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Nervous System > Headache > Flashcards

Headache Flashcards

1
Q

What is the most frequent disabling primary headache?

A

Migraine

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2
Q

When is migraine incidence higher?

A

In women during puberty and menopause

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3
Q

What is a migraine

A

Neurological chronic disorder with episodic attacks, characterised by recurrent and reversible attacks of pain and associated symptoms

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4
Q

Symptoms of migraine

A

Headache
Functional disability
Anticipatory anxiety
Associated symptoms

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5
Q

Triggers of migraine

A 
Stress 
Hunger 
Sleep disturbance 
Dehydration 
Diet 
Environmental stimuli 
Changes in oestrogen levels in women
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6
Q

Premonitory features of migraine

A 
Mood changes 
Fatigue 
Cognitive changes 
Muscle pain 
Food craving
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7
Q

Features of migraine

A 
Premonitory features 
Aura 
Early headache 
Advanced headache 
Postdrome features
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8
Q

Features of early headache in migraine

A

Dull headache
Nasal congestion
Muscle pain

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9
Q

Features of advanced headache in migraine

A 
Unilateral 
Throbbing 
Nausea 
Photophobia 
Phonophobia 
Osmophobia
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10
Q

Postdrome features of migraine

A

Fatigue
Cognitive changes
Muscle pain

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11
Q

What percentage of those who experience migraines will experience aura?

A

33%

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12
Q

What is aura?

A

Transient neurological symptom resulting from cortical or brainstem dysfunction which may involve visual, sensory, motor or speech symptoms

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13
Q

Duration of aura

A

15-60 minutes

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14
Q

What might an aura be confused with?

A

Transient ischaemic attack - loss of function, sudden onset, symptoms start at same time, can be localised to particular vascular area

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15
Q

What is a chronic migraine?

A

Headache on 15 or more days per month, of which 8 days have to be a migraine, for more than 3 months

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16
Q

Presenting features of transformed migraine

A

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

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17
Q

Most common cause of chronic migraine

A

Medication overuse

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18
Q

What is a medication overuse headache?

A

Headache present on 15 or more days/month which has developed or worsened whilst taking regular symptomatic medication

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19
Q

Most common primary headache in which medication overuse headache occurs

A

Migraine

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20
Q

What can cause a medication overuse headache?

A 
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

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21
Q

What is the most frequent primary headache?

A

Tension-type headache

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22
Q

Lifetime prevalence of tension-type headache

A

42% in men

49% in women

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23
Q

Features of tension-type headache

A

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

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24
Q

What might be felt on manual palpation of a patient with a tension-type headache?

A

Peri-cranial tenderness

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25
Q

What is a new daily persistent headache?

A

Daily and unremitting headache from soon after onset (3 or less days)

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26
Q

Diagnostic criteria for primary new daily persistent headache

A

Must have the headache for > 3 months and exclude secondary causes

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27
Q

What are the forms of primary new daily persistent headache?

A

Self-limiting

Unremitting

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28
Q

Cause of primary new daily persistent headache

A

40-60% no precipitating event

Can be associated with viral illness, trauma, surgery, stressful life event

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29
Q

Examples of secondary causes of heterogenous headache disorder

A 
Subarachnoid haemorrhage 
Cerebral venous sinus thrombosis 
Subdural haematoma 
Giant cell arteritis 
Infective/malignant meningitis
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30
Q

What is hemicrania continua?

