Headache Flashcards
define and give an example of a primary headache
there is no underlying medical cause:
> tension
> migraine
> cluster
define of a secondary headache
there is an identifiable/biochemical cause
give some examples of causes of secondary headaches
> tumour > meningitis > vascular disorders > systemic infection > head injury > drug induced
describe a tension headache
> primary > most frequent > not disabling > mild > bilateral > pressure/tightening > no significant associated features
what abortive treatment can be given for tension headaches?
> aspirin/paracetamol
NSAIDs
limit to 10 days per month
why must abortive treatment for tension headaches be limited to 10 days per month?
to avoid the development of medication overuse headache
what preventative treatment could you offer for tension headaches?
tricyclic antidepressants (amitriptyline, dothiepin, notriptyline)
what is migraine?
a chronic disorder with recurrent, reversible episodic attacks due to complex changes in the brain.
describe a migraine attack
> headache > nausea > photophobia > phonophobia > functional disability
name some triggers for migraine
> dehydration > sleep disturbance > diet > environmental stimuli > hunger > stress > changes in oestrogen levels in women
describe the pre-headache in migraine
premonitory: > mood change > fatigue > congnitive changes > muscle pain > food craving
aura
> somatosensory
describe the early headache in migraine
> dull headache
nasal congestion
muscle pain
describe the advanced headache in migraine
> unilateral > throbbing > nausea > photophobia > phonophobia > osmophobia
describe post headache symptoms in migraine
> fatigue
cognitive changes
muscle pain
what is aura?
transient neurological symptoms from cortical or brainstem dysfunction that may involve visual, sensory, motor or speech symptoms.
what can aura in migraine be confused with?
transient ischaemic attack
how do you differentiate between aura and a transient ischaemic attack?
in a TIA the symptoms all start at the same time and can be localised to a specific vascular area. in aura there is a slow evolution of symptoms
define chronic migraines
headache on more than or equal to 15 days a month of which more than or equal to 8 days have to be migraine for more than 3 months
what is a transformed migraine?
> history or episodic migraine with increasing frequency of headaches
migrainous symptoms becomes less frequent and severe
there are often episodes of migraine on a background of a severe and featureless frequent headache
when patients with chronic migraine with medication overuse what affect can discontinuing the medication have?
can dramatically improve the headache frequency
what is a medication overuse headache?
a headache that is present on more than or equal to 15 days a months which has developed or worsened whilst taking regular symptomatic medication
what abortive treatment is available for migraine?
> aspirin/NSAIDs
triptans
limited to 10 days per month
what prophylactic treatment is available for migraines?
> propranolol, candesartan
anti-epileptics
tricyclic antidepressants
venlafaxine
what sort of migraine gets better in pregnancy?
migraine without aura
in what migraine in the combined pill contraindicated in?
active migraine with aura but it is okay if there is no attacks for 5 years but stop if aura recurrs
in what patients should you avoid anti-epileptic drugs for migraine?
in women of child bearing age
what is the treatment for migraine in pregnancy?
> paracetamol for an acute attack
> propranolol or amitriptyline for preventative
name some trigeminal autonomic cephalalgias
> cluster headache
paroxysmal hemicranias
SUNCT
SUNA
describe the attack in a cluster headache
> pain is mainly orbital and temporal > very severe > unilateral > rapid onset (9mins max) > lasts 15mins to 3 hours > pains ceases rapidly > prominent ipsilateral autonomic symptoms > patients are restless and agitated in the attacks
what migrainous symptoms may be present in a cluster headache attack?
> premonitory symptoms (tiredness and yawning)
associated symptoms (vomiting, photophobia and phonophobia)
typical aura
describe the bouts in cluster headaches
> attacks cluster in bouts lasting 1-3months with periods of remission of about a month in between
in a bout of a cluster headache how frequently do attacks occur?
1 every other day to 8 per day
what may be present between cluster headache attacks?
background pain
what can trigger a cluster headache attack in a bout but not in remission?
alcohol
is there a rhythm in the time of the attacks and bouts?
yes as attacks occur at the same time each day and bouts at the same time each year
what is chronic cluster headache?
when bouts last more than a year without remission or remission lasts less than a month
in what trigeminal autonomic cephalalgia is carcidian periodicity absent?
SUNCT, paroxysmal hemicrania
what features of pain are different in paroxysmal hemicranias compared to cluster headache?
the features of pain are the same but the attacks last 2-30 minutes and only 50% are restless.
how frequent can paroxysmal hemicrania attacks be?
