Headache Flashcards
What is the difference between primary and secondary headaches?
- Primary = headache and it’s associated features are the disorder, not caused by underlying structural changes
- Secondary = headache secondary to underlying cause
What do CN III, IV and VI look like?
What are the red flag symptoms for headache? (SNOOPT)
- Systemic symptoms
- Neurological signs or symptoms
- Older age at onset (>50 years)
- Onset is acute (<5mins)
- Previous headache history different/absent
- Triggered headache (i.e. valsalva or posture)
NB - Also increasing frequency/severity, immunocompromise and papilloedema
What are the features of high pressure CSF headache?
- Worse in the morning
- Persistent nausea/vomiting
- Worse with physical exertion
- Worse lying flat, improved standing up
- Worse on valsalva
- Transient visual obscuration with change in posture
What examination findings are seen in high pressure CSF headaches?
- Optic disc swelling
- Impaired visual acuity
- Restricted visual fields/enlarged blind spot
- 3rd nerve palsy
- 6th nerve palsy
- Focal neurological signs
What are the causes of high pressure CSF headache?
- Mass effect (tumour, infarction with oedema, subdural, extradural, intracerebral haematoma, abscess)
- Increased venous pressure (cerebral venous sinus thrombosis, obstruction of jugular venous system)
- Obstruction to CSF flow/absorption (hydrocephalus, meningitis)
- Idiopathic (idiopathic intracranial hypertension)
What are the features of a low pressure CSF headache?
- Worse on sitting/standing up and relieved by lying down
- Results from CSF leakage
What are the causes of low pressure CSF headache?
- Post lumbar puncture
- Spontaneous intracranial hypotension (results from spontaneous dural tear, can occur following valsalva)
What are the features of migraine? (remember POUND)
- Most patients report triggers (hormonal, weather, stress, hunger, sleep disturbance, exertion, alcohol excess, foods - cheese, chocolate)
- Some have aura (visual, sensory, speech and mixed)
- Photophobia
- Phonophobia
- Osmophobia
- Mood disturbance
- Diarrhoea
- Autonomic disturbance
- POUND:
- Pulsatile
- hOurs in duration (4-72 hours)
- Unilateral in 60%, can radiate
- Nausea and vomiting
- Disabling intensity
NB - Hemiplegic migraine includes motor weakness (<24 hours)
What is the pathophysiology of migraine?
- Primary dysfunction of brainstem nuclei (V, VII-X)
- Pin results from pain sensitive cranial blood vessels and their innervating trigeminal fibres
- Vascular hypothesis (intracranial vasoconstriction with reflexive secondary vasodilation)
- Neurovascular hypothesis (migraine is disroder of endogenous pain modulating systesm, particularly subcortical structures)
What are the causes of thunderclap headache (abrupt onset of severe headache which reaches maximal intensity <5mins and lasts >1hr)?
- Subarachnoid haemorrhage (SAH)
- Intracerebral haemorrhage
- Arterial dissection (vertebral or carotid)
- Cerebral venous sinus thrombosis
- Bacterial meningitis
- Spontaneous intracranial hypertension (rare)
- Pituitary apoplexy (rare)
- Primary headaches
Management of migraine
- Headache diary
- Acute
- Triptans (oral or nasal)
- NSAIDs
- Aspirin
- Anti-emetic
- Prophylaxis
- Consider if 2+ attacks a month causing >3 days disability
- Topiramate
- Propranalol
- Amitryptyline
- Contraception
Features and management of cluster headache
- Severe and unilateral around orbits/temporal region
- Lasts 15-180 minutes and can occur 8x a day
- Accompanied by ipsilateral conjunctival congestion, lacrimation, orbital oedema, nasal congestion, facial swelling, miosis/ptosis, restlessness/agitation
- Usually males, smokers, clusters with remission for months/years, begin during sleep
- Manage with high flow O2 and triptans
- Verapamil for prophylaxis
Features and management of trigeminal neuralgia
- Severe sudden shock-like facial pain
- Triggered by light touch (washing, eating, cold wind)
- Lasts seconds but an occur in quick succession
- Unilateral, can affect one or all three branches
- Usually >50 years
- Usually results from damage to the myelin sheath around the trigeminal nerve due to compression (MS/tumour infiltration)
- Treat with AEDs (carbamazepine), antidepressants and surgical decompression
Features of central sinus venous thrombosis
- More common in women due to high thrombotic states (OCP, pegnancy)
- Can present suddenly of insidiously
- Diagnosis bt CTV or MRV
- Treat with heparin
