Headache Flashcards
What is a headache?
Pain and discomfort
Between orbits and occiput
Arising from pain sensitive structures
What is the classification of headache?
PRIMARY
- tension type
- migraine
- cluster
SECONDARY (Sinister)
Neurological
- Intracranial hypertension/SOL/pseudotumor cerebri
- intracranial infection
- SAH
- Arterial dissection
Non-neurological
- giant cell arteritis
- glaucoma
- acute (malignant) hypertension
- systemic infection
What are the pain sensitive structures causing headache?
Anterior headache
Eyes Sinuses Teeth Ear Face Carotid arteries
Posterior headaches
Cervical spine
Vertebral arteries
Global
Scalp Periosteum Meninges Venous sinuses Intracranial arteries
What are the features of secondary headaches?
Hyperacute/ Acute/ Subacute onset
Progressive daily
Awakened by/ with headache
Associated fever, meningism, focal signs
Papilloedema
Aggravated by straining
New headache in person >50 years old
What are the causes of acute headaches?
Sinusitis Migraine Cluster Glaucoma Arterial dissection Optic neuritis Post traumatic Vasodilator drugs ICH CNS infection Hydrocephalus
What are the causes of subacute headaches?
Chronic meningitis SOL CSDH Hydrocephalus Pseudotumour cerebri Giant cell arteritis Low CSF pressure
What are the causes of chronic headaches?
Tension type Migraine Analgesic overuse Ocular strain Vasodilator drugs Cervical spondylosis
What are the features of headache due to ICH/SAH?
Instantaneous headache
“Worst ever”
Thunderclap / blow to the back of the head type of feeling
Fall / LOC
vomiting
Focal signs
What are features of giant cell arteritis?
Chronic daily throbbing focal intractable headache
General malaise / constitutional symptoms
Tenderness over temporal region
Jaw claudication ( pathognomonic)
Blindness transient / permanent
Females > males
Age and ESR > 50
Tender swollen non pulsatile temporal arteries
What are the features of headache from intracranial hypertension?
Generalized progressive headache
Awaken by / with headache
Worse in the morning and by straining
Late- vomiting, vision loss, AMS
What are the vasodilator drugs?
Nitrates
Bronchodilators
Antihistamines
What are the features of tension type headaches?
Most common headache
Chronic daily
Bilateral Diffuse dull aching band like
“Tension”
Non throbbing
Mild to moderate pain lasting for minutes to days
Not limiting activity
No nausea /vomiting / photo or phonophobia
By muscle spasm from stress/ drugs
What is migraine?
Common disorder
Unilateral frontotemporal throbbing headache
Moderate to severe pain
Associated with nausea, vomiting, photo and phonophobia
Made worse by simple activity, prefer isolation
Episodic lasting hours to days
Early onset
Female to male 2:1
Family history
Two types
With aura/ classical 20%
Without aura/ common 80%
What is the aura of migraine?
A warning of visual, sensory or motor type
Lasting less than one hour
Followed by migraine headache within one hour
Most common is visual aura
- photopsia (colours flickering dots)
- fortifications spectra (zig zag lines)
- scintillating scotomas (central field defects)
What are the types of migraine with aura?
Visual aura
Basilar aura
Hemiplegic aura (DDx for stroke)
Retinal aura
What are the factors precipitating migraine?
Dietary
- alcohol
- chocolate
- cheese
Hormonal
- PMS
- OCP
Other
- stress
- fatigue
- exercise
- sleep deprivation
- minor head trauma
What is the management of migraine?
Avoidance of triggers / precipitants
Acute attacks
1. Simple analgesic + metoclopramide + antiemetic
- Triptans Oral or subcut (selective 5HT1 agonist) for reversing vasodilation- sumatriptan
- Ergotamine Oral/ inhaled/ iv/ supp (5HT agonist)
- Methylprednisolone IM or IV for status migranosus
Prophylaxis Propranolol Verapamil Antidepressants Anticonvulsants Pizotifen
What is cluster headache?
A trigeminal autonomic cephalalgia
Men> females, middle age onset
Combination of facial pain and autonomic dysfunction
Episodic clustered severe unilateral eye pain
Lasting minutes to hours
Associated with conjunctival injection, lacrimation, rhinorrhea, transient Horner’s
Precipitated by alcohol
What are the causes of facial pain?
Trigeminal neuralgia (V1, V2, V3) Post herpetic neuralgia (V1) Dental pain Acute sinusitis TMJ dysfunction Cluster headache Glaucoma
What is trigeminal neuralgia or tic douloureux?
Sudden severe paroxysmal
Unilateral
electric shock like/ shooting pain/ sharp/ stabbing
Usually in V2 V3
Several times per minute
Lasting seconds to minutes
Elderly
Female > male 2:1
Trigger zones and trigger factors
No sleep disturbance
Exclude secondary trigeminal pathology if sensory loss, young age, Bilateral, poor response to carbamazepine
What is postherpetic trigeminal neuralgia?
Dull, burning, persistent facial pain
Around V1
Evidence of scarring
And sensory loss
