Headache Flashcards
Give examples of primary headaches
- Tension type headache
- Migraine
- Cluster headache
Give examples of secondary headaches
- Tumour
- Meningitis
- Vascular disorder
- Systemic infection
- Drug induced
- Head injury
What are tension headaches?
○ Most frequent primary headache, but is NOT disabling and rarely presents to doctors
○ Lifetime prevalence of 42% in men and 49% in women
○ Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity
What is the treatment of tension headaches?
- Abortive treatment □ Aspirin or paracetamol □ NSAIDs □ Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache - Preventative treatment □ Rarely required □ Tricyclic antidepressants ® amitriptyline, dothiepin, nortriptyline
What is the epidemiology of migraines?
- 6 million people in the UK
- Lifetime prevalence: 10% in men and 22% in women
- Most sufferers aged 20 to 50
- High impact
- WHO rank it in their top 20 most disabling conditions
What is a migraine?
- Migraine is a complex neurologic disorder, the origin of which cannot be ascribed to a single brain site or mechanism
- Migraine is a neurologic chronic disorder with episodic manifestation (CDEM), characterized by recurrent and reversible attacks of pain and associated symptoms
- Migraine is no longer thought to be caused by a primary vascular event. It involves integrated brain mechanisms among a number of central nervous system (CNS) structures (cortex, brainstem, trigeminal system, meninges) and has a complex pathophysiology. It is generally recognized that migraine arises from a primary brain dysfunction that leads to activation and sensitization of the trigeminal system
- According to the International Headache Society (IHS) criteria, migraine both with and without aura requires that the headache attacks last 4 to 72 hours; in addition, the headaches must have at least 2 of the following features: unilateral location, pulsating quality, moderate or severe pain intensity, and/or aggravation by or causing avoidance of routine physical activity (e.g. walking, climbing stairs). During the headache phase, 1 of the following symptoms should be present: nausea and/or vomiting, photophobia, and phonophobia
What is the pathway of migraine?
- Migraine is manifested clinically as a constellation of symptoms that evolve through the various phases of a migraine attack
- The Premonitory Phase
□ Mood changes
□ Fatigue
□ Cognitive changes
□ Muscle pain
□ Food craving - Aura phase
□ Fully reversible
□ Neurological changes: Visual somatosensory - Early headache
□ Dull headache
□ Nasal congestion
□ Muscle pain - Advanced headache
□ Unilateral
□ Throbbing
□ Nausea
□ Photophobia
□ Phonophobia
□ Osmophobia - Postdrome
□ Fatigue
□ Cognitive changes
□ Muscle pain
What is the treatment for migraine?
- Abortive treatment □ Aspirin or NSAIDs □ Triptans □ Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache - Prophylactic treatment (preventative) □ Propranolol, Candesartan □ Anti-epileptics □ Topiramate, Valproate, Gabapentin □ Tricyclic antidepressants ® amitriptyline, dothiepin, nortriptyline □ Venlafaxine
What is trigeminal autonomic cephalalgias?
○ Unilateral head pain ○ Predominantly V1 ○ Very severe / Excruciating ○ Cranial autonomic symptoms ○ Conjunctival injection / lacrimation ○ Nasal congestion / rhinorrhoea ○ Eyelid oedema ○ Forehead & facial sweating ○ Miosis / ptosis (Horner’s syndrome) ○ Attack frequency and duration differs ○ Treatment responses differ
What are the types of trigeminal autonomic cephalalgias?
- Cluster headaches
- Paroxysmal Hemicrania
- SUNCT
- SUNA
- Trigeminal neuralgia
Describe a cluster headache attack
® Pain: mainly orbital and temporal
® Attacks are strictly unilateral
® Rapid onset (max within 9 mins in 86%)
® Duration: 15 mins to 3 hours (majority 45-90 mins)
® Rapid cessation of pain
® Excruciatingly severe (“suicide headache”)
® Patients are restless and agitated during an attack
® Prominent ipsilateral autonomic symptoms
® Migrainous symptoms often present
® Premonitory symptoms: tiredness, yawning
® Associated symptoms: nausea, vomiting, photophobia, phonophobia
® Typical aura (often under recognised)
Describe a cluster headache bout
® Episodic in 80-90%
◊ Attacks “cluster” into bouts typically lasting 1-3 months with periods of remission lasting at least 1 month
◊ Attack frequency: 1 every other day to 8 per day
◊ May be continuous background pain between attacks
◊ Alcohol triggers attacks during a bout, but not in remission
® Striking circadian rhythmicity
◊ attacks occur at the same time each day
◊ bouts occur at the same time each year
® 10-20% have chronic cluster
◊ Bouts last >1 year without remission or
◊ Remissions last <1 month
What are the treatments for cluster headaches?
® Abortive (Headache)
◊ Subcutaneous sumatriptan 6mg or nasal zolmitriptan 5mg
◊ 100% oxygen 7-12 l/min via a tight fitting non-rebreathing max is effective and safe
® Abortive (Headache bout)
◊ Occipital depomedrone injection (same side as the headache)
◊ Or tapering course of oral prednisone
® Preventative
◊ Verapamil (high doses may be required)
◊ Lithium
◊ Methysergide (risk of retroperitoneal fibrosis)
◊ Topiramate
What is paroxysmal hemicrania?
□ Pain: mainly orbital and temporal
□ Attacks are strictly unilateral
□ Rapid onset
□ Duration: 2-30 mins
□ Rapid cessation of pain
□ Excruciatingly severe
□ 50% are restless and agitated during an attack
□ Prominent ipsilateral autonomic symptoms
□ Migrainous symptoms may be present
□ In 10% attacks may be precipitated by bending or rotating the head
□ Background continuous pain can be present
□ 80% have chronic PH, 20% have episodic PH
□ Frequency: 2-40 attacks per day (no circadian rhythm)
□ Absolute response to indomethacin
What is the treatment of paroxysmal hemicrania?
® No abortive treatment
® Prophylaxis with indomethacin
® Alternatives – COX-II inhibitors, Topiramate
