Headache Flashcards
What are the different types of onset of a headache?
Acute
Sub-acute
Gradual
What are some relieving features of a headache?
Posture
Headache behaviour
What are some exacerbating features of a headache?
Posture
Valsalva (sneezing, coughing, straining etc)
Diurnal variation
What are some associated features of a headache?
Autonomic features (N+V) Photophobia Phonophobia Positive visual symptoms Ptosis Miosis Nasal stuffiness
What are red flags for headaches?
New onset headache >55 Known/previous malignancy Immuno-suppressed Early morning headache Exacerbation by valsalva
What is important in the PMHx for headache?
Beware previous CA, predisposition to thrombosis
What is important in the FHx for headache?
Migraines in family members
What is important in DHx for headache?
Headache diary- need to account for OTC medication
Are migraines more common in men?
No women!
What percentage of migraines are with aura?
20%
What is the IHS criteria for migraine without aura?
At least 5 attacks
Duration 4-72 hours
2 of: moderate/severe, unilateral, throbbing pain. worst movement
1 of: autonomic features, photophobia/phonophobia
What is the pathophysiology of migraines?
Vascular and neural influences in susceptible individuals
Stress triggers- cause serotonin to be released
Blood vessels constrict and dilate
Substance P irritates nerves and blood vessels causing pain
What is the duration of a migraine with aura?
20-60 minutes
What is the onset of headache after a migraine with aura?
<1 hour later
What are the symptoms of a migraine with aura?
Mostly visual- positive symptoms usually monochromatic)
What are the 3 types of visual aura?
Central scotomata
Central fortification
Hemianopic loss
What are some triggers of migraine?
Sleep Dietary Stress Hormonal Physical exertion
What are the non-pharmacological treatments for migraine?
Set realistic goals
Education- avoid triggers
Headache diary
Relaxation/stress management
What are the pharmacological treatments for migraine?
NSAIDS +/- anti-emetic
Triptans- 5HT agonist
Which triptans can be used in treatment of migraine?
Rizatriptan = electrician > sumatriptan
Frocatriptan for sustained relief
When is prophylaxis for migraines indicated?
More than 3 attacks per month or very severe
How is prophylaxis used for migraines?
Titrate drug as tolerated to achieve efficacy at lowest dose
Go slow and keep low
Trial each for minimum 4 months
What drugs can be used for prophylaxis?
Propranolol
Topiramate (Carbonic anhydrase inhibitor)
Others: Amitriptyline, gabapentin, pizotifen, Na valproate, Botox, Anti-calcitonin gene related peptide Ab
When should propranolol be avoided?
Asthma
Peripheral vascular disease
Heart failure
What are the side effects of topiramate?
Weight loss
Paraesthesia
Impaired concentration
Enzyme inducer
What are the side effects of amitriptyline?
Dry mouth
Postural hypotension
Sedation
How can lifestyle be modified for treatment of migraines?
Diet- regular intake, avoid triggers
Hydration- 2L/day minimum. decrease caffeine
Decrease stress
Regular exercise
Give examples of more complex migraines
Acephalgic Basilar Retinal Ophthalmic Hemiplegic Abdominal
What are the characteristics of a tension type headache?
Pressing tingling quality Mild to moderate Bilateral Absence of N+V Absence of photophobia or phonophobia
What are treatments for tension type headache?
Relaxation physiotherapy
Antidepressants- dothiepin or amitriptyline
Reassure
What are trigeminal autonomic cephalgias (TACs)?
Group of primary headache disorders characterised by unilateral trigeminal distribution pain
Associated with ipsilateral cranial autonomic features
What are ipsilateral autonomic features?
Ptosis Miosis Nasal stuffiness Nausea/vomiting Tearing Eye lide oedema
What are the 4 main types of TAC?
Cluster
Paroxsymal hemicrania
Hemicrania continua
SUNCT
Who gets cluster headaches?
Young (30-40s)
Men > women
When do cluster headaches occur?
Striking circadian (around sleep) Seasonal variation
What are the features of a cluster headache?
Severe, unilateral headache
Occurs 1-8 per day
Cluster bout may last from a few weeks to months
What is the duration of cluster headaches?
45-90mins
20mins-3hrs
What is the treatment for cluster headaches?
High flow O2 100% for 20mins
Sub-cutaneous sumatriptan
Steroids- reducing over 2 weeks
Verapamil for prophylaxis
Who gets paroxysmal hemicrania?
Elderly (50-60s)
Women> men
What are the features of a paroxysmal hemicranial?
Severe unilateral headache with unilateral autonomic features
What is the duration of paroxysmal hemicrania?
10-30 minutes (2mins-45mins)
1 to 40 times a day
N.B. shorter duration and more frequent than cluster
What is the treatment for paroxysmal hemicrania?
Absolute response to indomethicin
What does SUNCT stand for?
S= short lived (15-120 secs) U= unilateral N= neuralgiaform headache C= conjunctival injections T= tearing
What is the treatment for SUNCT headaches?
Lamotrigine
Gabapentin
What investigations are done for new onset unilateral cranial autonomic features?
MRI brain
MR angiogram
Who gets idiopathic intracranial hypertension?
Females> males
Obese
What are some symptoms of idiopathic intracranial hypertension?
Headache- diurnal variation
Morning N+V
Visual loss
What investigations can be done for IIH and what would be found?
MRI brain w/ MRV sequence- normal
CSF- elevated pressure, normal constituents
Visual fields- impaired
What are treatments for IIH?
Wgt loss
Acetazolamide
Ventricular atrial/lumbar peritoneal shunt
Monitor visual fields & CSF pressure
Who gets trigeminal neuralgia?
Elderly (>60)
Women > men
When does trigeminal neuralgia occur?
Triggered by touch
Usually V2/3
What are the features of trigeminal neuralgia?
Severe stabbing unilateral pain
What is the duration of trigeminal neuralgia?
1 -90secs
10-100 times per day
Bouts pain may last from few weeks to months before remission
What is the treatment for trigeminal neuralgia?
Carbamazepine Gabapentin Phenytoin Baclofen Surgical: ablation/decompression
What investigations can be done for trigeminal neuralgia?
MRI brain
What structures should be considered with facial pain?
Eyes Ears Sinuses Teeth TMJ
