Headache Flashcards
What is the most common type of headache?
Tension headache
What is the differential for recurrent acute attacks of headache?
migraine = classically visual/other aura lasting 15-30min followed within 1h by unilateral throbbing headache, associated with N+V, photophobia/phonophobia or allodynia (all stimuli produce pain). Cluster headache = rapid-onset, excrutiating pain around one eye lasts 15-160min, often nocturnal, clusters last 4-12 weeks followed by painfree period. Trigeminal neuralgia = paroxysms of intense stabbing pain, lasting seconds in CNV distribution, unilateral, face screws up in pain, triggered by washing affected area etc. Recurrent (Molaret’s) meningitis = suspect if fever/meningism with each headache, sned CSF for HSV2 PCR, check for recurring cause of aseptic meningitis - SLE, Behcet’s, sarcoid etc.
What are the signs/symptoms of cluster headaches?
rapid-onset, excrutiating pain around one eye (may become watery/bloodshot with lid swelling, lacrimation, facial flushing, rhinorrhoea, miosis +/- ptosis), strictly unilateral and almost always same side, lasts 15-160min, occurs once/twice a day and often nocturnal, clusters last 4-12 weeks followed by pain-free period. M:F = >5:1 and commoner in smokers
What is the management of cluster headaches?
acutely - 100% O2 for approx 15 min via non-rebreathable mask + sumatriptan s/c 6mg at onset
What is the management for trigeminal neuralgia?
MRI to exclude secondary causes, carbamazapine (start at 100mg/12h) - if not working then refer to specialist for lamotrigine/phenytoin or surgery
What is the differential for chronic headache?
tension headache - bilateral, nonpulsatile headache +/- scalp tenderness, no vomiting or sensitivity to head movement. Raised intracranial pressure - typically worse on waking, lying or bending forward, vomiting, papilloedema, seizures, false localising signs or odd behaviour. Medication overuse (analgesic rebound) headache - mixed analgesics (paracetamol +codiene/opiates), ergotamine and triptans
What is the differential for an acute headache with signs of meningism?
meningitis - fever, photophobia, stiff neck, purpuric rash, coma. Encephalitis - fever, odd behaviour, fits or decreased consciousness. Subarachnoid haemorrhage - sudden-onset, ‘worst ever’ headache, often occipital, stiff neck, focal signs, decreased consciousness
What is the differential for an acute headache without signs of meningism?
Head injury - lasts 2 weeks, analgesic resistant (potential subdural or extradural haemorrhage if drowsiness +/- lucid interval or focal signs). Venous sinus thrombosis - subacute/sudden headache with papilloedema. Sinusitis - dull, constant ache over frontal/maxillary sinuses, tenderss +/- postnasal drip, pain worse on bending forward, common with coryza, lasts 1-2 weeks. Tropical illness - malaria, typhus etc. Low pressure headache - from CSF leak eg post LP or skull fracture. Acute glaucoma - typically elderly, long-sighted, constant aching pain develops rapdily around one eye, radiating to forehead, markedly reduced vision, visual haloes, N+V, red congested eye, cloudy cornea, dilated nonresponsive pupil (may be oval), decreased acuity
What’s important to exclude in patients over 50 with a headache that has lasted a few weeks?
Giant cell arteritis - tender, thickened, pulseless temporal arteries, jaw claudication, ESR>40. Prompt diagnosis and steroids avoid blindness
What are some triggers of migraines?
CHOCOLATE - chocolate, hangovers, orgasms, cheese, oral contraceptives, lie-ins, alcohol, tumult or exercise
What are some examples of aura’s experienced prior to a migraine?
visual - choatic cascading, distorting, ‘melting’ and jumbling of lines, dots or zigzags, scotomatia or hemianopia. Somatosensory - paraesthesiae spreading from fingers to face. Motor - dysarthria and ataxis, ophthalmoplegia or hemiparesis. Speech - dysphasia or paraphasia eg phoneme substitution.
What is the management of migraines?
acute: NSAIDS (dispersible aspirin 900mg/6h) or triptans (sumatriptan/rizatriptan, CI: IHD, coronary spasm, uncontrolled HTN, recent lithium, SSRIs or ergot use, SE: arrhythmias, angina +/- MI) or ergotamine (1mg PO, CI: the pill, PVD, IHD, pregnancy, hemiplegic migraine, Raynaud’s, liver/renal impairment, HTN). Prevention: 1st - Propanolol 40-120mg/12h or amitriptyline 10-75mg or topiramate 25-50mg/12h or CCB, 2nd - valproate, pizotifen, gabapentin, pregabalin.
