Headache Flashcards
What are examples of primary causes of headaches?
Tension type headache
Migraine
Cluster headache
What is a secondary causes of headache?
Definable or structural biochemical cause
What are examples of secondary headaches?
Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced
What is the most frequenct primary headache?
Tension type
What are the features of tension type headaches?
Not disabling
Rarely presents to doctors
Mild
Bilateral
Pressing or tightening in quality
No significant associated features
Not aggravated by routine physical activity
What is abortive treatment for tension type headache?
–Aspirin or paracetamol
–NSAIDs
–Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
What is the preventative treatment for tension type headache?
Rarely required
Tricyclic antidepressants
•amitriptyline, dothiepin, nortriptyline
What is the most frequent disabling primary headache?
Migraine
What is the epidemiology of migraine?
10% in men
22% in women
Most sufferers aged 20 to 50
What is the underlying pathology of migraine?
It is generally recognized that migraine arises from a primary brain dysfunction that leads to activation and sensitization of the trigeminal system
Complex pathophysiology
What are definable features of a migraine?
Headache lasts 4 to 72 hours
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by / causing avoidance of routine physical activity
During the headache phase, 1 of the following symptoms should be present:
Nausea
Vomiting
Photophobia
Phonophobia
What are migraine triggers?
Stress
Hunger
Sleep disturbance
Dehydration
Diet
Environmental stimuli
Changes in oestrogen level in women
What are the five stages of migraine?
The premonitory phase
The aura phase
Early headache
Advacned headache phase
Postdrome
Premonitory symptoms are ecperienced by seventy percent of patients suffering from migraine, what are premonitory symptoms?
Premonitory symptoms are often seen as predictors of the headache attack.
Mood alterations, muscle pain, food cravings, cognitive changes, fluid retention, and yawning are common premonitory symptoms.
What is the aura phase?
An aura involves focal, reversible neurologic symptoms that often precede the headache.
What is affected by aura?
Visual somatosensory system
Speech
Visual aura is the most common aura symptom - loss of vision
Sensory aura - paresthesia in the hand spreading to the arm, elbow, face, lips and tongue
Motor aura is typically experienced on one side and affects the hand and arm
What is an aura called that is not followed by headache pain?
Acephalgic migraine
What separates the two stages of headache (early and advanced)?
Early headache: mild pain, without the sensory symptoms associated with migraine, may have muscle pain and nasal congestion
Advanced headache: Moderate to severe pain with associated symptoms of nausea, photophobia, phonophobia or disability
What is postdrome?
Phase of migraine-associated symptoms beyond the resolution of the headache; often entails significant disability that can last for 1 or 2 days
Such as fatigue
Cognitive changes
Muscle pain
What persentage of migraineurs are affected by aura?
33%
What causes aura?
Cortical or brainstem dysfunction
What is the duration of aura?
15- 60 minutes
What is the key difference between aura and TIA?
TIA- Symptoms all start at same time and can be localised to a specific vascular area
Aura -
•Slow evolution of symptoms
–Moves from 1 area to next e.g.
vision → sensory → speech
What is the definition of chronic migraine?
•Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months
In medication overuse migraine, how can headache frequency be improved?
Discontinuing the overused medication
What is meant by medication overuse headache?
•Headache present on ≥15 days / month which has developed or worsened whilst taking regular symptomatic medication
Who is particularly likely to develop a medication overuse headache?
Migraineurs
Migraineurs taking pain medication for another reason can develop chronic headache
What are common drugs that cause medication overuse headaches?
•Use of triptans, ergots, opiods and combination
analgesics >10 days / month
- Use of simple analgesics > 15 days per month
- Caffeine overuse: coffee, tea, cola, irn bru
What is abortive treatment for migraine?
Aspirin or NSAIDs
Triptans
Limit to 10 days per month (around 2 days per week) to aviod medication overuse headache
What is prophylactic treatment for migrain?
–Propranolol, Candesartan
–Anti-epileptics
•Topiramate, Sodium Valproate (teratogenicity), Gabapentin
–Tricyclic antidepressants
•amitriptyline, dothiepin, nortriptyline
–Venlafaxine
Why is the combined oral contraceptive pill contraindicated in active migraine with aura?
