Headache Flashcards by Hannah Thomas

List the main types of primary headache

Tension-type headache
Migraine
Trigeminal neuralgia
Trigeminal Autonomic Cephalalgias

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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

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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

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Which medications are most likely to cause headache?

Triptans
Ergots
Opioids
Combination analgesics
Simple analgesics
Caffeine

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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

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Describe the abortive and preventative treatments for tension-type headache

Abortive: aspirin, paracetamol, NSAIDs
Preventative: tricyclic antidepressants
- e.g. amitriptyline, dothlepin, nortriptyline

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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

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What symptoms are present in the advanced stage of a migraine?

Unilateral headache
Nausea
Photophobia
Phonophobia
Functional disability

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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

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Describe the abortive treatment for migrain

aspirin, NSAIDs, triptans

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Describe the prophylactic treatment for migraine

propanolol, candesartan
antiepileptics
tricyclic antidepressants
venlafaxine

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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

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Describe the treatment for trigeminal neuralgia

There is no abortive treatment
Prophylaxis: carbamazepine, oxcarbazepine
Surgical intervention: glycerol glanglion injection, radiosurgery, decompressive surgery

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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)

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Describe the type of pain experienced in cluster headaches

Rapid onset and cessation
Sharp, throbbing
Unilateral
Excruciatingly severe
(migraine symptoms often present as well)

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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