbital, supraorbital or temporal pain
Stabbing/pulsating pain
Pain accompanied by conjunctival injection and lacrimation
Duration of SUNCT
10-240 seconds
Cutaneous triggers of SUNCT
Wind
Cold
Tough
Chewing
Attack frequency of SUNCT
3-200 per day, no refractory period
Features of Trigemial Neuralgia
Unilateral or mandibular division pain
Stabbing pain
Autonomic features uncommon
Duration of trigeminal neuralgia
5-10 seconds
Cutaneous triggers of trigeminal neuralgia
wind
cold
touch
chewing
Abortive migraine treatments
Aspirin or NSAIDs
Triptans
Limit to 10 days per month to avoid medication overuse headaches
Prophylactic migraine treatments
Propranolol, candesartan
Anti-epileptics e.g. topiramate, valproate, gabapentin
Tricyclic antidepressants e.g. amitriptyline, dothiepin, nortriptyline
Venlafaxine
Lifestyle changes to make for treatment of migraine
Don't miss meals Stay hydrated Avoid changes in sleep patterns Regular exercise Trigger avoidance
Tension-type headache abortive treatment
Aspirin or paracetamol
NSAIDs
Limit to 10 days per month
Tension-type headache prophylactic treatment
Tricyclic antidepressants e.g. amitriptyline, dothiepin, nortriptyline
Venlafaxine
Mirtazapine
Cluster headache abortive treatment
Subcutaneous sumatriptan 6mg or nasal zolmatriptan 5mg
100% oxygen, 7-12 l/min via tight-fitting non-rebreathing mask
Headache bout abortive treatment
Occipital depomedrone injection on same side as headache
Tapering course of oral prednisone
Preventative treatment of headache bout
Verapamil
Lithium
Methysergide
Topiramate
Paroxysmal hemicrania treatment
No abortive treatment
Prophylaxis with indomethacin
COX-II inhibitors or topiramate
SUNCT/SUNA treatment
No abortive treatment Prophylaxis; lamotrigine topiramate gabapentin carbamazepine/oxcarbazepine
Trigeminal neuralgia treatment
No abortive treatment
Prophylaxis - carbamazepine, oxcarbazepine
Surgical intervention - glycerol ganglion injection, stereotactic radiosurgery, decompressive surgery
Presentations of headaches associated with more severe causes
Associated head trauma First or worst headache Sudden onset (thunderclap) New daily persistent headache Change in headache pattern or type Returning patient
Red flag headache presentations
New onset headache
New/change in headache if over 50, immunosuppression or cancer
Change in headache frequency, characteristics, associated symptoms
Focal neurological symptoms
Abnormal neurological examination
Neck stiffness/fever
High-pressure headache presentations
Headache worse lying down
Headache waking patient up at night
Headache precipitated by physical exertion
Headache precipitated by Valsalva manoeuvre
Risk factors for cerebral venous sinus thrombosis present
Low-pressure headache presentation
Headache precipitated by sitting/standing up
Giant cell arteritis presentation
Jaw claudication
Visual disturbance
Prominent/beaded temporal arteries
What is a thunderclap headache?
High intensity headache reaching maximum intensity in less than one minute
Majority will peak instantaneously
May be primary or secondary
Differential diagnoses for thunderclap headache
Primary headache Subarachnoid haemorrhage Intracerebral haemorrhage TIA/stroke Carotid/vertebral dissection Cerebral venous sinus thrombosis Meningitis/encephalitis Pituitary apoplexy Spontaneous intracranial hypotension
What number of patients presenting with thunderclap headache will have a subarachnoid haemorrhage?
1 in 10
Mortality of subarachnoid haemorrhage
50%
Risk of re-bleed in subarachnoid haemorrhage
4-6% in first 24-48 hours
40% in first month
Immediate treatment of subarachnoid haemorrhage
Coiling or clipping of aneurysm
Immediate investigations in suspected subarachnoid haemorrhage
CT brain
Lumbar puncture
Angiography (if after two weeks)
Presentation of meningitis
Nausea +/- vomiting Photophobia Phonophobia Stiff neck Rash
Encephalitis presentation
Altered mental state/consciousness
Focal symptoms/signs
Seizures
Warning features of headache, suggestive of space-occupying lesion/raised ICP
Headache
Headache worse in morning or waking patient from sleep
Headache worse when lying flat
Headache brought on by Valsalva manoeuvre
Seizures
Focal symptoms/signs
Non-focal symptoms/signs e.g. cognitive change
Visual obscuration
Pulsatile tinnitus
When might the cause of intracranial hypotension be iatrogenic?
Post-lumbar punture
Intracranial hypotension features
Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down
Investigation of intracranial hypotension
MRI brain and spine
Treatment of intracranial hypotension
Bed rest Fluids Analgesia Caffeine (IV) Epidural blood patch
When should giant cell arteritis be considered?
In any patient over the age of 50 presenting with new headache
Presentation of giant cell arteritis
Diffuse, persistent, severe headache Systemically unwell Scalp tenderness Jaw claudication Visual disturbance Prominent/beaded temporal arteries
Test results which would confirm giant cell arteritis diagnosis
Elevated ESR
Raised CRP and platelet count
Treatment of giant cell arteritis
High dose prednisolone
Temporal artery biopsy