2-40 times a day
to what do paroxysmal hemicranias have an absolute response to?
indometacin
describe the pain in SUNCT
> unilateral orbital, supraorbital or temporal
stabbing or pulsating
10-240 second duration
what are cutaneous triggers of SUNCT?
> wind, cold
touch
chewing
what is the attacks frequency of SUNCT?
3-200 per day with no refractory period
what Is pain in SUNCT accompanied by?
conjunctival injection and lacrimation
describe the pain in trigeminal neuralgia
> unilateral maxillary/mandibular division pain
stabbing
5-10 second duration
what are the triggers for trigeminal neuralgia?
> wind/cold
touch
chewing
what is the difference between trigeminal neuralgia and SUNCT?
trigeminal neuralgia had a refractory period
what abortive treatment is there for an cluster headache attack?
> subcutaneous sumatriptan
nasal zolmatriptan
100% oxygen 7-12 minutes via tight fitting mask
what is the abortive treatment for cluster headache bouts?
> occipital depomedrone injection (same side as the headache)
tapering course of oral prednisone
what is the preventative treatment for cluster headaches?
> verapamil
lithium
methysergide
topiramate
what is the abortive treatment for paroxysmal hemicrania?
there is no abortive treatment for this
what is the prophylactic treatment for paroxysmal hemicrania?
indometacin
what is the preventative treatment for SUNCT/SUNA?
> lamotrigine
topiramate
gabapentin
carbamazepine
what prophylactic treatment is available for trigeminal neuralgia?
> carbamazepine
> oxcarbazepine
what surgical intervention in available for trigeminal neuralgia?
> glycerol ganglion injection
stereotactic radiosurgery
decompressive surgery
what presentation of secondary headache more likely has a sinister cause?
> associated head trauma > first/worst > thunderclap > new daily persistent headache > change in pattern or type > returning patient
what are some red flags in secondary headache?
> new onset > change in headache: aged over 50, immunosuppressed or cancer > change in frequency, characteristic, associated symptoms > focal neurological symptoms > non-focal neurological symptoms > abnormal neurological examination > neck stiffness > high pressure > low pressure > Giant cell arteritis
what would suggest the headache is high pressured?
> worse lying down > on awakening > physical exertion > Valsalva manoeuvre > cerebral venous sinus thrombosis
what would suggest a low pressure headache?
> precipitated by standing up
what features would point to giant cell arteritis?
> jaw claudication
visual disturbances
beaded temporal arteries
define a thunderclap headache
high intensity headache reaching maximum intensity in less than one minute
what is the differential diagnosis for a thunderclap headache?
> primary > subarachnoid haemorrhage > intracerebral haemorrhage > TIA/stroke > carotid dissection > cerebral venous sinus thrombosis > meningitis/encephalitis > pituitary apoplexy > spontaneous intracranial hypotension
describe the presentation of a subarachnoid haemorrhage?
presenting with a sudden severe headache that peaks within a few minutes and last for a at least an hour
what investigations are carried out in a suspected sub arachnoid haemorrhage?
> CT brain
lumbar puncture after 12hours of headache onset
after 2 weeks an angiography is the only reliable investigation
what is the treatment for subarachnoid haemorrhages?
surgical clipping or coiling
describe meningitis
> nausea
photo/phonophobia
stiff neck
rash
describe encephalitis
> altered metal state
focal symptoms
seizures
rash
what should be considered for any patient presenting with headache and fever?
CNS infection
what features of a headache would suggest that there is an occupying lesion or raised intracranial pressure?
> worse on awakening > worse lying flat > focal signs/symptoms > non-focal symptoms (cognitive) > seizures > visual obscurations and pulsatile tinnitus
what can cause intracranial hypotension?
> dural CSF leak
spontaneous
iatrogenic
describe the postural component to the headache in intracranial hypotension
> worse upright
better lying down
can lose this postural component when it becomes chronic
what investigations are carried out in intracranial hypotension?
MRI or spine and the brain
what is the treatment for intracranial hypotension?
> bed rest > fluid > analgesia > caffeine (IV) > epidural blood patch
describe the headache in giant cell arteritis
> diffuse
persistant
severe
what features may accompany the headache in giant cell arteritis?
> systemic upset > scalp tenderness > jaw claudication > visual disturbance > enlarged temporal arteries
what is used to diagnose giant cell arteritis?
> elevated ESR
raised CRP
raised platelet count
what is the management for giant cell arteritis after a diagnosis is made?
> high dose prednisolone
> temporal artery biopsy
