Headache Flashcards
2 broad categories of headaches
Primary
Secondary
What is a primary headache/ cause
Headache that is due to the headache condition itself and not due to another cause
What is a secondary headache
Headache that is present because of another condition, i.e. a structural or biochemical cause
Name 3 primary headaches
Tension type headache
Migraine
Trigeminal autonomic cephalalgias, e.g. cluster headache
Name examples of trigeminal autonomic cephalagias (4) + name the most common one
Cluster headache - most common
Paroxysmal hemicranias
SUNCT (Short lasting unilateral headache with conjunctival injection & tearing)
SUNA (Short lasting unilateral headache with autonomic symptoms)
Name causes of secondary headaches (6) + name the secondary headaches that they cause
Brain tumour
Meningitis
Cerebrovascular disorders, e.g. aneurysm/haemorrhage
Systemic infection, e.g. sinus headache
Head injury, e.g. post-traumatic headache
Drug-induced, e.g. medication overuse headache, spinal headache (after epidural)
Name conditions that cause secondary headaches (7)
Trigeminal neuralgia Subarachnoid haemorrhage Meningitis Encephalitis Space occupying lesions/raised ICP Intracranial hypotension Giant cell arteritis
What headache does subarachnoid haemorrhage cause
Thunderclap headache (secondary)
What is the most frequent non-disabling/ disabling primary headache +
Tension type headache
Migraine - disabling
What is a migraine
Chronic, genetically determined, episodic neurological disorder that usually presents in early-to-mid life
What is the headache from a migraine thought to be caused by
Activation and sensitisation of the trigeminal sensory neurons
Triggers of migraine (4)
RF of migraine (4)
(slightly different things)
Stress
Lack of sleep
High caffeine intake
Changes in oestrogen level
Female
FH
Obesity
Overuse of headache medication
People with migraine are … to normal stimuli due to what
Hyper-responsive
Enhanced cortical responsiveness
Causes of enhanced cortical responsiveness in people with migraine (2)
Insufficient cortical inhibition
Reduced pre-activation of sensory cortices
Name the 4 phases of a migraine + label which 2 of these are pre-headache phases
Premonitory phase (pre-headache phase)
Aura phase (also pre-headahce)
Headache phase
Postdrome ( post-headache)
List some pre-monitory symptoms that may be predictors of a migraine attack (4)
Mood alteration
Food cravings
Fatigue
Increased irritability to light/sound
Does the aura phase occur in every migraine attack
No
What is aura
Term used to describe focal reversible neurological symptoms of a migraine that precedes the headache, e.g. visual, sensory, motor or speech symptoms
Name 3 types of aura (focal reversible neurological symptoms of a migraine that precedes the headache) + list symptoms that can occur during the aura phase of a migraine (5)
Visual - vision loss, blind spots, hemianopia - VISUAL IS MOST COMMON AURA
Sensory - paraesthesia
Motor - weakness on one side
An aura is not always followed by a headache - name this type of migraine
Acephalic migraine (migraine aura without headache)
What can the aura phase of a migraine often be confused with
TIAs
because also sudden onset, loss of function
What is the headache phase of a migraine attack subdivided into + describe the clinical features of each (2) (4)
Early phase - mild pain, no other symptoms
Advanced phase - moderate to severe pain + other symptoms (nausea, photophobia, functional disability)
Describe the postdrome phase of migraine attack (2)
Migraine associated symptoms may still be occurring after headache has resolved
Involves functional disability for 1 or 2 days
Clinical features of a migraine
- characteristics of the pain (4)
- migraine associated symptoms (3)
Headache of a migraine must have at least 2 of the pain characteristics and at least 1 of the migraine associated symptoms
Unilateral
Pulsating
Moderate or severe pain
Aggravated by routine/simple physical activity
Nausea
Photophobia
Phonophobia
Define criteria of a chronic migraine (3)
Headache for ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months
