Headache Flashcards
What are the different types of primary headache?
Tension-type Migraine Medication overuse Trigeminal autonomic cephalalgias Trigeminal neuralgia
What are the symptoms/signs of a tension-type headache?
Most common
Mild bilateral headache often pressing or tightening, with no associated features
Unaffected by physical activity
Frequent = 11-14days/month
Chronic >15
What are the signs/symptoms of a migraine?
Chronic/episodic Headache Nausea Photophobia Phonophobia Functional disability Anticipatory anxiety
What can trigger a migraine?
Stress Hunger Sleep disturbance Dehydration Diet Environmental stimuli Oestrogen cycle
What is the sequence of events in a migraine?
Premonition Aura (33%) - neurological symptoms Early headache Advanced headache Postdrome
What are ‘transformed migraines’?
Headaches that increase in frequency, often becoming daily, but with reduced migrainous symptoms
Can occur with/without medicaation
In those with medication overuse, discontinuing dramatically improves frequency
What difference does gender make in migraine?
Migraine without aura can get better in pregnancy, however migraine with aura usually does not
First migraine can occur during pregnancy, particularly with aura
What are the signs/symptoms of medication overuse headache?
Headache present 15+day/month worsening/developing while on regular medication
What medications are risk factors for medication overuse headaches and what frequency often causes them?
Triptans/ergots/opioids/combination analgaesics >10 days/month
Simple analgaesics >15 days/month
Caffeine also
What are the signs/symptoms of trigeminal autonomic cephalalgias?
Unilateral head pain (predominantly V1)
Severe, excruciating
Cranial autonomic symptoms
- conjunctival injection
- nasal congestion
- eyelid oedema
- forehead/facial sweating
- miosis, ptosis (Horner’s syndrome)
What is a cluster headache? Signs/symptoms?
Type of TAC Mainly orbital, temporal pain Strictly unilateral Rapid onset Duration 15m - 3hr Rapid cessation Migrainous symptoms often present Episodic, circadian rhythmicity Bouts of 1-3 months with remission periods ~1month
What is paroxysmal hemicrania? Signs/symptoms?
Headache mainly orbital/temporal Unilateral and rapid onset/cessation Duration 2-30 minutes Agitation/restless during Prominent ipsilateral autonomic symptoms Neck movements can precipitate (10%) No/less circadian rhythm Indomethacin responsive
What is SUNCT? Signs/symptoms?
Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing
Unilateral orbital, supraorbital, temporal pain
Stabbing/burning
Duration only seconds-minutes
Cutaneous triggers
- wind/cold, touch, chewing
High daily frequency (up to 200), no refractory period
What is trigeminal neuralgia?
Signs/symptoms?
Unilateral maxillary/mandibular pain (> opthalmic)
Stabbing
5-10 seconds duration
Cutaneous triggers
- wind/cold, touch, chewing
Frequency similar to SUNCT (up to 200/day), with refractory period
Autonomic features uncommon
How are tension-type headaches treated?
Aspirin/paracetamol
NSAIDs
Limit to 10days/month to avoid MOH
Preventative rarely required, but TCAs can be used (amitriptyline, dothiepin, nortriptyline)
How are migraines treated?
Abortive treatment
- aspirin/NSAIDs
- triptans
- limit to 10 days/month to prevent MOH
Prophylactic
- propranolol, candesartan
- anti-epileptics (topiramate, valproate, gabapentin)
- TCAs (amitriptyline, dothiepin, nortriptyline)
- venlafaxine
More difficult in pregnancy (avoid anti-epileptics)
Combined OCP contraindicated in migraine with aura
What are the different types of Trigeminal Autonomic Cephalalgias?
Cluster headache
Paroxysmal hemicrania
SUNCT/SUNA
What is the treatment for cluster headache?
Acute
- subcutaneous sumatriptan/nasal zolmatriptan, 100% O2
Bout
- Occipital depomedrone
Preventative
- verapamil
- lithium methysergide
- topiramate
What are the treatments for paroxysmal hemicrania?
