Headache Flashcards
What are primary headache?
Headache without underlying cause
What are common types of primary headache?
Tension
Migraine
Cluster
What can cause secondary headaches?
Tumours Meningitis Vascular disorders - e.g GCA Systemic infection Head injury - e.g SAH Drug induced
Are all secondary headaches sinister?
No
What is the most frequent headache?
Tension
Do TTH often present to the doctors?
No
What are the symptoms of a tension headache?
Mild
Bilateral headache
Often pressing or tightening in quality
Band round the head
What is classed as an infrequent tension headache?
<1 day/month
What is classed as a frequent tension headache?
1-14 days/month
What is classed as a chronic tension type headache (CTTH)?
> 15 days/month
What is the treatment for TTH?
Aspirin or paracetemol
NSAID’s
What should be the limit for TTH Rx?
Limit to 10 days per month to avoid the development of medication overuse headache
What is the most frequent disabling primary headache?
Migraines
Why are migraines more common in females?
Due to their hormone cycle
Change in oestrogen levels
What is a migraine?
Chronic disabling headache with features
What other symptoms can present in a headache?
Nausea Vomiting Photophobia Phonophobia Functional disability
What are common triggers of migraine?
Stress Hunger Sleep disturbance Diet Environmental stimuli Changes in oestrogen in women
What is the premonitory phase of a migraine?
Prediction of the headache attack
Mood alterations
Muscle pain,
Food cravings
What is the aura phase of a migraine?
An aura involves focal, reversible neurologic symptoms that often precede the headache
Seeing stars and fuzzy
What is aura?
Transient neurological symptoms
May involve visual, sensory, motor or speech systems
What can aura be confused with?
TIA
What is the duration of aura?
15-60 minutes
What is a chronic migraine?
Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months
What is the abortive treatment for migraine?
Triptans
Paracetemoy
NSAIDS
What is the prophylactic treatment for migraine?
Propanolol
Amitriptyline
How does migraine without aura change in pregnancy?
Gets better
How does migraine with aura change in pregnancy?
Usually does not change
What contraceptive is contraindicated in active migraine with aura?
Combined OCP
Oestrogen and progesterone
What is a migraine?
Chronic disorder with episodic attacks
Due to complex changes in the brain
What % of migraineurs ecperience aura?
33%
Who are particularly prone to medication overuse headaches?
Migraineurs
What is the limit for the use of drugs for migraine?
Limit to 10 days per month to avoid development of MOH
When can woman with migraines and aura go on the OCP?
If she hasn’t had an attack in 5 years
Why should anti-epileptics be avoided in pregnancy?
Because they are teratogenic
What should be used in a woman of child bearing age for pain relief?
Paracetemol
What is a trigeminal autonomic cephalalgia?
Trigeminal autonomic cephalgia (TAC) is the name for a type of primary headache that occurs with pain on one side of the head in the trigeminal nerve area and symptoms in autonomic systems
What are the 3 main TAC?
Cluster headache
Paroxysmal Hemicrania
SUNCT/SUNA
What is the pain experienced in TAC?
Predominantly of the area V1 supplies (eye and forehead area)
Very severe and excruciating
With ipsilateral autonomic symptoms
What cranial autonomic symptoms are there in TAC?
Red eye Nasal conjection Lacrimation Eyelid oedema Forehead and facial sweating
Where is the pain in cluster headache?
Mainly orbital and temporal
Are cluster attacks bi or unilateral?
Unilateral
What is the onset in cluster headaches?
Rapid
Max onset is 9 minutes
What is the duration of a cluster headache?
15mins to 3 hours
What are the symptoms of a cluster headache?
Excruciating unilateral pain
Suicide headache
Restlessness and agitation during an attack
Prominent ipsilateral autonomic symptoms
What are some assocaited symptoms of cluster headaches?
Tiredness, yawning, nausea, vomiting, photophobia, phonophobia
What is a bout in cluster headaches?
Attacks cluster into bouts typically lasting 1-3 months with periods of remission lasting at least 1 month
What is the attack frequency in a bout of cluster headaches?
1 every other day
to 8 per day
Can alcohol trigger cluster headaches?
During a bout yes
During remission no
What is cluster headache all about in the history?
Timing
Comes in bouts of daily attacks
Then goes away for months at a time
What is chronic cluster headaches defined as?