Do associated migraine symptoms improve/worsen in people with chronic migraine (2)
Improve
Become less frequent and less severe
Symptoms (3) /signs (3) of a migraine in adults
Prolonged headache - UNILATERAL PULSATILE PAIN
Nausea
Functional disability
Photophobia
Photophobia
Headache worse with activity
Signs of migraine in children (3)
Confusion
Ataxia
Aphasia
What does chronic migraine often cause and ultimately what other type of headache does this lead to
Medication overuse
Leads to medication overuse headache (secondary headache)
Are migraines unilateral or bilateral
Are tension type headaches unilateral or bilateral
Unilateral
Bilateral
Clinical features of a tension type headache (5)
- pain characteristics (4)
- other symptoms
Bilateral
Generalised head pain, but often frontal or occipital
Non-pulsatile
Constricting pain - feels like a tight band
Tenderness of head, neck and muscles of mastication
Abortive (acute attack) (3)
+
preventative (ongoing chronic*) (2)
treatment of tension type headaches (TTH)
*chronic tension headache = >7 a month
Abortive treatment:
Aspirin or paracetamol or NSAIDs
Preventative: (rarely used)
Tricyclic antidepressants
-Amitryptiline
-Doxepin
Abortive (acute attack) (3)
+
preventative (ongoing) (4)
treatment of migraines
Abortive:
- Aspirin or NSAIDs - for mild acute attack
- Triptans - for severe acute attack
Preventative (ongoing):
- propanolol - beta blocker
- anti-convulsants - topiramate
- tricyclic antidepressants - amitryptiline
- antidepressant - venlafaxine (if have co-existing depression)
How long is abortive treatment for headaches used
10 days a month to prevent medication overuse headache
Treatment of migraine in pregnant people (2)
Paracetamol only
Avoid triggers
Anti-epileptics (e.g. sodium valproate, lamotrigine, topiramate, carbamazepine, levetericetam) shouldn’t be given to what people
Women of child bearing age
What are trigeminal autonomic cephalalgias
A group of headache disorders characterised by attacks of unilateral pain in the head or face
+ associated IPSILATERAL cranial AUTONOMIC features such as eye watering, redness, rhinorrhoea, nasal congestion, and ptosis
Cranial autonomic signs (7) of trigeminal autonomic cephalalgias
Conjunctival injection Lacrimation Nasal congestion/rhinorrhoea Eyelid oedema Forehead + facial sweating Miosis (constriction of pupil) ptosis
What division of CN V is involved in trigeminal autonomic cephalalgias
CN V1 - ophthalmic
Cluster headaches
- duration
- frequency
- pattern throughout year
Longest and least frequent of all the TACs
Last 15 mins - 3 hours
Up to 8 attacks a day
Last average 3 months then remission of up to a year; could be just a month
What do cluster headache attacks correlate with physiologically
Circadian rhythm - attacks usually occur same time each day and the bout occurs same time each year
Symptoms /signs of cluster headaches
- pain (characteristic, location)
- other symptoms (4)
- autonomic signs (6)
Excruciating (sharp stabbing, burning) UNILATERAL pain localised to the orbital, supra-orbital, and/or temporal areas
Associated symptoms - nausea, vomiting, photophobia, agitation/restless
Ipsilateral autonomic signs: • conjunctival injection • Lacrimation • Rhinorrhoea • eyelid oedema/swelling • facial sweating • ptosis
Treatment of cluster headaches
- abortive treatment of an acute attack (2)
- acute attack suppression (2)
- preventative treatment/ongoing treatment (3)
Abortive treatment of acute attack:
• Subcutaneous sumatriptan (triptan)
• Supplemental oxygen
Acute attack suppression:
• Greater occipital nerve (GON) block - mixture of steroid + LA injected into GON on symptomatic side
• Prednisolone
Preventative:
• Verapamil - CCB - 1ST LINE, OR
• Lithium OR
• Topiramate - anticonvulsant
Pain character of:
- Cluster headache
- Paroxysmal hemicrania
- SUNCT
Sharp throbbing
Sharp throbbing
Stabbing burning, pulsating
Symptoms (1) /signs (7) of paroxysmal hemicranias
-pain (characteristic, location)
Excruciating unilateral pain localised to orbital and temporal areas
Ipsilateral cranial autonomic signs (7) - see other flashcard
Duration/frequency of paroxysmal hemicranias (PH)