Aura with migraine comes with risk of stroke
Combination OCP also comes with a risk of stroke
The two combined is considered to be too high
Name some trigeminal autonomic cephalalgias
Cluster headache
Paroxysmal hemicrania
SUNCT (•Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing)
SUNA (•Short-lasting Unilateral Neuralgiform headache with Autonomic Symptoms)
What are cranial autonomic symptoms?
- Conjunctival injection / lacrimation
- Nasal congestion / rhinorrhoea
- Eyelid oedema
- Forehead & facial sweating
- Miosis / ptosis (Horner’s syndrome)
Where is the pain in a cluster headache?
Mainly orbital and temporal, strictly unilateral
Rapid Onset
Excruciatingly severe
What is the duration of a cluster headache?
15 mins to 3 hours, rapid cessation of pain
Where are autonomic symptoms in a headache?
Ipsilateral
What are the migrainous symptoms often common in cluster headache?
–Premonitory symptoms: tiredness, yawning
–Associated symptoms: nausea, vomiting, photophobia, phonophobia
–Typical aura (often under recognised)
What is the frequency of cluster headaches?
Cluster into bouts lasting 1-3 months with periods of remission lasting at least 1 month.
During a bout, attack frequency is around 1 every other day / 8 every day
May be background pain between attacks
What is the effect of alcohol on cluster headache?
–Alcohol triggers attacks during a bout, but not in remission
Describe the rhythmicity of cluster headaches
–attacks occur at the same time each day
–bouts occur at the same time each year
What is a chronic cluster (10 - 20% have a chronic cluster)
–Bouts last >1 year without remission or
–Remissions last <1 month
What are the following autonomic cephalalgias?
- Cluster Headache
- Paroxysmal Hemicrania
- SUNCT
Where is the pain in paroxysmal hemicranial?
Mainly orbital and temporal
Attacks are strictly unilateral
Migrainous symptoms may be present
What is the duration of an attack in paroxysmal hemicrania?
2- 30 minutes
Rapid cessation of pain
Where are autonomic symptoms present in paroxysmal hemicranial?
Ipsilateral
What is the frequency of attacks of paroxysmal hemicrania?
2-40 attacks per day
What is the treatment for PH?
Indomethacin
Describe the pain in SUNCT
- Unilateral orbital, supraorbital or temporal pain. Described as stabbing or pulsating
- Pain is accompanied by conjunctival injection and lacrimation
What is the duration of a SUNCT?
10 - 240 seconds
What are the cutaneous triggers for SUNCT?
Wind, cold
Touch
Chewing
What is the attack frequency of SUNCT?
3-200/day, no refractory period
What is the pain like in trigeminal neuralgia?
Unilateral maxillary or mandibular division pain - ophthalmic division
Stabbing pain
Lasts 5-10 seconds
What are the cutaneous triggers for trigeminal neuralgia?
- Wind , cold
- Touch
- Chewing - laughing?
What is the attack frequency of trigeminal neuralgia?
Similar to SUNCT, has a refractory period
What are the autonomic features of trigeminal neuralgia?
Uncommon
What is the treatment of trigeminal neuralgia?
Carbamazepine
What is abortive treatment for cluster headache - during the actual headache?
Subcutaneous sumatriptan
Nasal zolmatriptan
100% oxygen 7-12 litres per minute
What is abortive treatment for cluster headache bout?
Occipital depomedrone injection - same side as the headache
Tapering course of oral prednisone
What is preventative treatment for cluster headache?
Verapamil (high dose may be acquired)
Lithium
Topiramate
Methysergide
What is the treatment for paroxysmal hemicrania?
No abortive treatment
Prophylaxis with indometacin
Alternatives - COX-II inhibitors
Topiramate
What is the treatment for SUNCT/SUNA?
No abortive treatment
Prophylaxis is carbamazepine and oxycarbazepine
What is the surgical intervention for trigeminal neuralgia?
Glycerol ganglion injection
Stereotactic radiosurgery
Decompressive surgery
Which presentations of headache are likely to have a sinister cause?
