Headache Flashcards
What would you ask about in headache history?
Onset - rapid/gradual? Course - pattern - time of day/month/seasonal - frequency Duration Severity Timing Nature/character Precipitating factors Relieving actors Associated symptoms - aura? Previous episodes
Drug history - analgesia
Social history
Why is it important to ask about drug history?
Exclude medication overuse (analgesic rebound) headache
Paracetamol _ codeine/opiates, ergotamine, triptans can cause episodic headache becoming daily headache.
Analgesia must be withdrawn
Limit use of OTC analgesia
What are red flags for headache?
Thunderclap headache - SAH - sudden onset occipital, stiff neck
Associated fever
Meningism ± associated rash
RICP - morning headache worse on coughing and bending forward
New neurological deficit
New cognitive dysfucntion
Personality change
Reduced conscious level
Head injury
New onset headache in elderly - GCA
Significant change in pattern of chronic headache
Give clinical manifestations, investigations, management, complications of tension headache
Recurrent, non-disabling, bilateral headache, often described as a tight band.
Not aggravate by routine activities
Simple analgesia
Give clinical manifestations, investigations, management, complications of cluster headache
Once or twice a day, often nocturnal, episodes lasting 15 minutes to 2 hours with clusters typically lasting 4-12 weeks then pain free period of months/years.
Rapid onset intense pain around one eye that may become watery and bloodshot with lid swelling, lacrimation, facial flushing, rhinorrhoea
Almost always affects same side
More common in men and smokers
Give 100% oxygen for 15 min via a non-rehreathe mask
Sumatriptan SC 6mg at onset (or zolmitriptan nasal spray)
Avoid triggers e.g. alcohol Consider corticosteroids (short term), verapamil, lithium
Give clinical manifestations, investigations, management, complications of medication overuse headache
Present for 15 days or more per month
Developed or worsened while taking regular symptomatic medication
Patients using opioids and triptans at most risk
Common reason for episodic headache becoming chronic daily headache.
Withdraw analgesia
Aspirin or naproxen ay ease the rebound headache
Preventative may help (tricyclics, valproate, gabapentin)
Limit the use of OTC analgesia
Give clinical manifestations, investigations, management, complications of temporal arteritis
Patient > 60 years old
Usually rapid onset < 1 month of unilateral ehadache
Jaw claudication
Scalp tenderness
Tender palpable temporal artery
May be visual disturbances from anterior ischaemic optic neuropathy
Raised ESR
Temporal artery biopsy will show skip lesions
Treat with high dose prednisolone
Urgen ophthalmology review
Give clinical manifestations, investigations, management, complications of Idiopathic intracranial hypertension
Young overweight females on OCP, steroids, lithium Headache Blurred vision Papilloedema Enlarged blind spot 6th nerve palsy
Mx
Weight loss
Diuretics - acetazolamide
Topiramate (+weight loss)
Repeat LP
Optic nerve sheath decompression and fenestration may be required to prevent optic nerve damage.
Lumboperitonial/ventriculoperitoneal shunt to reduce ICP
Give clinical manifestations, investigations, management, complications of subarachnoid haemorrhage
Sudden onset thunderclap headache, severe, occipital N/V Meningism (photophobia, neck stiffness) Coma Seizures
CT - acute blood is typically distributed in the basal cisterns, sulk and ventricular system
LP - xanthocrhonimia (RBC breakdown)
Refer to neurosurgery
Can be caused by intracranial aneurysm (beery)
AV malformation
Give clinical manifestations, investigations, management, complications of trigeminal neuralgia
Paroxysms of intense stabbing pain lasting seconds in the trigeminal nerve distribution
Unilateral, affecting mandibular/maxillary divisions
Face screws up with pain
Triggered by washing affected area, shaving, earring, talking
Male>50
Can be caused by compression of trigeminal root by anomalous or aneurysmal intracranial vessels or tumour, chronic meningeal inflammation, MS, zoster
MRI required to exclude secondary causes
Mx Carbemazepine LAmotrigine Phenytoin Gabapentin
If drugs fail - surgery may be necessary - microvascular decompression
Give clinical manifestations, investigations, management, complications of sinusitis
Facial pain - forntal pressure pain, worse on bending forward
Nasal discharge - thick, purulent
Nasal obstruction - mouth breathing
Post-nasal drip
Inflammation of mucous membranes of paranasal sinuses
Strep pneumonia, HAemophilus influenza, rhinovirus
Analgesia
Intranasal decongestants or nasal seline
If recurrent/chronic
Intranasal corticosteroids are often beneficial
