Headache Flashcards
What are the red flag symptoms for headache?
Abrupt or split second onset
Diurnal variation
Postural variation
Progressively worsening headache
Neurological symptoms and signs
Systemic symptoms and signs
Secondary risk factors-sinusitis, cancer, head injury
What are red flag signs of headache?
Pyrexia Neck stiffness Papilloedema Focal neurological signs Tender temporal arteries
Tension type headache:
- is this common?
- describe the nature of the headache?
Most common type of headache, mild to moderate
Tight band quality, generalised, discomfort, pressed tingling quality, feeling of pressure at vertex
Tension type headache:
- uni or bilateral?
- is there systemic upset/photophobia/N+V?
- how often does this occur?
- when does this worsen?
Bilateral
No systemic upset, photophobia or aura (no N&V)
Often daily occurrence
Worsens:
otowards end of the day
oanxiety, noise or glare
Tension type headache:
- what is this assoc. with?
- what is found on physical examination?
losely assoc. with musculoskeletal problems esp. neck muscle tension and neck trauma e.g. whiplash
1/3 pt.s have depressive symptoms
physical examination normal: may be inappropriate muscle contraction over head and neck
What is the treatment for tension type headache
- conservative
- acutely
- prophylaxis
Conservative: explanation, exacerbating factors e.g. ill fitting dentures/glasses/teeth grinding, relaxation exercises
acute treatment: aspirin, paracetamol or an NSAID are first-line
prophylaxis: NICE recommend ‘up to 10 sessions of acupuncture over 5-8 weeks’
(low-dose amitriptyline is widely used in the UK for prophylaxis against tension-type headache. The 2012 NICE guidelines do not however support this approach)
Migraine - what is the diagnostic criteria?
Need both:
oFive attacks or more
oPhotophobia, phonophobia or nausea
\+ Need two or more: oModerate to severe headache oUnilateral oThrobbing oWorse on movement
Describe the nature of a migraine headache?
Episodic
– lasts 4hr to 3 days
oUnilateral
oThrobbing
oExacerbated by exertion/movement
oAssociated with systemic upset: nausea, vomiting, phonophobia, photophobia, fatigue, hyperaesthesia, autonomic dysfunction
Does everyone with migraine get an aura?What is the aura assoc. with migraine?
30% have an aure: visual/dysphasic/positive sensory e.g. pins and needles
oFocal cerebral cortical and or brainstem dysfunction
ogradual progression
oresolves over 60 min
(migraine with aura contraindication for OCP)
What are common trigger factors for migraine?
tiredness, stress
alcohol
combined oral contraceptive pill
lack of food or dehydration
cheese, chocolate, red wines, citrus fruits
menstruation
bright lightsWhat is the acute treatment for migraine?
First-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol
for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
if the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide* or prochlorperazine and consider adding a non-oral NSAID or triptan
What is used for migraine prophylaxis?
- prophylaxis for 2+ a month, review after 12wks
- topiramate or propranolol used (Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives)
- if these measures fail acupuncture or gabapentin
- riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people’
-menstrual migraine either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of ‘mini-prophylaxis’
Medication overuse headache:
- how long are these present
- when do these develop
- who is most at risk
- what co-morbidity is possible?
Present for 15 days or more per month
Developed or worsened whilst taking regular symptomatic medication
Patients using opioids and triptans are at most risk
May be psychiatric co-morbidity
medication overuse headache:
-what is the treatment?
Stop analgesia, gradually or overnight
oReplace with amitryptiline and NSAID combo
oWarn patients of transient worsening
oif severe consider hospital admission
oBrief course oral steroid for 5-10days may be useful
Cluster headache:
-what is the nature of this headache?
Rapid onset
- Unilateral, severe pain BEHIND ONE EYE or supraorbital
- Clusters - refer to episodes of onset roughly 2/day lasting 30-180mins for 4-12 weeks duration
