Headache Flashcards

1
Q

What factors should you cover in the history of someone presenting with a headache ?

A
  • Onset/ Peak - Acute Vs Sub-acute Vs Gradual
  • Relieving features - Posture, headache behaviour
  • Exacerbating - Posture, valsalva (sneezing, coughing, straining etc). Diurnal variation
  • Associated features - Autonomic features (N+V), photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness etc
  • Past medical history - Beware previous CA, predisposition to thrombosis
  • Family history- particularly migraine
  • Drug history - Headache diary may allow accurate account of OTC medication ingestion
  • Social history
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2
Q

What are the red flags in someone presenting with a headache which warrants further investigation ?

A
  • New onset headache >55
  • Known/previous malignancy
  • Immuno-suppressed
  • Early morning headache
  • Exacerbation by valsalva maneouver
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3
Q

What are the two main types of migraine ?

A
  • Migraine with aura (20%)
  • Migraine without aura (80%)
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4
Q

Who is migraines more common in and how often do people usually have migranes ?

A

Women 2.5:1

On average most have 1 attack per month

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5
Q

What is the diagnostic criteria for a mirgane without aura ?

A

Have to have had > or equal to 5 attacks

Attacks last 4-72 hours if untreated or unsuccessfully treated

Headache has at least two of the following characteristics:

  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Symptoms are aggravation by or causing avoidance of routine physical activity

During headache, at least one of the following

  • Nausea and / or vomiting
  • Photophobia (experience of discomfort or pain to the eyes due to light exposure) / Phonophobia (fear of loud sounds)

Headache not attributable to any other disorder

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6
Q

What is the diagnostic criteria for migraine with aura

A

At least 2 attacks fulfilling the following criteria

Aura consisting of at least one of the following, but no motor weakness:

  • Fully reversible visual symptoms including positive features (e.g. flickering lights, spots or lines) and /or negative features (i.e. loss of vision)
  • Fully reversible sensory symptoms including positive features (i.e. pins and needles) and / or negative features (i.e. numbness)
  • Fully reversible dysphasic speech disturbance

Aura duration 20-60 minutes

Headache follows < 1 hours later but aura can occur simultaneously

Headache fulfilling criteria for Migraine without Aura begins during the aura or follows aura within 60 minutes (except occuring > or equal to 5 times as only needs to 2 times with aura)

Headache not attributed to another disorder

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7
Q

Describe the pathophysiology of migraine

A
  • Stress triggers changes in the brain, these changes cause serotonin to be released
  • Blood vessels constrict and dilate
  • Chemicals including substance P irritate nerves and blood vessels causing pain.
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8
Q

What are the potential triggers for migraines ?

A
  • Sleep
  • Dietary - chocolate, cheese
  • Stress
  • Hormonal - Oral contraceptives
  • Physical exertion
  • Alcohol
  • Lie-ins
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9
Q

What can be used to help identify triggers in someone presenting with migraines ?

A

Headache diary

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10
Q

What investigations are required in someone presenting with mirganes ?

A

For typical migraine no investigations are required

Consider imaging if:

  • Late onset >55
  • Known malignancy
  • Acephalgic migraine - migraine aura without headache
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11
Q

What is a medication overuse headache ?

A

Also known as rebound headache usually occurs when analgesics are taken frequently to relieve headaches. Rebound headaches frequently occur daily, can be very painful and are a common cause of chronic daily headache.

Common causes are mixed analgesics (paracetamol + codeine/ opiates), ergotamine (ergot alkaloid) and triptans

medication overuse headache is a common reason for episodic headaches becoming daily, analgesia must be withdrawn and then limited

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12
Q

What is the lifestyle/ education adivce you should recommend to someone experiencing migraines ?

A
  • Avoid triggers and eat a healthy balanced diet
  • Ensure hydration taking in a min of 2L per day and decrease caffeine intake
  • Decrease stressors
  • Regular exercise
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13
Q

What is the treatment of acute migraines (i.e. one happening right now)?

A
  • 1st line = NSAID (including aspirin) OR triptan OR both together
  • 2nd line = paracetamol
  • Consider adding an an antiemetic even in the absence of N&V but esp if they have N&V or gastroparesis e.g. metoclopramide or prochlorperazine
  • NSAID - either aspirin, naproxen or ibuprofen
  • Triptans include - 1st sumatriptan (try others if needed) rizatriptan, eletriptan, (clue is in the name for these ones)
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14
Q

When should you consider prophylactically treating someone with migraines ?

A

If they have >3 attacks per month or very severe disabiling symptoms

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15
Q

When prophylactically treating someone for migraines how long should a drug be trialled for to see if its working ?

A

A min of 4 months

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16
Q

Along with drug management what other treatments can you offer someone for prophylactic treatment of migraines ?

A

Non-phramacological management with acupuncture or relaxation exercises

17
Q

What are the drug options for the prophylactic treatment of migraines ?

A
  • 1st line options are - propanolol (B- blocker) or topiramate (propanolol preferred if women of child bearing age due to topiramates risk of teratogenicity)
  • Amitriptyline sometimes considered
  • 2nd line = course of acupuncture therapy
18
Q

What are the contraindications to B-blockers ?

A

Contraindicated in asthma and PVD

19
Q

What is the mechanism of action of topiramate and what are the side effects caused by it ?

A

Mechanism of action - it is a carbonic anhydrase inhibitor which acts on Na/Ca channels, inhibiting gultamate and enhancing GABA

SE - weight loss, parasethesia (pins & needles), impaired concentration & enzyme inducer

20
Q

What are the side effects caused by amitriptyline ?

A

dry mouth, postural hypotension, sedation

21
Q

What are some of the other options in the prophylactic treatment of migraines after the 1st line options ?

A

sodium valproate, riboflavin or a triptan (zolmitriptan or frovatriptan)

22
Q

Very briefly what might make you think someone has sinusitis ?

A

Dull, constant ache over frontal or maxillary sinuses, with tenderness +/- post-nasal drip

Pain is worse on bending over

23
Q

Very briefly what might make you think someone has GCA ?

A
  • Older
  • Has a headache that has lasted a few weeks
  • Tender, thickened pulseless temporal arteries
  • Jaw calduication
24
Q

Very briefly what might make you think someone has acute glaucoma ?

A
  • Typically in elderly long sighted people
  • Constant aching pain develops rapidly around one eye radiating to the forehead
  • Maredly reduced vision, haloes
  • Nausea and vomiting
  • Red congested eye
  • Cloudy cornea
  • Dilated non-responsive pupil
  • Decreased visual acuity
25
Q

What are the signs/symptoms of a tension headache ?

A
  • Bilateral, non-pulsatile headache +/- scalp muscle tenderness
  • No vomiting or sensitivity on head movement