Headache Flashcards
Types of headache
Primary
Secondary
What % of headaches are primary?
90%
What is a primary headache?
A headache that has no underlying medical cause
What is a secondary headache?
A headache which has an identifiable structural or biochemical cause
Types of primary headaches
Tension type headache
Migraine
Cluster Headache
Causes of secondary headaches
Tumour Meningitis Vascular disorders Systemic infection Head injury Drug induced
What is the most frequently disabling primary headache?
Migraine
Which gender gets more migraines?
Females
What age is the most common for migraines?
20 - 50
Features of migraine
A chronic disorder
Episodic attacks
Features of migraine attacks
Episodic
Recurrent
Reversible
Presentation of migraine
Headache Nausea Vomiting Photophobia Phonophobia Functional disability Nasal congestion Muscle pain Osmophobia
Effects of in between attacks of migraine
Enduring predisposition to future attacks
Anticipatory attacks
How long can headache attacks of migraine last for?
4 to 72 hours
To diagnose migraines by the international headache society, what must be present?
Unilateral location Pulsating quality Moderate or severe pain intensity And/or aggravation by or causing avoidance of routine physical activity (e.g. walking, climbing stairs) During the headache phase, 1 of the following symptoms should be present, - nausea and/or vomiting - photophobia - phonophobia
Possible physiological changes in the CNS that have been found in migraine suffers are…..
Between attacks - deficit of habituation or potentiation, reported for several sensory modalities (visual, auditory, somatosensory, cognitive and painful stimuli)
Interictal allodynia - alteration in thresholds between episodes
Triggers for migraine
Stress Hunger Sleep disturbance Dehydration Diet Environmental stimuli Changes in oestrogen level in women
When do women commonly get migraines due to changes in oestrogen level?
Before / during period
Features of the headache in migraine
Unilateral
Throbbing
Pre migraine symptoms
Aura Mood changes Fatigue Cognitive changes Muscle pain Food craving
Postdrome symptoms of migraine
Fatigue
Cognitive changes
Muscle pain
What % of migrainerus have aura?
33%
What is an aura?
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve visual, sensory, motor or speech systems
Where does an aura start and go?
Starts in periphery
Spreads all over brain
Evolution of symptoms - moves from one area to next e.g. vision to sensory to speech
Duration of aura
15 - 60 mins
Treatment of migraine
Abortive treatment - aspirin - NSAIDs - Triptans (if they dont work) Prophylactic treatment - propanolol - candesartan - antiepileptics (topiramate, valproate, gabapentin) - Venlafaxine
What is an issue of migraine treatment in women?
Teratogenic
Abortive treatment for migraine is limited to what and why?
10 days per month (approx. 2 days per week) to avoid the development of medication overuse headache
In migraine without aura, in what situation in women do they get better?
Pregnancy
Does migraine with aura usually get better in any situation in women?
No
What migraine can particularly occur for the first time during pregnancy?
Migraine with aura
What is contraindicated in active migraine with aura?
OCP
Treatment of migraine in pregnancy
Acute attack; paracetamol
Preventative; Propanolol or amytiptyline
Definition of chronic migraine
Headache on over and including 15 days per month, of which over and including 8 days have to be migraine, for more than 3 months
What is a transformed migraine?
History of episodic migraine
Increasing frequency of headaches over weeks/months/years
Migranous symptoms become less frequent and less severe
Presentation of transformed migraine
Episodes of severe migraine on the background of less severe featureless frequent daily headache
Types of transformed migraine
With medication use
Without medication use
Definition of medication overuse headache
Headache present on and over 15 days/month which has developed or worsened whilst taking regular symptomatic medication
Who are particular prone to medication overuse headache?
Migraineurs
Causes of medication overuse headache
Migraneurs taking triptans, opoids and combination analgesics for other things > 10 days/months
Simple analgesics > 15 days per month
Caffeine overuse; tea, coke, irn bru, coffee
Types of trigeminal autonomic cephalalgias
Cluster headache
Paroxysmal hemicrania
SUNT
SUNA
What does SUNCT stand for?
Short lasting unilateral neuralgiform headache with conjunctival injection and tearing
What does SUNA stand for?
Short lasting unilateral neuralgiform headache with autonomic symptoms
Symptoms of trigeminal autonomic cephalalgias
Unilateral head pain - predominately V1 Very severe/excruciating Cranial autonomic symptoms - conjunctival injection/lacrimation - nasal congestion/rhinnorhoea - eyelid oedema - forehead and facial swelling - miosis/ptosis (horners syndrome)
Features of a cluster headache attack
Pain - orbital - temporal Sharp and throbbing Strictly unilateral Restless and agitated - rocking / walking about Prominent ipsilateral autonomic symptoms Redness of eye, lacrimation, lid swelling Nasal stuffiness Migraneous symptoms often present - premonitory symptoms; tiredness, vomiting - Associated symptoms; nausea, vomiting, photophobia, phonophobia Typical aura
Onset of the attack of cluster headache
Rapid onset (max within 9 mins in 86%)
Duration of cluster headache attack
15 mins to 3 hours
Majority 45 - 90 mins
Rapid cessation of pain
- very quick, very severe and then goes very quickly
What % of people with cluster headaches have episodic symptoms?
