Headache Flashcards
what aspects in the Hx are important in a PC of headache
Onset/ Peak:
Acute Vs Sub-acute Vs Gradual
Relieving features:
Posture, headache behaviour
Exacerbating:
Posture, valsalva (sneezing, coughing, straining etc). Diurnal variation.
Demographic
Associated features:
N+V, photophobia, phonophobia, positive visual symptoms, ptosis, miosis (constriction of pupils)
what are red flags for headaches
New onset headache >55 Known/previous malignancy Immuno-suppressed Early morning headache Exacerbation by valsalva (coughing, sneezing, raised ICP)
what features in the PMH should be acquired in a headache Hx
previous cancer
predisposition to thrombosis
what are the demographics of migraines
commoner in women
on average 1 attack per month
20% with aura
80% without aura
Sx of migraine
- visual or other aura
- unilateral, throbbing headache
- often premenstrual
- N+V
- photophobia, phonophobia
- allodynia
what is the criteria for migraine without aura
at least 5 attacks: 4-72 hours
2 of: Moderate/ severe, unilateral, throbbing pain, worst movement.
1 of: Autonomic features, photophobia/ phonophobia
what is the pathophysiology of migraines
vascular and neural influences cause migraines in susceptible individuals
Stress triggers changes in the brain, these changes cause serotonin to be released
Blood vessels constrict and dilate
Chemicals including substance P irritate nerves and blood vessels causing pain.
what is aura
fully reversible visual, sensory, motor or language symptoms
duration 20-60 minutes
headache follows < 1 hour later and can occur simultaneously
what Tx can be used in an acute migraine
NSAID
- aspirin, naproxen, ibuprofen
Triptans
- Rizatriptan, frovatriptain
what class of drugs is triptans
5HT agonist
when should a triptan be given
at start of the headache
when is frovatriptan given
for sustained relief
when is prophylaxis given in cases of migraine
More than 3 attacks month or very severe attacks
what are drugs used in prophylaxis in migraines
Propranolol (beta blocker)
Topiramate (carbonic anhydrase inhibitor)
Amitriptyline
when should propranolol be avoided
in asthma, PVD, heart failure
what are SE of topiramate
weight loss
paraesthesia
impaired concentration
side effects of Amitriptyline
dry mouth
postural hypotension
sedation
what else could be used if amitriptyline was not suitable in migraines
gabapentin
pizotifen
sodium valproate
what lifestyle changes can decrease the risk of a migraine
Diet- regular intake, avoid triggers, healthy balanced diet
Hydration- at least 2 litres day, decrease caffeine
Stress- decrease
Regular exercise
what are trigeminal autonomic cephalgias (TACs)
group of primary headache disorders
characterised by unilateral trigeminal distribution pain
occurs in association with prominent ipsilateral cranial autonomic features.
what are ipsilateral cranial autonomic features
Ptosis Miosis Nasal Stuffiness Nausea/ vomiting Tearing Eye lid oedema
what are the 4 types of TCA
cluster
paroxsymal hemicrania
hemicrania continua
SUNCT
what is features of a cluster headache
30-40s Men more than women can last 20-120 mins can have up to 8 a day often nocturnal
Sx of cluster headaches
rapid onset of severe unilateral headache excruciating pain around one eye bloodshot, watery eye lid swelling, lacrimation facial flushing, rhinorrhoea miosis +/- ptosis
what is the acute treatment of a cluster headache
High flow oxygen 100% for 20mins
sumatriptan 6mg sc
steroids - reducing course over 2 weeks
what is prophylactic treatment for cluster headaches
verapamil
who gets Paroxysmal hemicrania
Elderly (50s-60s)
women> men
symptoms of Paroxysmal hemicrania
- severe unilateral headache
- unilateral autonomic features
- multiple severe, yet short, headache attacks affecting only one side
features of Paroxysmal hemicrania
2 mins-45 hours
1 to 40 a day
Tx of Paroxysmal hemicrania
Indomethicin
- absolute response
what does SUNCT stand for
S= Short lived (15-120 secs) U=unilateral N= neuralgiaform headache C= conjunctival injections T= Tearing
what does conjuntival injection meaning
bloodshot eyes
Tx for SUNCT
Lamotrigine
Gabapentin
who with headaches require investigation
new onset unilateral cranial autonomic features
what Ix should be done in the cases of new onset unilateral cranial autonomic features
MRI brain
MR angiogram
who gets trigeminal neuralgia
> 60y/o women > men triggered by touch often 1-90s 10 to 100 days
Sx of trigeminal neuralgia
severe stabbing unilateral pain in the trigeminal nerve distribution
what is first line Tx for Trigeminal neuralgia
Carbamazepine 100mg
what is used if Carbamazepine isn’t working for trigeminal neuralgia
Gabapentin
Phenytoin
Lamotrigine
what Tx is used if patient is not responsive to anti-convulsant treatment in trigeminal neuralgia
Baclofen
what options are there if drug treatment doesn’t work in trigeminal neuralgia
surgical abalation
surgical decompression
