Headache Flashcards
List the main types of primary headache
Tension-type headache
Migraine
Trigeminal neuralgia
Trigeminal Autonomic Cephalalgias
What is the difference between primary and secondary headache?
In primary headache, there is no underlying medical cause, whereas in secondary headache there is an identifiable structural or biochemical cause
What is the maximum dose of headache treatments such as NSAIDS? What may happen if this is exceeded?
10 days per month (about 2 days per week)
Risk of developing a medication-induced headache
Which medications are most likely to cause headache?
Triptans Ergots Opioids Combination analgesics Simple analgesics Caffeine
List the possible causes of secondary headache
Subarachnoid haemorrhage (typically causes a “thunderclap” headache)
Raised ICP e.g. due to a space occupying lesion
Intracranial hypotension
Giant cell arteritis
Meningitis and Encephalitis
Describe the abortive and preventative treatments for tension-type headache
Abortive: aspirin, paracetamol, NSAIDs
Preventative: tricyclic antidepressants
- e.g. amitriptyline, dothlepin, nortriptyline
What are the five stages of a migraine?
- Premonitary features such as mood changes, fatigue
- Aura (not always present)
- Early headache - dull, may include nasal congestion and muscle pain
- Advanced headache
- Postdrome - may include fatigue, muscle pain and cognitive changes
What symptoms are present in the advanced stage of a migraine?
Unilateral headache Nausea Photophobia Phonophobia Functional disability
What would be classified as a chronic migraine?
Headache on at least 15 days per month, of which at least 8 must be migraine, for more than 3 months
Describe the abortive treatment for migrain
aspirin, NSAIDs, triptans
Describe the prophylactic treatment for migraine
propanolol, candesartan
antiepileptics
tricyclic antidepressants
venlafaxine
What is trigeminal neuralgia?
Pain associated with the trigeminal nerve:
a stabbing unilateral maxillary or mandibular pain (occasionally opthalmic) - i.e. facial pain
- triggered by wind/cold, touch or chewing
- 5-10 seconds duration
- has a refractory period
Describe the treatment for trigeminal neuralgia
There is no abortive treatment
Prophylaxis: carbamazepine, oxcarbazepine
Surgical intervention: glycerol glanglion injection, radiosurgery, decompressive surgery
List the types of trigeminal autonomic cephalalgias
Cluster headache.
Paroxysmal hemicrania (chronic or episodic)
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)
Long-lasting autonomic symptoms with hemicrania (LASH)
Describe the type of pain experienced in cluster headaches
Rapid onset and cessation Sharp, throbbing Unilateral Excruciatingly severe (migraine symptoms often present as well)
Describe the patterns of headache seen in cluster headache
Rapid onset and cessation
Duration 15min - 3hrs
Frequency ranges from one every other day to eight in one day
Bouts last for up to three months
Often seen in circadian rhythms; attacks occur the same time each day, bouts occur same time each year
Describe the abortive treatment for cluster headaches
To treat headache - tablets don’t work!
- subcutaneous sumatriptan
- nasal zolmatriptan
- 100% oxygen
To treat bout:
- occipital injection of depomedrone
- oral prednisone
Which drugs are used for preventative treatment of cluster headache
Verapamil - most evidence for efficacy
Lithium
Methysergide
Topiramate
How does paroxysmal hemicrania differ from cluster headache?
Shorter duration (2-30mins) More frequent (2-40 per day) No circadian rhythm No abortive treatment Prophylaxis with indometacin
Describe the presentation of SUNCT and SUNA
unilateral orbital supraorbital or temporal pain
pain is stabbing/pulsating (saw-tooth pattern)
- 10-240 seconds duration
- cutaneous triggers e.g. wind/cold, chewing, touch
- attack frequency: 3-200 per day
- no refractory period
What is the difference between SUNCT and SUNA?
SUNCT: pain is accompanied by conjunctival tearing and lacrrimation
SUNA: pain is accompanied by autonomic symptoms
Describe the treatment of SUNCT and SUNA
There is no abortive treatment Prophylaxis with drugs: - lamotrigine - topiramate - gabapentin - carbamazepine/oxcarbazepine
What is the differential diagnosis when a patient presents with a thunderclap headache?
Primary headache (migraine) Subarachnoid haemorrhage (10%) Intracerebral haemorrhage TIA/Stroke Carotid/Vertebral artery dissection Cerebral venous sinus thrombosis Meningitis/encephalitis Sponaneous intracranial hypotension
What are the potential causes of SAH?
Ruptured aneurysm (85%)
Traumatic brain injury
Other vascular abnormalities
What investigations should be carried out if SAH is suspected?
Examination - however this is often normal!
CT brain must be done ASAP
LP at least 12 hours after headache onset to allow time for blood to be broken down
- looking for bilirubin in the CSF
Beyond two weeks after headache onset an angiogram is required
What type of headache is caused by intracranial hypotension?
Postural headache: headache is worse when sitting or standing upright
What is the treatment for intracranial hypotension?
bed rest, fluids, anaglesics
oral or IV caffeine
Epidural blood patch (the patient’s own blood is injected between the 2 dural layers)
Describe the type of headache that is caused by raised ICP
Progressive headache with associated signs and symptoms:
- worse in the morning and on lying flat
- focal signs/symptoms may be present
- non-focal symptoms such as congnitive/personality changes, drowsiness
- seizures
(associated signs and symptoms depend on the cause of raised ICP)
What are the potential causes of raised ICP?
Tumour e.g. glioblastoma multiforme, meningioma
Cerebral abscess
Venous infarct
Hydrocephalous
What is Papilloedema?
Swelling of the optic disc secondary to raised ICP
What is giant cell arteritis?
Inflammation of the large arteries
Causes secondary headache
What is the importance of giant cell arteritis?
Should be considered in any patient over the age of 50 presenting with a new headache.
Important to rule out due to risk of blindness or stroke
Describe the features of giant cell arteritis
Headache is usually diffuse, persistant, may be severe
Patient may be systematically unwell
Specific features include scalp tenderness, jaw
claudication and visual disturbance
Temporal arteries may be prominent, beaded or
enlarged
How is giant cell arteritis diagnosed?
Elevated ESR (erythrocyte sedimentation rate) Raised CRP (C-reactive protein; marker of inflammation) Should also arrange a temporal artery biopsy to confirm, after starting treatment
What is the treatment for giant cell arteritis?
High dose prednisolone
What is the difference between ESR and CRP?
Raised ESR indicates chronic inflammation, whereas raised CRP indicates acute inflammation
