Headache Flashcards
what are the two type so headache
primary
secondary
what are more common - primary or secondary headaches
90% primary
what are types of primary headaches
tension type
migraine (+/- chronic)
cluster headache
medication overuse headache
trigeminal autonomic cephalagias
what are the characteristics of tension type headaches
most frequent type of primary headache
NOT disabling
- mild, bilateral
- pressing or tension quality
- no associated features
what makes a tension headache infrequent, frequent or chronic
infrequent <1day/month
frequent 1-14 days/month
chronic >15 days/month
what are the treatments for tension type headaches
abortive
- aspirin/paracetamol
- NSAIDS
preventive
- tricyclic antidepressants
how should abortive treatment of TTH be taken and why
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
what is migraine
most frequent DISABLING headache (in the WHO tope 20 disabling conditions)
chronic disorder with episodic attacks - complex brain changes
what is the basic pathology of migraine
arises from primary brain dysfunction that leads to activation and sensitisation of the trigeminal system
what are the symptomsfor migraine
during:
headache
nausea, photophobia, phonophobia
fucntional disability
inbetween:
enduring predisposition to future attacks
what are some triggers for migraine
sleep disturbance hunger dehydration diet stress environmental stimuli changes in oestrogen level in women
what are the five stages in a migraine
premonition (pre headache)
aura (mild) early headache (moderate) advanced headache (severe)
postdrome (post headache)
what are the symptoms seen in the premonition stage
mood changes fatigue cognitive changes muscle pain food craving
what are the symptoms seen in the aura stage
fully reversible
neurological changes: Visual somatosensory
what are the symptoms seen in the early headache stage
dull headache
nasal congestion
muscle pain
what are the symptoms seen in the advanced headache stage
unilateral throbbing nasuea photophobia phonophobia olfactophobia
what are the symptoms seen in the postdrome stage
fatigue
cognitive changes
muscle pain
what is aura
transient neurological symptoms from cortical/brainstem dysfunction
involves visual, sensory, motor, speech - slow evolution of symptoms from one area to the next
duration - 15-60 mins
how can aura be confused with an ischaemic attack
loss of function
sudden onset
symptoms all start at the same time and can be localised to a specific vascular area
what classifies a chronic migraine
headache >15 days/month of which >8 days are migraine
for more than 3 months
what is a transformed migraine
history of episodic migraine increasing in frequency over weeks/months/years
but migrainous symptoms become less frequent and severe
can occur with or without escalation in medication use
what is classified as a medication overuse headache
headache >15 days/month which has developed whilst taking regular symptomatic medication
particularly occurs in migraines
what can cause medication overuse headache and how can it be improved
>10 days/month: triptans ergots opioids combination analgesics
> 15 days/month:
simple analgesics
caffeine overuse
improvement seen when stopping use
what are the treatments for migraine
abortive:
aspirins/NSAIDS
triptans
prophylactic: propanolol, candesartan anti-epileptics tricyclic antidepressants venalafaxine
how can migraine be affected in pregnancy
first migraine can present in pregnancy
migraine without aura gets better during pregnancy
treatment more difficult during pregnancy:
acute attack - paracetamol
preventative - propranolol, amitriptiline
what drug is contraindicated for active migraine with aura
combined OCP
what migraine treatments must be avoided in women of child bearing age
anti-epileptics - teratogenic
what are the different types of trigeminal autonomic cephalagias
cluster headache
paroxysmal hemicrania
SUNCT - short lasting unilateral neuralgiform headache with conjunctival injection and tearing
SUNA - short lasting unilateral neuralgiform headache with autonomic symptoms
trigeminal neuralgia
what are the characteristics of trigeminal autonomic neuralgia
unilateral head pain
very sever/excruciating
cranial autonomic symptoms
what are some of the cranial autonomic symptoms
Conjunctival injection / lacrimation
Nasal congestion / rhinorrhoea
Eyelid oedema
Forehead & facial sweating
Miosis / ptosis (Horner’s syndrome)
what are the characteristics of cluster headache
pain - mainly orbital and temporal
strictly unilateral
rapid onset
duration 15mins-3hours
rapid cessation of pain
“suicide headache”
what are the symptoms of cluster headache
prominent ipsilateral autonomic symptoms
premonitory - tiredness, yawning
associated - nausea, vomiting, photophobia, phonophobia
typical aura
when can cluster headaches occur
episodic bouts
- bouts last 1-3 months
- remission for ~1 month
- attack frequency - 1 every other day to 8 per day
what is the circadian rhythmicity of cluster headaches
attacks occur at the same time each day
bouts occur at the same time each year
what constitutes a chronic cluster