2-30 mins - shorter than cluster
1-40 attacks a day - more frequent than cluster (up to 8)
Paroxysmal hemicranias are more often chronic or episodic
Chronic
Treatment of paroxysmal hemicranias (2) + what drug does PH respond to very well*
*Indomethacin - eliminates symptoms
Anti-epileptic - topiramate
Symptoms (1) /signs of short lasting unilateral headache with conjunctival injection + tearing (SUNCT) (8) + where is pain localised
-pain (characteristic, location)
Excruciating unilateral pain located in orbital, supraorbital and temporal area
Ipsilateral autonomic signs (8)
Duration/frequency of SUNCT
5 secs - 3 mins
3 - 200 attacks a day
Triggers of SUNCT/SUNA (4)
Wind
Cold
Touch
Chewing
Name the 3 patterns of attacks in SUNCT
single stab attacks;
groups of stabs;
saw-tooth pattern - group of stabs occurring in quick succession such that the pain does not return to baseline between stabs
Abortive/preventative (4) treatment of SUNCT/SUNA
No abortive treatment
Preventative with anti-convulsants/epileptics: Lamotrigine, Topiramate gabapentin Carbamazepine
What is trigeminal neuralgia
Facial pain syndrome of the areas innervated by the trigeminal nerve
2 causes of trigeminal neuralgia
Compression of CN V often due nearby blood vessel
MS - loss of myelin of CN V
What divisions of CN V are involved in trigeminal neuralgia
CN V2 & V3
Symptoms of trigeminal neuralgia
-pain (characteristic + location)
Severe sharp stabbing FACIAL PAIN in the lower face - jaw, teeth and gums
NO AUTONOMIC SYMPTOMS/SIGNS
Duration/frequency of trigeminal neuralgia
5 secs - 10 secs
3 - 200 attacks a day
Treatment of trigeminal neuralgia
- abortive treatment
- preventative (ongoing) treatment (2)
- surgical treatment if medication unresponsive (2)
No abortive treatment - just prescribed with anticonvulsants when diagnosed
Prophylaxis with anti-convulsants:
• carbamazepine OR oxcarbazepine
Surgical intervention:
• Microvascular decompression
• Ablative surgery - e.g. steriotactic radiosurgery
Triggers of trigeminal neuralgia (4) - same as SUNCT triggers
Touching your face
Wind
Chewing
Cold
List some red flags of secondary headaches (6)
New onset headache Change in headache frequency or character Focal neurological symptoms Neck stiffness/fever Hypotension Giant cell arteritis
Symptoms/signs of a thunderclap headache caused by subarachnoid haemorrhage
+ duration of headache
High intensity headache reaching max intensity in less than a min and lasts for at least an hour
Differentials of a thunderclap headache (subarachnoid haemorrhage isn’t the only cause) (4)
Primary headache - migraine, primary exertion headache
Subarachnoid haemorrhage
TIA/stroke
Carotid/vertebral dissection
Treatment of thunderclap headache caused by subarachnoid haemorrhage (4)
Surgical clipping of aneurysm or endovascular coil embolisation
CCBs
Anticonvulsants
Causes of a headache due to raised ICP/space occupying lesion (4)
Tumour - e.g. GBM, meningioma
Haemorrhage
Cerebral abscess
Hydrocephalus
Clinical features of a headache caused by raised ICP/space occupying lesion (4)
Headache worse in morning
Headache worse lying flat or brought on by valsalva (cough, strain)
Focal symptoms/signs
Seizures
Cause of intracranial hypotension
Dural CSF leak either spontaneous or iatrogenic (e..g post LP)
What improves/worsens a low pressure headache (i.e. a headache caused by intracranial hypotension)
Improves when lying down
Worsens when upright
Treatment of a headache caused by intracranial hypotension (5)
Bed rest IV fluids Analgesia IV caffeine - to raise CSF pressure Epidural blood patch - injecting a sample of your own blood into the epidural space; clotting factors of the blood close the hole in the dura
Where is the headache localised in giant cell arteritis
Temporal areas
What condition is giant cell arteritis associated with
Polymyalgia rheumatica
Symptoms of polymyalgia rheumatic (2)
Aching and stiffness in the neck, shoulders, hips, and proximal extremities
Treatment of a headache caused by giant cell arteritis
High dose prednisolone
Investigations of giant cell arteritis (4)
ESR - raised
CRP - raised
FBC
Temporal artery biopsy - definitive diagnosis