A

Strictly unilateral continuous headache that has an absolute response to indomethacin

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31
Q

Features of hemicrania continua

A

Continuous moderately severe headache that waxes and wanes in intensity
Episodic or chronic
Strictly hemicranial
Superimposed exacerbations of more severe pain

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32
Q

Associated symptoms of hemicrania continua

A

Occur with exacerbations of pain
Ipsilateral cranial autonomic features e.g. rhinorrhoea, eyelid oedema
Idiopathic stabbing headache
Migrainous features

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33
Q

Examples of trigeminal autonomic cephalalgias

A

Cluster headache
Paroxysmal hemicranias
Short-lasting unilateral neuralgiform headache with conjunctival injection (SUNCT)
Short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA)

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34
Q

Features of trigeminal autonomic cephalalgias

A

Unilateral head pain
Very severe/excruciating
Varied attack frequency, duration and response to treatment

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35
Q

Cranial autonomic symptoms

A 
Conjuctival injection/lacrimation 
Nasal congestion/rhinorrhoea 
Eyelid oedema 
Forehead and facial sweating 
Miosis/ptosis
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36
Q

Features of cluster headache

A 
Mainly orbital and temporal pain 
Attacks strictly unilateral 
Rapid onset
Rapid cessation of pain 
Excruciatingly severe pain
37
Q

Duration of cluster headache

A

15mins - 3 hours

38
Q

Onset of cluster headache

A

9 mins max

39
Q

Associated symptoms of cluster headache

A 
Restlessness 
Agitated 
Prominent ipsilateral autonomic symptoms 
Migrainous symptoms 
Premonitory symptoms e.g. tiredness 
Nausea
Vomiting 
Photophobia 
Phonophobia 
Aura
40
Q

In what percentage of people are cluster headaches episodic?

A

80-90%

41
Q

How long do bouts of cluster headache attacks typically last?

A

1-3 months with periods of remission lasting at least 1 month

42
Q

Attack frequency of cluster headaches

A

1 every second day - 8 per day

43
Q

When does alcohol trigger a cluster headache attack?

A

During a bout, but not during remission

44
Q

What percentage of people have chronic cluster headaches?

A

10-20%

45
Q

Frequency of chronic cluster headaches

A

Bouts last > 1 year without remission

or remissions last < 1 month

46
Q

Features of paroxysmal hemicrania

A 
Pain mainly orbital and temporal 
Attacks strictly unilateral 
Rapid onset 
Rapid cessation of pain
Excruciatingly severe 
Prominent ipsilateral ANS symptoms 
Restless and agitated (50%)
47
Q

Duration of paroxysmal hemicrania

A

2-30 mins

48
Q

Features of SUNCT

A

Unilateral orbital, supraorbital or temporal pain
Stabbing/pulsating pain
Pain accompanied by conjunctival injection and lacrimation

49
Q

Duration of SUNCT

A

10-240 seconds

50
Q

Cutaneous triggers of SUNCT

A

Wind
Cold
Tough
Chewing

51
Q

Attack frequency of SUNCT

A

3-200 per day, no refractory period

52
Q

Features of Trigemial Neuralgia

A

Unilateral or mandibular division pain
Stabbing pain
Autonomic features uncommon

53
Q

Duration of trigeminal neuralgia

A

5-10 seconds

54
Q

Cutaneous triggers of trigeminal neuralgia

A

wind
cold
touch
chewing

55
Q

Abortive migraine treatments

A

Aspirin or NSAIDs
Triptans
Limit to 10 days per month to avoid medication overuse headaches

56
Q

Prophylactic migraine treatments

A

Propranolol, candesartan
Anti-epileptics e.g. topiramate, valproate, gabapentin
Tricyclic antidepressants e.g. amitriptyline, dothiepin, nortriptyline
Venlafaxine

57
Q

Lifestyle changes to make for treatment of migraine

A 
Don't miss meals 
Stay hydrated 
Avoid changes in sleep patterns 
Regular exercise 
Trigger avoidance
58
Q

Tension-type headache abortive treatment

A

Aspirin or paracetamol
NSAIDs
Limit to 10 days per month

59
Q

Tension-type headache prophylactic treatment

A

Tricyclic antidepressants e.g. amitriptyline, dothiepin, nortriptyline
Venlafaxine
Mirtazapine