80 - 90%
How many attacks of cluster headaches do people get during a cluster?
1 every other day to 8 per day
may be continuous background pain between attacks
When does alcohol trigger cluster headaches?
During a bout, not attacks
What is so peculiar about cluster headaches?
Striking circadian rhythm
- attacks occur at same time each day
- bouts occur at same time each year
What % of people with cluster headaches have a chronic cluster?
10 - 20%
Features of chronic cluster headaches
Bouts last > 1 yr without remission OR
Remissions last < 1 month
Features of paroxysmal hemicrania headaches
Pain
- orbital
- temporal
Strictly unilateral
Excrutiatingly severe
50% restless and agitated during an attack
Prominent ipsilateral autonomic syndromes
Migraneous symptoms may be present
Background continous pain may be present between the attacks
Onset of paroxysmal hemicrania headaches
Rapid onset
Duration of paroxysmal hemicrania headaches
2 - 30 mins
How quickly does the pain cessede after the attack of a paroxysmal hemicrania headache?
Rapidly
10% of paroxysmal hemicarnia attacks are precipitated by what?
Bending
Rotation of the head
What % of patients have chronic and episodic PH?
Chronic - 80%
Episodic - 20%
Frequency of paroxysmal hemicrania headaches/attacks
2 - 40 attacks per day
Circadian rhythm of paroxysmal hemicrania
It does not have a circadian rhythm
What does paroxysmal hemicrania have an absaloute response to?
Indomethacin
Features of SUNCT
Unilateral
Orbital, supraorbital or temporal pain
Stabbing / pulsating pain
Conjunctival injection and lacrimation
Duration of SUNCT
10 - 240 seconds
What are the triggers of SUNCT?
Cutaneous triggers
- wind
- cold
- touch
- chewing
Attack frequency of SUNCT
2 - 200 per day
No refractory period
Presentation of trigeminal neuralgia
Unilateral
Maxillary or mandibular division pain > opthlamic division
Therefore lower face
Stabbing pain
Duration of trigeminal neuralgia
5 - 10 seconds
Triggers of trigeminal neuralgia
Cutaneous triggers
- wind
- cold
- touch
- chewing
Frequency of attacks of trigeminal neuralgia
2 - 200 per day
Has a refractory period
Are autonomic features in trigeminal neuralgia common?
No
What is trigeminal neuralgia usually caused by?
A blood vessel touching the nerve
Treatment of cluster headache
Abortive - headache
- subcutaneous sumatriptan or nasal zolmatriptan
- 100% oxygen 7-12 l/min via a tight fitting non rebreathing mask
Abortive - the bout
- occipital depomedrone injection on the same side as the headache
- tapering course of prednisolone
Preventative
- VERAPAMIL
- lithium
- methysergide
- topiramate
How does 100% oxygen treat an attack of a cluster headache?
High flow oxygen dampens down the autonomic pathway
How much treatment can be used in cluster headache vs migraine?
Migraine - up to 2 per WEEK
Cluster headache - up to 2 per DAY
Treatment of paroxysmal hemicrania
NO abortive treatment Prophylaxis - indometacin Also could try - COX-II inhibitors - Topiramate
Treatment of SUNCT/SUNA
NO abortive treatment Prophylaxis - lamotrigine - topiramate - gabapentin - carbamazepine
Treatment of trigeminal neuralgia
NO abortive treatment Prophylaxis - CARBAMAZEPINE - oxcarbazepine Glycerol ganglion injection Stereotactic radiosurgery Decompressive surgery
Red flags for secondary headache
New onset headache New or change in a headache if - > 50 y/o - immunosuppression or cancer Change in headache frequency, characteristics or assosiated symptoms Focal neurological symptoms Non focal symptoms of - drowsiness - depressed - cortical symptoms Abnormal neurological examination Neck stiffness / fever High pressure Low pressure GCA - jaw claudication or visual disturbance
What indicates a high pressure headache?
Headache worse when
- lying down
- wakening up the patient
- precipitated by physical exertion
- precipitated by the valsalva manouvre
What indicates a low pressure headache?
Precipitated by sitting/standing up
What is a high pressure headache a risk factor for?
Cerebral venous sinus thrombosis
Headache presentations which are more likely to have a sinister cause
Assosiated head trauma First or worst Sudden (thunderclap) onset - feels like they have been hit with something New daily persistent headache Change in headache pattern or type Returning patient
A longstanding episodic headache is unlikely to be caused by what?
A serious intracranial pathology
What is the most frequent primary headache?
Tension type headache
What % of men and women have tension type headaches?
42% men
49% women
Presentation of a tension type headache
Mild, bilateral headache which is often pressing or tightening in quality
No significant associated features
Not aggravated by routine physical activity
Classification of tension type headaches
Infrequent TTH
Frequent TTH
Chronic TTH
How often do you have to have a headache for in a month to have infrequent TTH?
