Headache Flashcards
Primary and secondary headaches
Primary
- headache that is due to the headache condition itself, and not a symptom of another condition
Secondary
- a headache that is a symptom of an underlying pathology, and not a condition in itself
Important features of a headache history
Mode of onset - acute, subacute, chronic, recurrent or episodic
Subsequent course - episodic, progressive or chronic
Site
- unilateral, bilateral, frontal, temporal or occipital
- radiation to neck, arm or shoulder
Character - constant, throbbing, stabbing or dull/pressure like
Frequency and duration
Accompanying features
- neurological symptoms, necks stiffness, autonomic symptoms
Exacerbating factors
- movement, light, noise, smell (e.g. migraine), coughing, sneezing, bending (e.g. raised ICP)
Precipitating factors
- alcohol, menstruation, stress, postural change and head injury (subdural or post-traumatic headache)
Time of onset - morning (migraine, raised ICP), woken at night (cluster)
Past history of headache
FH: migraine, intracranial heamorrhage
General health
Drug history - analgesic abuse, recreational drugs and vasodilatiors
Significance of clinical signs when examining a patient with headache
Depending on the clinical signs, a diagnosis can be made
- very little imaging can to do help, especially in a primary cause
Headache red flag symptoms - indicate a secondary cause
S - systemic signs and symptoms
- fever, weight loss, history of malignancy or immunosupression
N - neurological signs/symptoms
- hemiparesis, hemisensory loss, diploplia, dysarthria
O - onset
- sudden, painful headache reaching peak intensity within minutes
O - older age
- new onset headache >50 years
P - progression of existing headache
- change in quality, locating, frequency of existing headache
P - positional
- leaning forward, lying down, coughing, exertion
Others -
Unilateral headache and eye pain - cluster headache or acute angle glaucoma
Unilateral headache and ipsilateral symptoms - migraine, tumour, vascular disease
Persisting headache and scalp tenderness - giant cell arteritis
Features of high and low pressure headaches
Raised ICP
- generalised ache
- aggravated by bending, lying down, coughing or straining (all riase ICP)
- worse in the morning (may awaken patient from sleep)
- severity gradually progresses
- nausea and vomiting
- fits
- transient loss of vision (due to sudden change in ICP)
- papilloedema
- false localising signs
- impaired consciousness
Low ICP
- pain worse when upright (relieved on lying flat)
- better first thing in the morning, worse on getting up
- pain worse around the back of the head
- nausea
- mild neck discomfort
- potentially some neurological symptom due to stretching of the nerves in the brain
Differentials for episodic headaches
Migraine Cluster headache Benign coital, exertional and cough headache (diagnosis of exclusion) Intermittent hydrocephalus Paroxysmal hypertension
Differentials for chronic headaches
Tension-type headache Analgesic overuse headache Chronic migraine + analgesia overuse Post-traumatic headache Low pressure headache
Differentials for subacute headaches
Intracranial tumour Meningitis/encephalitis Venous sinus thrombosis Subdural heamatoma Intracranial abscess Giant-cell arteritis Benign intracranial hypertension Acute hydrocephalus Hypertensive crisis Acute glaucoma
Differentials for acute onset headaches
SAH Intracerebral heamorrhage Arterial dissection First episode of migrain/cluster headaches Coital/exertional headache
Assessment of headaches
Detailed history and red flag assessment
Observations
- BP, pulse, RR, temperature, sats
General appearance
- rash, consciousness level and confusion
Extracranial structures
- carotid arteries, temporal arteries, sinuses and TPM joint
Neck
- signs of meningeal irritation, tenderness of cervical paraspinal muscles and limitation in range of movement
Neurology
- fundoscopy
- cranial and peripheral nerve exam
- gait
In primary or benign causes of headache, these examinations should be normal
Investigations - only required if secondary headache suspected
- CT/MRI may be required
- LP and CSF analysis
Headache diaries to help pinpoint diagnosis
Management of cluster headache
Acute - oxygen for 15 ming - subcutaneous sumatriptin 6mg Chronic - avoid triggers e.g. alcohol - corticosteriods (short course - prednisolone and tapering) - verapamil or lithium
Management of tension-type headaches
Stress management
Avoid triggers
Massage and relaxation therapies
Anti-depressants - TCAs in selected cases
Analgesia - short term NSAIDs and paracetamol
Management of an analgesia overuse headache
Typically seen in overuse of opiate medication
- wean patient off of opiate based medication
- concurrently commence a small dose of amytriptyline and occasional paracetamol or NSAIDs for acute exacerbations
Pathogenesis of migraine
Thought to have a vascular component and to be related to the release of vasoactive substanced. The level of serum 5-hydroxytriptamine rises with prodromal symptoms and falls during the headache
The headache may follow abnormal electrical activity within the cortex or ‘spreading depression’ and subsequent brainstem activation leading to alterations in cranial vascular tone
Clinical presentation of migraine
Prodrome - precedes headache by hours/days - yawning, craving, mood/sleep change Aura Headache - 1 hour throbbing, unilateral headache - isolated aura with no headache - episodic severe headache without aura (often pre-menstrual) - nausea/vomiting - photophobia/phonophobia - allodynia