60
Q

Cluster headache abortive treatment

A

Subcutaneous sumatriptan 6mg or nasal zolmatriptan 5mg

100% oxygen, 7-12 l/min via tight-fitting non-rebreathing mask

61
Q

Headache bout abortive treatment

A

Occipital depomedrone injection on same side as headache

Tapering course of oral prednisone

62
Q

Preventative treatment of headache bout

A

Verapamil
Lithium
Methysergide
Topiramate

63
Q

Paroxysmal hemicrania treatment

A

No abortive treatment
Prophylaxis with indomethacin
COX-II inhibitors or topiramate

64
Q

SUNCT/SUNA treatment

A 
No abortive treatment 
Prophylaxis;
lamotrigine 
topiramate 
gabapentin 
carbamazepine/oxcarbazepine
65
Q

Trigeminal neuralgia treatment

A

No abortive treatment
Prophylaxis - carbamazepine, oxcarbazepine
Surgical intervention - glycerol ganglion injection, stereotactic radiosurgery, decompressive surgery

66
Q

Presentations of headaches associated with more severe causes

A 
Associated head trauma 
First or worst headache 
Sudden onset (thunderclap) 
New daily persistent headache 
Change in headache pattern or type 
Returning patient
67
Q

Red flag headache presentations

A

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

68
Q

High-pressure headache presentations

A

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

69
Q

Low-pressure headache presentation

A

Headache precipitated by sitting/standing up

70
Q

Giant cell arteritis presentation

A

Jaw claudication
Visual disturbance
Prominent/beaded temporal arteries

71
Q

What is a thunderclap headache?

A

High intensity headache reaching maximum intensity in less than one minute
Majority will peak instantaneously
May be primary or secondary

72
Q

Differential diagnoses for thunderclap headache

A 
Primary headache 
Subarachnoid haemorrhage 
Intracerebral haemorrhage 
TIA/stroke 
Carotid/vertebral dissection 
Cerebral venous sinus thrombosis 
Meningitis/encephalitis 
Pituitary apoplexy 
Spontaneous intracranial hypotension
73
Q

What number of patients presenting with thunderclap headache will have a subarachnoid haemorrhage?

A

1 in 10

74
Q

Mortality of subarachnoid haemorrhage

A

50%

75
Q

Risk of re-bleed in subarachnoid haemorrhage

A

4-6% in first 24-48 hours

40% in first month

76
Q

Immediate treatment of subarachnoid haemorrhage

A

Coiling or clipping of aneurysm

77
Q

Immediate investigations in suspected subarachnoid haemorrhage

A

CT brain
Lumbar puncture
Angiography (if after two weeks)

78
Q

Presentation of meningitis

A 
Nausea +/- vomiting 
Photophobia 
Phonophobia 
Stiff neck 
Rash
79
Q

Encephalitis presentation

A

Altered mental state/consciousness
Focal symptoms/signs
Seizures

80
Q

Warning features of headache, suggestive of space-occupying lesion/raised ICP

A

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

81
Q

When might the cause of intracranial hypotension be iatrogenic?

A

Post-lumbar punture

82
Q

Intracranial hypotension features

A

Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down

83
Q

Investigation of intracranial hypotension

A

MRI brain and spine

84
Q

Treatment of intracranial hypotension

A 
Bed rest 
Fluids 
Analgesia 
Caffeine (IV) 
Epidural blood patch
85
Q

When should giant cell arteritis be considered?

A

In any patient over the age of 50 presenting with new headache

86
Q

Presentation of giant cell arteritis

A 
Diffuse, persistent, severe headache 
Systemically unwell 
Scalp tenderness 
Jaw claudication 
Visual disturbance
Prominent/beaded temporal arteries
87
Q

Test results which would confirm giant cell arteritis diagnosis

A

Elevated ESR

Raised CRP and platelet count

88
Q

Treatment of giant cell arteritis

A

High dose prednisolone

Temporal artery biopsy

Nervous System (44 decks)

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