bouts lasting >1 year without remission
remissions lasting <1 month
what are the characteristics of paroxysmal hemicranias
pain - mainly orbital and temporal
unilateral
rapid onset
duration - 2-30 mins
frequency 2-40 attacks per day (no circadian rhythm)
rapid cessation of pain
10% attacks may be precipitated by bending or rotating the head
what are the symptoms of paroxysmal hemicranias
no neurological symptoms associated with it
prominent ipsilateral autonomic symptoms
migraine symptoms
what is the treatment for paroxysmal hemicrania
no abortive treatment
prophylactic:
indometacin
what are the characteristics of SUNCT
pain - orbital, supraorbital, temporal
unilateral
stabbing or pulsating pain
- with red eye and lacrimation
duration - 10 secs - 4 mins
frequency - 3-200/day
- no refractory period
what are the triggers for SUNCT
cutaneous triggers
- wind, cold
- touch
- chewing
what are the characteristics of trigeminal neuralgia
pain - maxillary, mandibular - ophthalmic division
unilateral
stabbing pain
duration 5-10 seconds
frequency - 3-200 day
- refractory period
what are the triggers for trigeminal neuralgia
cutaneous triggers:
wind, cold
touch
chewing
what are the treatments for cluster headache
abortive headache:
subcutaneous sumatriptan
abortive bout:
occipital depomedrone injection
preventative:
verapamil
lithium
what are the treatments for SUNCT/SUNA
no abortive treatment
prophylaxis:
gabapentin
carbamazepine
what are the treatments for trigeminal neuralgia
no abortive treatment
prophylaxis:
carbamazepine
surgical intervention
- glycerol ganglion injection
- decompressive surgery
what features can predict a sinister secondary headache
Associated head trauma
First or worst
Sudden (thunderclap) onset
New daily persistent headache
Change in headache pattern or type
Returning patient
what are some secondary headache red flags
new onset headache
new/change in headache (esp >50, immunosuppression, cancer)
neck stiffness/fever
high pressure - worse when lying down
low pressure - worse when sitting up
abnormal neurological examination
jaw claudication
visual disturbance
prominent/beaded temporal arteries
what is a thunderclap headache
high intensity headache reaching maximum intensity in less than 1 minute
can be primary or secondary - no differentiating features
what are the differential diagnosis for thunderclap headache
Primary headache (migraine, primary thunderclap headache, primary exertional headache, primary headache associated with sexual activity)
Subarachnoid haemorrhage
Intracerebral haemorrhage
TIA / stroke
Carotid / vertebral dissection
Cerebral venous sinus thrombosis
Meningitis / encephalitis
Pituitary apoplexy
Spontaneous intracranial hypotension
what is a subarachnoid haemorrhage
bleeding into the subarachnoid space
how might someone present with a subarachnoid haemorrhage
sudden severe headache that peaks within a few minutes and lasts for at last an hour
examination often normal - never consider a patient “too well” for SAH
what investigations can diagnose SAH
SAME DAY hospital assessment
CT brain
LP - must be done >12 hours after headache onset - allows for breakdown of bilirubin
CT +/- LP unreliable beyond 2 weeks and angiography required after this time
what is the most common cause of subarachnoid haemorrhage
aneurysm - early clipping/coiling can save lives!
how might meningism present
nausea +/- vomiting
photo/phonophobia
stiff neck
headache and fever
look for non-blanching rash!
how might encephalitis
altered mental state/consciousness
focal sympotms/signs, seizures
headache and fever
what are the warning features for a space occupying lesion and /or raised ICP
progressive headache
Headache worse in morning or wakes patient from sleep
Headache worse lying flat or brought on by valsalva (cough, stooping, straining)
Focal symptoms or signs
Non-focal symptoms e.g. cognitive or personality change, drowsiness
Seizures
Visual obscurations and pulsatile tinnitus
what can cause intracranial hypotension
dural CSF leak
spontaneous
iatrogenic (post LP)
what are the characteristics of intracranial hypotension headache
clear postural component - develops or worsens soon after assuming an upright posture
- resolves when lying down
once it becomes chronic - often looses postural component
what investigations cane diagnose intracranial hypotension
MRI - brain and spine
what is the treatment for intracranial hypotension
bed rest, fluids, analgesia, caffeine
IV caffiene
epidural blood patch
what can cause raised intracranial pressure
cerebral abscess
hydrocephalus
papilloedema
menangioma
what is giant cell arteritis and when should it be considered
arteritis of large arteries
should be considered in any patient over the age of 50 years presenting with a new headache
what are the characteristics of giant cell arteritis
usually diffuse, persistent, cane be severe headache
systemically unwell
scalp tenderness, jaw claudication, visual disturbance
prominent/beaded temporal arteries
what can help diagnose GCA
elevated ESR
raised CRP
raised platelet count
what is the treatment for GCA
high dose prednisolone
temporal artery biopsy
