Headache Flashcards
Differentials for acute headache.
TICOS
T Trauma to head I Infection (meningitis or encephalitis) C Cerebrovascular (subarachnoid haemorrhage or intracranial haemorrhage/infarction) O Ocular (glaucoma) S Sinusitis
Migraine diagnosis (if without aura)
a) At least ___ attacks
b) Duration: __ - __ hours (if longer, could be…?)
c) At least 2 out of what 4 symptoms?
d) AND, at least one of what other symptoms?
a) 5
b) 4 - 72 (longer - could be status migrainosus
c) Unilateral, pulsating, moderate/severe intensity, aggravated by activity or leads to activity avoidance
d) Nausea, vomiting, photo/phonophobia
Migraine treatment
a) Acute (steps 1 - 3)
b) Pregnancy acute
c) Prophlyaxis - in who? What drugs?
a) Step 1: Oral aspirin/ibuprofen +/- prochlorperazine
Step 2: Rectal diclofenac
Step 3: Triptans
b) Pregnancy: Paracetamol (not aspirin, NSAIDs or triptans)
c) Frequent attacks: two or more attacks per month that produce disability lasting for three days or more. Drug: beta-blockers (1st line), amitryptilline (2nd line), valproate/topiramate (3rd line)
Tension-type headache:
a) How many episodes?
b) At least 2 out of what 4 features?
c) Best painkillers for acute/episodic TTH
d) Best for chronic TTH
a) 10
b) Bilateral or generalised, and of mild-to-moderate intensity (interfering with but not preventing activities).
Frontal-occipital.
Non-pulsatile in quality (pressing or tightening).
Not aggravated by routine physical activity.
c) NSAIDs (if CI: paracetamol)
d) Amitryptiline
Cluster headache:
a) Number of episodes
b) Of what frequency?
c) Pain type
d) Plus at least one out of what 5 features?
a) 5
b) From every other day to 8 times daily
c) Severe, or very severe, unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated.
d) Ipsilateral conjunctival injection and/or lacrimation.
Ipsilateral nasal congestion and/or rhinorrhoea.
Ipsilateral eyelid oedema.
Ipsilateral forehead and facial sweating.
Ipsilateral Horner’s (miosis and/or ptosis).
A sense of restlessness or agitation.
Episodes of severe throbbing, claw-like, or boring pain usually on one side of the face; in, around, or behind the eye; and occasionally reaching to the back of the neck. Without any other features. DD?
Paroxysmal hemicrania
Cluster headache:
a) Acute management - 1 drug, 1 possible adjuvant therapy
b) Prophylaxis - 1st line (2 common SEs)
a) Sumatriptan (SC injection) and oxygen
b) Verapamil - dizziness, constipation, may need ECG monitoring (risk of heart block)
Medication-overuse headache
a) Present for at least…?
b) Medication has been used for how long?
c) Offending drug classes
d) Management
a) > 15 days/ month. Headache which has developed or markedly worsened during medication overuse. Headache which resolves or reverts to its previous pattern within 2 months of discontinuing medication.
b) Regular overuse for 3 or more months
c) Triptans, opioids, ergots or combination preparations on at least 10 days per month.
Has taken paracetamol, aspirin (or other non-steroidal anti-inflammatory drugs (NSAIDs)) or combinations of these on at least 15 days per month.
d) Withdraw offending medication and replace with prophylaxis: prednisolone, naratriptan, amitriptyline, sodium valproate, gabapentin, topiramate or propranolol
Substance withdrawal headache
a) Describe
b) Common substances
a) Daily intake of a substance for more than 3 months that is then stopped abruptly
b) Opioids, Oestrogen (includes COCP), Caffeine
Idiopathic intracranial hypertension.
a) Cause/ risk factors
b) Features
c) Management
a) Young obese females, endocrine disorders (eg Cushings, hypothyroidism), medications
b) Headache, other raised ICP features
c) Conservative: weight loss
Medical: acetazolamide
Surgical: VP shunt
SAH.
a) Risk factors
b) Clinical features
c) Initial investigations and management
d) If initial investigation negative - do what? and when?
a)
b)
c)
d) LP for xanthochromia (bilirubin in CSF - yellow); 12 hours to 12 days