< 1 day / month
How often do you have to have a headache for in a month to have frequent TTH?
1 - 14 days / month
How often do you have to have a headache for in a month in order to have a chronic TTH?
> 15 days / month
Treatment for a tension type headache
Abortive - aspirin or paracetamol - NSAIDs Preventative (rarely required) - tricyclic antidepressants 1. amytriptyline 2. dothiepin 3. nortriptyline
What is abortive treatment in TTH limited to and why?
10 days per month (approx. 2 days per week)
To avoid the development of medication overuse headache
Definition of a thunderclap headache
A high intensity headache reaching maximum intensity in less than 1 minute
Differential diagnosis for thunderclap headache
Primary - migraine - primary thunderclap headache - primary exertional headache - primary headache associated with sexual activity SAH Intracerebral haemorrhage TIA/Stroke Carotid/vertebral dissection Cerebral venous sinus thrombosis Meningitis/encephalitis Pituitary apoplexy Spontaneous intracranial hypotension
What is the most common cause for thunderclap headache?
SAH
What does SAH stand for?
Subarachnoid haemorrhage
What is SAH usually due to?
An aneurysm that bursts
What parts of the head does the subarachnoid space cover? Therefore what does this mean for the presentation of a SAH?
Goes around the whole brain
Therefore the headache is over the whole head
How many patients who have a thunderclap headache will have a SAH?
1 in 10
Mortality of SAH
50%
Examination findings of SAH
Often NORMAL
Investigations for SAH
CT brain
LP (> 12 hours after headache onset)
CT +/- LP unreliable after 2 weeks and angiography is required after this time
If think the cause of the thunderclap headache is meningitis, what must be done?
DO not wait for results to do treatment - start immediately
When should CNS infection be considered in a patient with a headache? When the patient has all of….
Headache and fever
Meningism
Encephalitis
What does encephalitis consist of?
Altered mental state / consciousness
Focal symptoms / signs
Seizures
What does ICP stand for?
Intracranial pressure
What does papilloedema present with?
Headache
What is papilloedema?
BILATERAL swollen optic discs
What does papilloedema indicate?
Raised ICP
What is glioblastoma multiforme? What does it present with?
A tumour
Presents with a seizure
Features that are suggestive of a space occupying lesion and/or raised ICP
Progressive headache with assosiated symptoms/signs
Warning features
- headache worse in morning
- headache wakens patient from sleep
- headache worse by lying flat or brought on by valsalva
- focal symptoms/signs
- non focal symptoms (cognitive or personality change, drowsiness)
- Seizures
- visual obscurations and pulsatile tinnitus
Examples of the valsalva manouvre
Cough
Stooping
Straining
Examples of visual obscurations seen due to high CSF pressure
Clouding/dulling on vision when stand up / move
Pathology of intracranial hypotension
Dural CSF leak
Causes of intracranial hypotension
Spontaneous
Iatrogenic (post LP)
Features of intracranial hypotension headache
Better when lie flat
Worsens soon after assuming upright posture and lessens or resolves shortly after lying down
When an intracranial hypotension headache becomes chronic, what feature does it often lose?
Its postural component
Investigations of intracranial hypotension
MRI brain and spine
What would be seen on MRI in intracranial hypotension?
CSF leaking out a hole in the meningeal sac
Brain sags down
Pulls down meninges/nerves
Treatment of intracranial hypotension
Bed rest Fluids Analgesia Caffeine (e.g. 1 can red bull qds) IV caffeine Epidual blood patch
What does epidural mean?
In epidual space
How does an epidural blood patch work?
Put patients blood in the epidural space and the blood will tract up and down, causing irritation which will seal the hole
What is GCA on spectrum with?
Polymyalgia rheumatica
What does GCA stand for?
Giant cell arteritis
Pathology of GCA
Arteritis of the large arteries
Big blood vessels to eye/brain
Narrowing of blood vessels due to inflammation - risk of infarction to the optic nerve and brain
Who should GCA always be considered in?
Any patient > 50 y/o presenting with new headache
Presentation of GCA
Headache - diffuse - persistent - may be severe Systemically unwell Scalp tenderness Jaw claudication Visual disturbance Prominent, beaded or enlarged temporal arteries Elevated ESR (usually > 50) Raised CRP Raised platelet count
Definition of claudication
Exercise induced pain
Definition of jaw claudication
Pain when eat which stops when stop eating
Investigations of GCA
History and exam
ESR and CRP
Temporal artery biopsy
Treatment for GCA
Prednisolone
What is the 1st choice for prophylaxis of tension type headache?
Acupuncture
What anti emetic has strong extra pyramidal side effects common in children and young adults?
Metoclopramide
What group of symptoms are common in children with migraine?
Gastrointestinal
Prophylaxis of primary sexual headache
Indomethacin
Propanolol
What is a contraindication to triptan use?
CVS disease
Examples of higher cognitive impairments
Disinhibition (aggression) Change in impulse control e.g. gambling Inflexible thinking Poor problem solving Worsening decision making
