Headache Flashcards
List the 3 different classifications of headache
- Primary headache
- Secondary headache
- Trigeminal and other cranial neuralgias and other headaches
Define a primary headache
Four main groups of headaches thought to be due to a primary malfunction of neurons and their networks
Define a secondary headache
A headache that is symptomatic of some underlying pathology
List the causes of primary headaches
- Migraine
- Tension-type headache
- Cluster headache and other trigeminal autonomic cephalagias
- Other primary headaches (e.g. primary stabbing headache)
List the causes of secondary headaches
- Medication overuse
- Head and/or neck trauma
- Cranial or cervical vascular disorder - vascular malformation or intracranial haemorrhage
- Non-vascular intracranial disorder - raised ICP, idiopathic intracranial hypertension
- A substance or its withdrawal
- Infection - meningitis, encephalitis, abscess
- Disorder of homeostasis - hypercapnia or HTN
- Disorder of facial or cranial structures - acute sinusitis
- Associated with emotional disorders
Define a tension type headache
Symmetrical headache of gradual onset, often described as tightness, a band or pressure.
Usually no other symptoms.
List the different types of migraine
- Migraine with aura
- Migraine without aura
- Uncommon types of migraine
What are the characteristics of migraine without aura?
- Episodes may last 1-72hrs
- Commonly bilateral (but may be unilateral)
- Pulsatile
- Temporal or frontal area
- Often associated with unpleasant GI disturbance
- Associated with photophobia and phonophobia
- Aggravated by physical activity
- Relieved by sleep
What are the characteristics of migraine with aura?
- Headache is preceded by an aura (visual, sensory or motor)
- Aura may occur without headache
- Absence of problems between episodes
- Frequent presence of premonitory symptoms (tiredness, difficulty concentrating, autonomic features)
- Attacks usually last for a few hours
Discuss the types of visual aura associated with migraine
- Negative phenomena - hemianopia, scotoma (small areas of visual loss)
- Positive phenomena - fortification spectra (seeing zig-zag lines)
List the uncommon types of migraine
- Familial hemiplegic migraine
- Sporadic hemiplegic migraine
- Basilar-type migraine
- Periodic syndromes
What are the different periodic syndromes that can be present?
- Cyclical vomiting
- Abdominal migraine
- Benign paroxysmal vertigo of childhood
What are the features of cyclical vomiting?
- Recurrent stereotyped episodes of vomiting and intense nausea
- Associated with pallor and lethargy
- Well in between episodes
What are the features of abdominal migraine?
- Episodic midline abdominal pain
- Recurrent, bouts last 1-72hrs
- Pain is moderate to severe in intensity
- Associated with vasomotor symptoms, nausea and vomiting
- Well between episodes
What are the features of benign paroxysmal vertigo of childhood?
- Recurrent brief episodes of vertigo
- Occur without warning and resolve spontaneously
- Otherwise healthy children
- Between episodes neurological exam, audiometric and vestibular function tests are normal
List the red flag symptoms for space occupying lesion in a child presenting with headache
- Headache worse lying down or with coughing and straining
- Headache wakes child up
- Associated confusion, and/or morning or persistent nausea or vomiting
- Recent change in personality, behaviour or educational performance
List the red flag physical signs for space occupying lesion in a child presenting with headache
- Growth failure
- Visual field defects (craniopharyngioma)
- Squint
- Cranial nerve abnormality
- Torticollis
- Abnormal coordination (cerebellar lesions)
- Gait (upper motor neurone or cerebellar signs)
- Papilloedema
- Bradycardia
- Cranial bruits (arteriovenous malformations)
What would you ask about in the history of a child presenting with headache?
- Premonitory symptoms
- Aura
- Character
- Position
- Radiation
- Frequency
- Duration
- Triggers
- Relieving and exacerbating factors
What other things should be considered when asking about headache?
- Triggers - stress, relaxation, food, menstruation
- Emotional or behavioural problems
- Vision checked (refractive error)
- Head trauma
- Alcohol, solvent or drug abuse
- Analgesia over-use
What are the characteristics of medication overuse headaches?
- Patient with primary headache develops rebound chronic daily headache (headache on 15 or more days of the month)
- Use acute analgesics or triptans on more than 2 days a week
- Withdrawing offending medication resolves this in 2wks
How can we manage headache?
- Mainstay is Hx and exam
- Make a specific headache diagnosis
- Written, child friendly information
- Advise children on how to live with and control the headaches
- Rescue treatments
- Prophylactic treatments
- Psychosocial support
What rescue treatments can be used in the management of headache?
- Analgesia - Paracetamol and NSAIDs; take ASAP
- Antiemetics - prochlorperazine or cyclizine
- Triptans - serotonin agonists (sumatriptan)
- Physical treatments - cold compresses, warm pads, topical forehead balms
What prophylactic treatments can be used in the management of headache?
- Sodium channel blockers (topiramate or valproate)
- Beta-blockers (propranolol)
- Tricyclics (pizotifen - can cause weight gain and sleepiness; amitriptyline - can cause dangerous arrhythmias in overdose
- Acupuncture
What kinds of psychosocial supports can be used in the management of headache?
- Psychological support (to help with particular stressors)
2. Relaxation and other self-regulating techniques, addressing lifestyle issues
What are the characteristic features of a tension headache?
- Regular
- Often frontal
- Not associated with vomiting, paraesthesia, visual disturbance or abnormality on examination
When is a tension headache defined as chronic?
If present for more than 6wks
How is tension headache managed?
- Reassurance
- Suggest analgesia if needed but unlikely to make much difference
- Encourage child to partake in normal activities as much as possible
List the indicators of raised ICP
- Abnormal examination:
- Heel-toe walking
- Finger-nose coordination
- Eye movements
- Fundi (papilloedema) - Severe short history:
- Vomiting
- Morning headache
- Visual disturbance
List the secondary causes of intracranial hypertension
- Drugs:
- Steroid withdrawal
- Vitamin A
- Thyroid replacement
- OCP
- Phenothiazines - Systemic disease:
- Iron deficiency
- Guillain Barré syndrome
- SLE - Endocrine changes:
- Adrenal failure
- Hyperthyroidism
- Hypoparathyroidism
- Menarche
- Pregnancy
- Obesity - Head injury
How does raised ICP present?
- Early morning headache
- Blurred or double vision
- Vomiting
What signs will be present on clinical examination and investigations for idiopathic intracranial hypertension (IIH)?
Neuro - There may be ataxia
Eyes - Papilloedema; scotoma on visual field testing
Imaging - normal
LP - raised ICP (>20cm CSF); normal CSF cell count, protein and glucose
How is IIH managed?
- Weight loss in obese pts
- Remove causal medication (if cause)
- Diuretics - reduce CSF formation
- Steroids - can cause rebound problems when withdrawn
- Serial LP or surgery
- Monitoring of eyes and visual fields
List the diagnostic criteria for paediatric migraine without aura
A. At least 5 attacks fulfilling B-D B. Headache attack lasting 1-48hr C. Headache has at least two of: - Bilateral or unilateral location - Pulsating quality - Moderate to severe intensity - Aggravation by routine physical activity D. During headache, at least one of: - Nausea and/or vomiting - Photophobia and/or phonophobia
List the diagnostic criteria for paediatric migraine with aura
A. Idiopathic recurring disorder: headache that usually lasts 1-48hr
B. At least two attacks fulfilling C
C. At least 3 of the following:
- One or more fully reversible aura symptoms indicating focal cortical and/or brainstem dysfunction
- At least one aura developing gradually over >4mins, or two or more symptoms occurring in succession
- No aura lasting >60mins
- Headache follows in <60mins
