Headache Flashcards
What is the typical presentation of a headache caused by raised ICP?
Gradual onset, dull, generalised headache
Idiopathic intracranial hypertension is most common in which sex? It is almost always associated with which other factor?
Females - almost always associated with obesity (especially recent weight gain)
Headaches as a result of raised ICP often have diurnal variation. Describe the pattern?
These headaches are usually worse in the morning after wakening
What can make headaches as a result of raised ICP worse?
Lying down, coughing, straining, sneezing, bending forwards
What are two other symptoms which are often associated with headaches as a result of raised ICP?
Nausea and vomiting, visual field defects
Relating to vision, what signs may be seen on examination of a patient presenting with a headache as a result of raised ICP?
Papilloedema (bilateral enlarged blind spots and swollen discs) and a reduced visual field
What is a visual sign which is not commonly seen in a case of headache as a result of raised ICP but may be seen late on?
Decreased visual acuity
What investigations are used for a patient presenting with a headache as a result of raised ICP?
MRI head and MR venography, CSF sample from LP
When investigating a patient with a headache with signs of raised ICP, an MRI head and MR venography are used to rule out what?
Space occupying lesions and venous sinus thrombosis respectively
When investigating a patient with a headache with signs of raised ICP, what would normally be the result of their LP? Having an LP can have what effect on the patient’s symptoms?
Elevated pressure and normal constituents. Having an LP can often make the patient feel much better - the headache and visual field assessment will both improve
What are some medications which increase the risk of idiopathic intracranial hypertension and what are they used for?
Isotretinoin and tetracycline for acne, prednisolone for many conditions, tamoxifen for breast cancer and beclomethasone for acne
What are the long term outcomes of idiopathic intracranial hypertension if not managed well?
Not life-threatening but vision is under threat (i.e. can lead to blindness) if not controlled
What are the management options for a headache as a result of raised ICP?
Treat underlying cause (if there is one), weight loss, acetazolamide, CSF shunts
What type of drug is acetazolamide and what is its function? What are some side effects that it may cause?
A carbonic anhydrase inhibitor - may make people confused or cause tingling
What should be monitored in a patient with idiopathic intracranial hypertension?
Visual fields and CSF pressure
What is the typical presentation of a tension headache?
A band of pain or pressure around the forehead with no other neurological features. These are mild-moderate in severity and are bilateral.
Who are typically affected by tension headaches?
Women and the young
Patients with persistent tension headaches are screened for what?
Anxiety and depression
What is the most likely cause for a tension headache?
Stress
What is the investigation for a person presenting with a tension headache?
Usually no investigation is required
What are some treatment options for tension headaches?
Simple analgesia, reassurance, relaxation physiotherapy
If the first line treatments for tension headache are not working, what medication can be tried and how long for?
An anti-depressant e.g. dothiepin or amitriptylline for 3 months
What are the trigeminal autonomic cephalgias?
A group of primary headache disorders characterised by a unilateral trigeminal distribution pain that occurs with prominent ipsilateral cranial autonomic features
What are some autonomic features which may occur in an autonomic trigeminal cephalgia?
Facial sweating, ptosis, miosis, nasal stuffiness, N+V, tearing, eyelid oedema
Describe the classic presentation of a cluster headache?
A one-sided, retro-orbital stabbing pain with ipsilateral cranial autonomic features
Who is cluster headache most likely to occur in?
Those aged 30-40, four times more common in men
When is a cluster headache most likely to occur? During a bout, what can trigger a headache?
At night, during a bout headaches can be triggered by alcohol
What is the average duration of a cluster headache? How often do they occur in a day during a cluster?
45-90 minutes, occurring 1-8 times a day
How long can a bout of cluster headaches last for?
A few weeks - months (followed by a prolonged period of remission)
How will patients with a cluster headache act?
Agitated and restless
The facial pain in a cluster headache is caused by the activation of which nerve? The autonomic features of cluster headache are caused by activation of which nerve?
CNV1 / Parasympathetics of CNVII
What investigations should all patients with a new trigeminal autonomic cephalgia undergo?
MRI brain and MR angiogram
Why should all patients with a new trigeminal autonomic cephalgia have an MRI scan?
It can rarely be caused by a lesion in the hypothalamus
How are cluster headaches treated in the acute phase?
100% high flow oxygen for 20 minutes and 6mg S/C sumatriptan
How are cluster headaches prevented?
A reducing course of steroids for 2 weeks and then verapamil for prophylaxis
What is the outcome of cluster headaches?
Can go on for life or can go into remission, even after many years of headaches
Who is paroxysmal hemicrania most likely to occur in?
Older adults aged 50-60, more common in females
What is the difference between paroxysmal hemicrania and cluster headache?
Paroxysmal hemicrania causes more frequent headaches but with a shorter duration
How is paroxysmal hemicrania treated? What is important to know about this?
Indomethacin 50mg tds - this is an absolute response
What is SUNCT?
Short lived, unilateral, neuralgiform headache with conjunctival injection and tearing (a TAC)
What can be used to treat SUNCT?
Lamotrigine or gabapentin
Who is trigeminal neuralgia most common in?
Elderly (> 60), more common in females
What triggers trigeminal nerualgia?
Touch, usually of the V2/V3 area of the face
What type of pain will trigeminal neuralgia cause?
Severe unilateral stabbing/shooting pain
How long will an episode of trigeminal neuralgia last for? How often does this occur in a day?
1-90 seconds / 10-100 times a day (this can last for weeks-months before remission)
What is the most common cause of trigeminal neuralgia?
An abnormal blood vessel (superior cerebellar artery) touching the trigeminal nerve which irritates and demyelinates it, causing abnormal neuronal discharges in response to normal stimulation
What investigation is used for trigeminal neuralgia and why?
MRI brain - to check for a lesion of the trigeminal nucleus or nerve root e.g. MS, stroke, tumour
How can trigeminal neuralgia be treated?
Carbamazepine or gabapentin - can also be treated surgically with ablation or decompression
What is a thunderclap headache?
A headache which has a near immediate onset and reaches peak severity in seconds
What are some associated features of a thunderclap headache?
Nausea or vomiting and phono/photophobia
Thunderclap headache is treated as potential what until proven otherwise?
Subarachnoid haemorrhage
What is the management of a thunderclap headache?
Immediate clinical assessment and imaging, most likely a plain CT