–Associated head trauma
–First or worst
–Sudden (thunderclap) onset
–New daily persistent headache
–Change in headache pattern or type
–Returning patient
What are red flags for headache?
- new onset headache
- new or change in headache
–aged over 50
–Immunosupression or cancer
- change in headache frequency, characteristics or associated symptoms
- focal neurological symptoms
- non-focal neurological symptoms
- abnormal neurological examination
- neck stiffness / fever
- high pressure
–headache worse lying down
–headache wakening the patient up
–headache precipitated by physical exertion
–headache precipitated by valsalva manoeuvre
–risk factors for cerebral venous sinus thrombosis
•low pressure
–headache precipitated by sitting / standing up
•GCA (giant cell arteritis)
–jaw claudication or visual disturbance
–prominent or beaded temporal arteries
What is the definition of a thunderclap headache?
High intensity headache reaching maximum intensity in less than a minute
Majority have peak instantaneously
What is the differential diagnosis for thunderclap headache?
–Primary (migraine, primary thunderclap headache, primary exertional headache, primary headache associated with sexual activity)
–Subarachnoid haemorrhage
–Intracerebral haemorrhage
–TIA / stroke
–Carotid / vertebral dissection
–Cerebral venous sinus thrombosis
–Meningitis / encephalitis
–Pituitary apoplexy
–Spontaneous intracranial hypotension
What is the most comon cause of thunderclap haemorrhage?
SAH - sub arachnoid haemorrhage
1 in 10 patients with thunderclap headache will have SAH
What is the most common cause of SAH?
Aneurysmal
What is potential treatment of brain aneurysms?
Coiling
Clipping
What is investigation for Subarachnoid haemorrhage?
For all patients presenting with a sudden severe headache that peaks within a few minutes and lasts for atleast an hour
–CT +/- LP is unreliable beyond 2 weeks and angiography is required beyond this time
Brain CT
Lumbar puncture - Wait for 12 hours for lumbar puncture, need to wait for the blood to break down so we can see bilirubin in the blood
What should be considered with any patient presenting with a headache and a fever?
CNS infection (Meningitis and encephalitis)
What are the symptoms of meningitis?
Nausea with or without vomiting
Photophobia
Phonophobia
Stiff neck
rash
What are the symptoms of encephalitis?
Altered mental state / consciousness
Focal symptoms and signs
Seizures
rash
What are causes of raised intracranial pressure?
Papilloedema
Cerebral abscess
Venous infarct with local area of haemorrhage
Hydrocephalus
What are features suggestive of a space occupying lesion and / or raised intracranial pressure?
Progressive headache with associated symptoms and signs
–Headache worse in morning or wakes patient from sleep
–Headache worse lying flat or brought on by valsalva (cough, stooping, straining)
–Focal symptoms or signs
–Non-focal symptoms e.g. cognitive or personality change, drowsiness
–Seizures
–Visual obscurations and pulsatile tinnitus
What causes intracranial hypotension?
Dural CSF leak
Can be spontaneous or iatrogenic (post lumbar puncture)
What are the features of intracranial hypotension?
- Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down
- Once the headache becomes chronic it often loses its postural component
What is the investigation for intracranial hypotension?
MRI brain and spine
What is the treatment for intrcranial hypotenison?
–Bed rest, fluids, analgesia, caffeine
(e.g. 1 can red bull qds)
–i.v. caffeine
–Epidural blood patch
Blood patch – epidural – anaesthetic – in epidural space – take the patients own blood in epidural space, blood will track up and down and cause an iritation, stiffeneing of the meninges
Describe the symptoms present in someone with giant cell arteritis?
Diffuse headache, may be severe
Systemically unwell
Scalp tenderness
Jaw claudication
Visual disturbance
Prominent temporal arteries may be present
Elevated ESR supports the diagnosis (ESR: Abbreviation for erythrocyte sedimentation rate, a blood test that detects and monitors inflammation in the body. It measures the rate at which red blood cells (RBCs) in a test tube separate from blood serum over time, becoming sediment in the bottom of the test tube.)
Raised CRP and platelet count are other usedful markers
What action is taken if giant cell arteritis is suspected?
HIgh dose prednisolone
Temporal artery biopsy
