Headache Flashcards
Migraine tends to occur in whom?
Young females.
What features may be associated with headaches?
- Photophobia.
- Phonophobia.
- Positive visual symptoms.
- Ptosis, miosis.
- Nasal stuffiness.
- Autonomic features e.g. n+v.
Red flags in headaches?
- New onset >55 y/o.
- Known/previous malignancy.
- Immuno-suppressed.
- Early morning headache.
- Exacerbated by valsalva/coughing/sneezing (which raise ICP).
Are most migraines with or without aura?
Without- 80%.
IHS criteria for migraine without aura.
- At least 5 attacks.
- Duration of 4-72 hours.
- 2 of: moderate/severe pain, unilateral pain, throbbing pain, pain worse on movement.
- 1 of: autonomic features, photophobia or phonophobia.
How may migraines be induced by stress?
- Serotonin release in the brain causes constriction and dilation of blood vessels.
- Chemicals e.g. substance P irritate nerves and blood vessels to cause pain.
How long does aura last in migraine?
20-60 minutes.
Do migraine and aura always occur simultaneously?
No.
Aura may occur an hour before headache onset or simultaneously.
What types of aura are associated with migraine?
- Visual.
- Sensory.
- Motor.
- Language symptoms.
Describe visual aura of migraine.
- Central scotoma.
- Central fortification.
- Hemianopic loss.
Migraine may be triggered by?
Sleep, diet, stress, hormones, physical exertion.
Non-pharmacological treatment of migraine?
- Set realistic goals.
- Avoid triggers.
- Headache diary.
- Relaxation/stress management.
Pharmacological treatment of acute migraine?
- Acute: NSAID (aspirin, naproxen, ibuprofen, triptans ASAP +/- anti-emetic if gastroparesis.
Dose of aspirin in acute migraine?
ASAP 900mg +/- anti-emetic if gastroparesis.
Dose of Naproxen in acute migraine?
ASAP 250mg +/- anti-emetic if gastroparesis.
Dose of ibuprofen in acute migraine?
ASAP 400mg +/- anti-emetic if gastroparesis.
Pharmacological prophylaxis of migraine should be considered when?
If more than 3 attacks per month or if very severe.
What is the aim of migraine prophylaxis?
To titrate drug as tolerated to achieve efficacy at lowest dose possible.
How long must migraine prophylaxis drugs be trialed?
A minimum of 4 months each.
Which beta-blocker reduces migraine frequency in 60-80% of patients?
Propranolol.
Daily dose of propranolol to reduce migraine frequency?
80-240mg.
When should propranolol be avoided?
Asthma, PVD, heart failure.
What is topiramate?
Carbonic anhydrase inhibitor (Na+/GABA).
Daily dose of topiramate in prevention of migraine?
25-100mg.
Adverse effects of Topiramate?
- Weight loss, paraesthesia, impaired concentration, enzyme inducer.
Side effects of amitriptyline?
Dry mouth, postural hypotension, sedation.
Describe a tension type headache.
- Pressing tingling quality.
- Mild to moderate pain.
- Bilateral.
- Absence of N+V.
- Absence of photophobia/phonophobia.
- Episodic or chronic nature.
Management of tension type headache?
- Relaxation physiotherapy.
- Anti-depressant (dothiepin or amitriptyline) for 3 months.
- Reassurance.
What are trigeminal autonomic cephalgias (TACs)?
Primary headache disorders characterised by pain in a unilateral trigeminal distribution in association with prominent ipsilateral cranial autonomic features.
Name the ipsilateral cranial autonomic features associated with trigeminal autonomic cephalgias (TACs).
- Ptosis.
- Miosis.
- Nasal stuffiness.
- Nausea/vomiting.
- Tearing.
- Eye lid oedema.
What are the four main types of trigeminal autonomic cephalgias (TACs)?
- Cluster headaches.
- Paroxysmal hemicrania.
- Hemicrania continua.
- Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT).
Cluster headache is most common in who?
Men in their 30s-40s.
When do cluster headaches typically occur?
- Striking circadian (around sleep).
- Seasonal variation.
Features of a cluster headache?
Severe unilateral headache lasting 45-90 mins and occurring 1-8x a day.
A cluster bout may last from weeks to months.
Management of cluster headaches?
- High flow 100% oxygen for 20 mins.
- Sub/cut Sumatriptan 6mg.
- Steroids: reduce course over 2 weeks.
- Prophylactic Verapamil.
Paroxysmal hemicrania is most common in who?
Woman in their 50s-60s.
Features of paroxysmal hemicrania?
- Severe unilateral headache.
- Unilateral autonomic features.
- Last 10-30 mins 1-40x a day.
Management of paroxysmal hemicrania?
Indomethicin.
If it don’t respond to indomethicin, it ain’t paroxysmal hemicrania.
SUNCT stands for?
- Short lived.
- Unilateral.
- Neuralgiaform headache.
- Conjunctival injections.
- Tearing.
Management of SUNCT?
- Lamotrigine, Gabapentin.
Who requires investigation for headache?
New onset unilateral cranial autonomic features.
What is the imaging used in investigating new onset unilateral cranial autonomic features?
- MRI brain.
- MR angiogram.
Who is idiopathic intracranial hypertension most common in?
Obese females.
How does idiopathic intracranial hypertension?
- Diurnal variation.
- Morning n+v.
- Visual loss.
What will MRI brain with MRV sequence show in idiopathic intracranial hypertension?
Normal.
What will CSF show in idiopathic intracranial hypertension?
Elevated pressure but normal constituents.
Management of idiopathic intracranial hypertension?
- Weight loss.
- Acetazolamide.
- Ventricular atrial/lumbar peritoneal shunt.
- Monitor visual fields and CSF pressure.
Apart from imaging and CSF tap what should be tested in idiopathic intracranial hypertension?
Visual fields.
Trigeminal neuralgia is more common in?
Elder women (>60 y/o).
Trigeminal neuralgia is triggered by?
Touch usually in V2/3 dermatome.
Features of trigeminal neuralgia?
- Severe stabbing unilateral pain.
- Lasting 1-90 seconds 10-100x a day.
- Bouts of pain may last weeks to months before remission.
Medical management of trigeminal neuralgia?
Carbamazepine, Gabapentin, Phenytoin, Baclofen.
Surgical management of trigeminal neuralgia?
Ablation, decompression.
Investigation of trigeminal neuralgia?
MRI brain.
What other non-neurological structures should be considered in headaches with facial pain?
- Eyes.
- Ears.
- Sinuses.
- Teeth.
- TMJ.
