Headache Flashcards
Wat are teh differentials for headaches
Chronic • Migraine • Cluster headaches • Drugs: Analgesics, Caffeine, Vasodilators (i.e. side effects of other drugs) • Tension headaches • Neuralgia (trigeminal) • ICP ↑: tumours • Giant cell arteritis • Systemic: HTN (pheochromocytoma, pre- eclampsia),
Acute
• Vascular: Haemorrhage: SAH, intracranial bleed, sinus venous thrombosis • Infection/Inflammation: Meningitis, Encephalitis, Abscess
• Ophthalmic: Acute glaucoma
• Situational: cough, exertion, coitus
What are primary headaches
Primary
• Due to the headache condition itself, not due to another cause
• E.g. migraine, tension, cluster
What are secondary headaches
Secondary
• Headache that is present because of another condition
• E.g. headache in meningitis/sinusitis/SAH
• Medication overuse is in this category
What is the important thing to know about the headach
- How worried you are about the cause of the headache?
- What you are going to do next? • Investigations?
- Start some treatment?
- Send to specialist?
- Send straight to A+E?
Desxribe the history for headache
History
• HPC: SOCRATES/ SQITARS
• Causal factors/ triggers
• PMHx: problems related to headaches i.e. previous history
• DHx: analgesia/ drugs that give headache as a side effect
• FHx
• SHx: stress, eating, dehydration • Red Flags
Describe the examination for each abe
• Observations
• Neuro (peripheral and cranial)
• Any related system depending on what you are worried about
Sepsis??
When does a patient need to do to a+e for a headache
Ss
What ae the red flag symptoms of headache
Asking about red flags.
Snoop
Descrbe SOL headache
- Gradual onset
- Progressive
- Associated neurology
- Change in vision
- Features of increased ICP
- Early morning headache
- N+V
- Worse on coughing or bending
Describe the epidemiology of migraines
Epidemiology
2% general population have chronic migraines Females > males (6% males, 18% females) 80% have had first attack by 30
Severity tends to decrease as age increases
Describe the history for migraine
S – Unilateral, often frontal Q – Sudden or gradual onset, Throbbing/ pulsating I – Moderate T – Between 4 and 72 hours. May be cyclical A – Photo/phonophobia R – Sleep make better, medication S - +/- aura, N+V
Triggers: Food, sleep, stress Often has FHx
?Cause – vascular dysfunction vs neuronal dysfunctio
Descirb ethe epidemiology of ensign headache
Epidemiology
Most common type of headache Females >males
Young > old
First onset > 50 unusual
Describe history of tension headache
S – Bilateral, frontal (vertex-bitemporal)
Q – Squeezing, non-pulsatile
I – Less severe (mild-moderate) (10 min to 48 h)
T – Worse at the end of the day. ? Less than 15 times per month (episodically v chronic
A – stress, poor posture, lack of sleep R – ? To neck
S – mild nausea
No FHx
Usually responsive to OTC medication
Describe teh epidemiology of medication overuse headache
Epidemiology
3rd most common type of headache 1-2% UK population
20% population who have headaches 30-40 years old
Females>males
What is a education overuse headache
- Defined as headache present on at least 15 days per month
- Does not improve after OTC medication
- Regular overuse greater than 3 months of one of the following:
- Triptans or opioids (codeine) on at least 10 days of the month
- Paracetamol, aspirin or NSAIDs on at least 15 days of the month
- Resolves completely after 2 months following discontinuation of medication
- Initially may get worse before it gets better - Explain to patient then it will get worse before it gets better. Reboud headache initially which is worse. Goes away after 2 months
Describe the mechanisms or medication overuse headache
- Headache mechanism is thought to be an increase in headache pain receptors - (only if taking mecocation for a headache in the first place, not for another reason)
- Mixed symptoms
- Often co-existing with depression/ sleep disturbance
- Difficult to manage
- Might get withdrawal
Descrbe the epidemiology of cluster headache
Epidemiology
1/1000 people Males>females
Usually begins 20-40 years old
Describe the presentation of a cluster headache
Cant get away. Agitated. Extremely severe. Increase in sympathetic overdrive. Red watery eye, one run, congestion, wearing, partial ptosis
S – Around/behind one eye
Q – sharp, penetrating
I –Very severe and constant intensity
T – Rapid onset. Attacks last 15min–3hrs, 1-2x/day, mostly nocturnal.
• Clusters last 2-12wks, remission lasts 3mo-3yrs
• Can be chronic vs. episodic
A – head injury, alcohol, cigarette smoking R – No radiation
S – Red, watery eye, nasal congestion
Triggers: Alcohol, histamine, GTN, heat, exercise, solvents, lack of sleep
Describe teh epidemiology of trigeminal neuralgsi
Epidemiology
Peak incidence 50-60 Prevalence increases with age ~25/100,000 UK population Females > males
Descrbe the presentation of trigeminal neuralgia
90-95% caused by compression of CNV by loop of artery or vein
5% attributed to tumours, MS, skull base abnormalities or AV malformations
S – unilateral, often over the eye
Q – stabbing, sharp, “electric shock”
I – severe
T – sudden onset, lasts a few seconds to 2 minutes
A – light touch to face, eating, cold wind, vibrations
R – radiates to eyes, lips, nose and scalp
Preceding symptoms: tingling, numbness
More common with PHx chronic pain
What are the investigations to do next
• Investigations?
Headache diary - how did it feel, timing, what they were doing
Imaging- CT/ MRI
Describe the treatment for some headaches
Simple analgesia Migraine: Triptans
Cluster headaches: High flow oxygen
Decsribe ethe referrer always criteria for headaches for urgent referrall
Refer urgently patients with:
• Symptoms related to the CNS in whom a brain tumour is suspected, including:
• progressive neurological deficit • new-onset seizures
• headaches
• mental changes
• cranial nerve palsy
• unilateral sensorineural deafness
• Headaches of recent onset accompanied by features suggestive of raised intracranial pressure, for example:
• vomiting
• drowsiness
• posture-related headache
• pulse-synchronous tinnitus
• or by other focal or non-focal neurological symptoms, for example blackout, change in personality or memory
• Suspected recent-onset seizures (refer to neurologist)
• Refer urgently patients previously diagnosed with any cancer who develop any of new onset neurological symptoms
When should uget refuel be considered with progression of…..
Consider urgent referral (to an appropriate specialist) in patients with rapid progression of:
• subacutefocalneurologicaldeficit
• unexplainedcognitiveimpairment, behavioural disturbance or slowness, or a combination of these
• personalitychangesconfirmedbyawitness and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour
• Considernon-urgentreferralordiscussion with specialist for:
• unexplained headaches of recent onset:
• present for at least 1 month
• not accompanied by features suggestive of raised intracranial pressure.