No abortive treatment
Prophylaxis with indomethacin
Alternatives include COX-II inhibitors, topiramate
What are the treatments for SUNCT/SUNA?
No abortive treatment
Prophylaxis with lamotrigine, topiramate, gabapentin, carbamazepine
What are the treatments for trigeminal neuralgia?
No abortive treatment
Prophylaxis with carbamazepine, oxcarbazepine
Surgical interevention - glycerol ganglion injection, steriotacticradiosurgery, decompressive surgery
What is a secondary headache and what are risk factors/causes?
Headache with identifiable structural/biochemical cause
Tumour Meningitis Vascular disorders Systemic infection Head injury Drug-induced
What features predict sinister headache? Red flags?
Serious intracranial pathology unlikely in longstanding episodic headache
But, presentations like to have sinister cause include:
- associated head trauma
- first/worst
- sudden (thunderclap)
- new daily persistent
- change in pattern/type (particularly >50yo, immunosuppressed, cancer)
Focal/nonfocal neurological symptoms, abnormal neurological exam
Neck stiffness/fever
High pressure signs
Low pressure signs
Giant cell arteritis signs
- jaw claudication, visual disturbance, prominent/beaded temporal arteries
What signs suggest high pressure in headache?
Worse lying down
Wakes patient
Physical exertion/valsalva precipitate
Risk factors for cerebral venous sinus thrombosis
What signs suggest low pressure in headache?
Precipitated by sitting/standing up
What features suggest a space occupying lesion and/or raised ICP?
Progressive headache with associated symptoms/signs
Warning features
- worse in morning or wakes
- worse lying flat
- focal symptoms/signs
- non-focal symptoms e.g. cognitive or personality change, drowsiness
- seizures
- visual obscurations, pulsatile tinnitus
What are signs of intracranial hypotension?
Post-LP (can be spontaneous as well)
Clear postural component to headache
Develops/worsens soon after assuming upright posture, resolves shortly after lying down
Once becomes chronic, often loses postural component
What is giant cell arteritis? what are the features, signs, symptoms, management?
Arteritis of large arteries
Should be considered in any patient over 50 presenting with new headache
Diffuse, persistent, severe headache
Systemically unwell
Scalp tenderness, jaw claudication, visual disturbance
Prominent, beaded, enlarged temporal arteries may be present
Elevated ESR almost universal
Raised CRP/platelet other useful markers
High dose prednisolone should be started if diagnosis likely, with temporal artery biopsy arranged
Causes/differential diagnoses of thunderclap headache?
Primary SAH Intracerebral haemorrhage TIA/Stroke Carotid/vertebral dissection Cerebral venous sinus thrombosis Meningitis/encephalitis Pituitary apoplexy Spontaneous intracranial hypotension
Features of SAH? When to suspect and what action to take?
1/10 patients with thunderclap have SAH
- 85% aneurysm
- 50% mortality, 20% of survivors become dependent
- rebleed risk 40% in first month
All patients who present with sudden severe headache that peaks within minutes and lasts for >1 hour
- examination often normal
- NEVER consider patient ‘too well’ for SAH
CT brain as early as possible
LP (must be at least 12 hours after onset)
- CT +/- LP unreliable after 2 weeks, angiography required
Symptoms signs of meningitis and encephalitis?
CNS infection should be considered in any patient with headache and fever
Meningism - nausea/vomiting, photo/phonophobia, stiff neck
Encephalitis
- altered mental state/consciousness, focal symptoms/signs, seizures
Rash?
Causes of raised ICP?
Glioblastoma multiform Cerebral abscess Venous infarct with focal haemorrhage Meningioma Hydrocephalus Papilloedema
Management in suspected intracranial hypotension?
MRI brain and spine
Treatment
- bed rest, fluids, analgaesia, caffeine
- IV caffeine
- epidural blood patch
