Headache Flashcards
State the difference between a primary and a secondary headache and give some examples of each
Primary headache- no underlying medical cause-tension type headache, migraine, cluster headache
Secondary headache- has an identifiable structural or biochemical cause- tumour, meningitis, head injury
Describe the characteristics of a tension-type headache
Mild, bilateral headache which is often pressing or tightening in quality and has no significant associated features and is not aggravated by routine physical activity
How are tension-type headaches treated?
Abortive treatment- aspirin/paracetamol or NSAIDS (Limit to 10 days per month to avoid medication overuse headache)
Preventative treatment- tricyclic antidepressants (rarely required)
What are the common triggers of migraines?
Stress Hunger Sleep disturbance Dehydration Diet Environmental stimuli Changes in oestrogen level in women
What are the symptoms of migraine?
During attacks- headache, nausea, photophobia, phonophobia, functional disability
In-between attacks- Anticipatory anxiety
What are the different stages of a migraine?
Premonitory Aura Early headache Advanced headache Postdrome
What are the characteristics of the premonitory phase of a migraine?
Mood changes Fatigue Cognitive changes Muscle pain Food craving
What are the characteristics of the aura phase of a migraine?
Fully reversible
Neruological changes
Visual somatosensory
What are the characteristics of the early headache phase of a migraine?
Dull headache
Nasal congestion
Muscle pain
What are the characteristics of the advanced headache phase of a migraine?
Unilateral Throbbing Nausea Photophobia Phonophobia Osmophobia
What are the characteristics of the postdrome phase of a migraine?
Fatigue
Cognitive changes
Muscle pain
How long does aura tend to last and what are its symptoms?
15-60 minutes
Sudden onset loss of function affecting visual, sensory motor or speech systems
How is chronic migraine defined?
Headache on at least 15 days per month, of which at least 8 days have to be migraine, for more than 3 months
What are the characteristics of a transformed migraine?
History of episodic migraine
Increasing frequency of headaches over time
Migrainous symptoms become less frequent and more severe
What are the causes of medication overuse headache?
Use of triptans, ergots, opioids and combination analgesics >10 days/month
Use of simple analgesics >15 days/month
Caffeine overuse
What are the characteristics of medication overuse headache?
Headache present on at least 15 days/month which has developed or worsened whilst taking regular symptomatic medication
What is the abortive treatment for migraines?
Aspirin or NSAIDs
Triptans
Limit to 10 days per month
What is the prophylactic treatment for migraines?
Propanolol, candesartan
Anti-epileptics
Tricyclic antidepressants
Venlafaxine
How is migraine treated in pregnancy?
Acute attack- paracetamol
Preventative- propanolol or amitriptyline
What are the characteristics of cluster headaches?
Excruciating pain that is mainly orbital and temporal, and is strictly unilateral
Rapid onset
Lasts 15 mins to 3 hours
Patients are restless and agitated during attack
Prominent ipsilateral autonomic symptoms
How are episodic cluster headaches characterised?
Attacks cluster into bouts lasting 1-3 months with periods of remission lasting at least a month
Attack frequency ranges from 1 every other day to 8 per day
May be continuous pain between attacks
Attacks occur at the same time each day and bouts occur at the same time each year
How are chronic cluster headaches characterised?
Bouts last longer than a year without remission
OR
Remissions last less than a month
What are the characteristics of paroxysmal hemicrania?
Excruciating pain that is mainly orbital and temporal and strictly unilateral
Rapid onset and last 2-30mins
~50% patients are restless and agitated during an attack
Prominent ipsilateral symptoms
2-40 attacks per day with no circadian rhythm
What are the characteristics of SUNCT?
Short-acting unilateral nerualgiform headache with conjunctival injection and tearing (SUNCT)
Unilateral orbital, supraorbital or temporal pain
Stabbing or pulsating pain
10-240 second duration
Cutaneous triggers- wind, cold, touch, chewing
Attack frequency ranges from 3-200/day with no refractory period
Pain accompanied by conjunctival injection and lacrimation
What are the characteristics of trigeminal neuralgia?
Unilateral maxillary or mandibular division pain
Stabbing pain
5-10 second duration
Cutaneous triggers- wind, cold, touch, chewing
Attack frequency ranges from 3-200/day with a refractory period
How can cluster headaches be managed?
Abortive (headache)- subcutaneous sumatriptan or nasal zolmatriptan 100% oxygen at 7-12L/min Abortive (headache bout)- Occipital depomedrone injection (same side as headache) Tapering course of prednisone Preventative- Verapamil Lithium Methysergide Topiramate
How can paroxysmal hemicrania be managed?
No abortive treatment
Prophylaxis with indometacin, COX-II inhibitors or topiramate
How can SUNCT be managed?
No abortive treatment Prophylaxis- Lamotrigine Topiramate Gabapentin Carbamazepine/oxcarbazepine
How can trigeminal neuralgia be treated?
No abortive treatment Prophylaxis- carbamazepine or oxcarbazepine Surgical intervention: -Glycerol ganglion injection -Steriostatic radiosurgery -Decompressive surgery
What presentations of a secondary headache indicate a sinister cause?
Associated head trauma First or worst Sudden/thunderclap onset New daily persistent headache Change in headache pattern or type Returning patient
How is a thunderclap headache characterised?
A high intensity headache reaching maximum intensity in under a minute
What are the warning features of a headache caused by a space occupying lesion or raised intracranial pressure?
Headache worse when the patient wakens from sleep
Headache worse lying flat
Headache brought on by valsalva (cough, straining etc)
Focal symptoms or signs
Seizures
Visual obscurations and pulsatile tinnitus
What are the characteristics of intracranial hypotension?
Clear postural component to the headache that may be lost when headache becomes chronic
How is intracranial hypotension investigated and managed?
Investigation- MRI brain and spine
Treatment- Bed rest, fluids, analgesia
IV caffeine
Epidural blood patch
When should giant cell arteritis be considered?
In any patient over 50 presenting with new headache
What are the characteristics of giant cell arteritis?
Diffuse, persitent and sometimes severe headache Patient systemically unwell Scalp tenderness Jaw claudication Visual disturbance
How should giant cell arteritis be investigated and managed?
Elevated ESR supports diagnosis
Raised CRP and platelet count also useful markers
High dose prednisolone started and take a temporal artery biopsy