Remissions < 1 month or
Bouts last > 1 year without remission
Where is pain felt in paroxysmal hemicrania?
Mainly orbital and temporal
Is paroxysmal pain usually bi or uni later?
Unilateral
What is the duration of paraoxysmal hemicrania?
2-30 mins
What is the pain intensity for paroxysmal hemicrania?
Very severe
Does cluster headache have circadian rhythm?
Yes Frequently
Does SUNCT have circadian rhythm?
Absent
Does circadian rhythm occur in paroxysmal hemicrania?
Not typically
What is SUNCT?
Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT syndrome), is a rare headache disorder that belongs to the group of headaches called trigeminal autonomic cephalalgia (TACs).
What autonomic symptoms are experienced with SUNCT?
Lacrimation Ptsosis Eyelid oedema Nasal conjestion Conjunctival injection
What is the character of pain in SUNCT?
Stabbing or pulsating pain
What is the duration of SUCNT?
2-240 seconds
What is trigeminal neuralgia?
Trigeminal neuralgia (TN or TGN) is a chronic pain disorder that affects the trigeminal nerve
Which branches are usually affected in trigeminal neuralgia?
V2/V3 >V1
What is the character of pain in trigeminal neuralgia?
Stabbing
What is the duration of pain in trigeminal neuralgia?
5-10 seconds
Are autonomic features common in trigeminal neuralgia?
No
What is the difference between SUNCT and trigeminal neuralgia?
TN- no autonomic features
Predominantly over eye area
SUNCT- autonomic features
Predominant over maxillary and mandibular area
What triggers trigeminal neuralgia?
Wind
Cold
Touch
Chewing
What presentations of secondary headache are more likely to have a sinister cause?
Associated head trauma First or worst Progression in headache Sudden thunderclap headache New daily persistent headache Changes in pattern or type Returning patient
What are red flags for headaches?
New onset New or change >50 on immunosuppresion have cancer changes in headache frequency, characteristics or associated symptoms Focal neurological symptoms Abnormal examination Neck stiffness or fever, photophobia
What is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than minutes
Starts mainly at back of head
What is the main worry with thunderclap headaches?
SAH
What is the main cause of subarachnoid haemorrhage?
85% aneurysmal
Berry aneurysms
What is the mortality for subarachnoid haemorrhage?
50%
What is the presentation of SAH?
All patients presenting with a sudden severe headache that peaks within a few minutes and lasts for at least 1 hour need to be assessed
Examination is often normal!
Never consider a patient ‘too well’ for SAH
When should LP be done for SAH?
> 12 hours
What are the symptoms of meningitis?
Meningism: nausea +/- vomiting, photo/phono phobia, stiff neck
Non blancing rash
What are the warning features for a headache that could be due to space occupying lesion or raised ICP?
Headache: Worse in morning Worse lying down Brought on by valsalva Focal symptoms or signs Seizures Visual obscurations Pulsatile tinnitus
What is pulsatile tinnitus?
Ear noise that is heard in time with heartbeat
What is ICP hypotension due to?
Dural CSF leak
What causes iatrogenic ICP hypotension?
Post lumbar puncture
What is distinguishing about headaches with low ICP?
Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down
What investigations should be done for low ICP?
MRI brain and spine
What is the treatment for low ICP?
Bed rest Analgesia Caffeine IV caffeine Epidural blood patch
What is an epidural blood patch?
Using the patients own blood to seal the hole
What causes the pain in low ICP headaches?
Due to low pressure the brain sinks
Pulls on the vessels and the meninges causing pain
What is giant cell arteritis?
Arteritis of large arteries
Temporal arteritis
What type of headache is experience with giant cell arteritis?
Diffuse, persistent and may be severe
What supports the diagnosis of giant cell arteritis?
Raised ESR
What are the special clinical features of giant cell arteritis?
Scalp tenderness,
Jaw claudication
- pain when eating or chewing
Visual disturbance
What are other useful markers for giant cell arteritis?
Raised CRP
Raised platelet count
Rx for giant cell arteritis?
High dose prednisolone
What investigation should be done to confirm the diagnosis of giant cell arteritis?
Temporal artery biopsy
What is giant cell arteritis?
Giant-cell arteritis (GCA), also called temporal arteritis, is an inflammatory disease of blood vessels.
Inflammation of the temporal artery
