Headache Flashcards
Causes of functional headaches (old classification)
External compression - muscle tension or tight headwear
Benign exertional - migraine or cough related pain
Sexual activity - preorgasmic or postorgasmic, orgasmic headaches are disease related
Headaches can be broken into
Functional and disease associated
Symptoms of disease related (sinister) headaches
Stabbing headache - icepick pain (brain freeze) <3mins
Exploding head syndrome - loud bang in head or myoclonic jerk equivalent, common when falling asleep
Epilepsy
Environmental causes of headaches
Drugs - alcohol, weed, coke, Chinese restaurant syndrome, hot dog syndrome, histamine
Location - mountain sickness (hydration and aspirin)
Metabolic - low oxygen, high CO2, low glucose, rebound after vasodilators
Chinese restaurant syndrome
Headache due to high mono sodium glutamate intake
Pressure tightness in face and burning trunk
Hot dog syndrome
Headache due to nitrates in cured meats
Used to give a red appearance
For a diagnosis of migraine
Five or more lifetime attacks lasting 4-72hrs
Two or more headache features - Moderate/severe pain, Unilateral,Throbbing/pulsating,Exacerbated by routine activities
One or more non-headache features - nausea, photophobia, phonophobia, smell sensitivity
Aura
Must exclude other causes of headaches
Types of benign headache
Acute - migraine, everyday-tension-type headache, other
Chronic - cluster (4hrs), other
A common cause of chronic daily headaches
Long term high dose Analgesic use
Different drugs take longer to ware off, codeine and caffeine may take three month. NSAIDs only a couple of days
Migraine prevalence
Much more common in women, linked to hormones
Affect mid aged people most
Peak at 40-50 years
Onset early in life with increased frequency with age
Likely diagnosis of patients presenting to headache clinic
Chronic daily headache (CDH) - 60%
Migraine - 33%
Cluster headaches - 5%
Short sharp headaches - 4%
Cluster headaches
Severe, recurrent unilateral headache affecting the temporal and periorbital region
Rapid onset lasting up to an hour, associated with redness of the eye, ipsilateral lacrimation and horner’s syndrome
Cluster headaches most often occur
More common In Men with peak onset at 30
Often will continue occurring for 1-4 months followed by a 6 month headache free period
Tension headaches
Feeling of tightness around the occipitotemporal area bilaterally due to tension in the muscles
Usually without associated features
Often occur chronically and daily and can be precipitated by a stressful event
Raised intracranial pressure
Dull throbbing pain generalised around the whole top half of the head getting worse over time
Is worse on waking and often wakes the patient from sleeping
Is aggregated by straining and improves when the patient stands
Associated with nausea/vomiting, confusion, papilloedema and visual disturbances
Migraines are associated with
Patent foremen ovale - higher frequency of significant PFO in patients with migraine with aura, no effect of closure
Mental disorders - causality unknown. Likely that in part due to the QOL impact of frequent severe migraines
Patent foremen ovale are also associated with
As well as migraine with aura Arterial hypoaemia Transient global amnesia Paradoxical gas embolism/decompression illness Paradoxical thromboembolism and stroke
Temporal Arteritis
Unilateral temporal pain with scalp tenderness, and jaw claudication
Palpation of the sup. temporal artery is painful and pulseless
If untreated permanent visual loss is possible, other features include fever, malaise and weight loss.
Temporal arteritis commonly affects
Women over the age of 60
There is a strong association with polymyalgia rheumatica
Sinusitis
Infection and Inflammation of the sinuses causing blockage
Presents as a persistent, worsening cold with a constant dull ache over the frontal and maxillary sinuses and facial tenderness
Associated with fever, congestion and sore throat.
Worse on bending over
Trigeminal Neuralgia
Multiple episodes of unilateral stabbing pain lasting seconds
Mainly in the maxillary and mandibular areas of the trigeminal distribution
Triggered by brushing teeth, eating, drinking, shaving or washing
Red flags for sinister headaches
Age of onset >50yrs
Additional symptoms: rash, temperature, scalp tenderness
Persistent symptoms or signs between attacks
Abrupt onset, especially with vomiting
Time course of a migraine
A prodromal phase of increasing hypo perfusion leading to development of an aura
Onset of a headache with hyperperfusion which slowly normalises during recovery
Drug Treatments for migraine
Triptans plus NSAIDs- relief from pain and associated symptoms
- 5HT1b mediated vasoconstriction
- 5HT1d trigeminal inhibition and decreased spinal pain transmission
Erogots - useful for symptomatic relief but worse side-effects
Status migrainous
Frequent, semi-regular migraine attacks
Can become chronic migraine if superimposed over CTTH
Preventative treatment for migraines
Topiramate
Acupuncture supported for frequent migraines
Botox
Now approved for migraine treatment
Cgrp release is blocked to prevent central sensitisation and may down-regulate production of neuropeptides in the dorsal horn
Found to give extra 40hours a month of headache free life
Cerebral abscess
Can present with continous headache leading to collapse and confusion and focal neurological symptoms
Subarachnoid haemorrhage
Will present with symptoms of raised intracranial pressure after head trauma or exterior
May show very rapid progression
Tumour or other space occupying lesion (SOL)
May present with headaches or symptoms of RIP
As tumour grows will develop focal neurological symptoms/visual disturbance/aura without migraine etc
Meningitis
Continuous headache with sudden fever and blanching rash
Becomes confused with neck stiffness and possible positive kernig’s sign (pain limiting passive extension of a flexed knee when the hip is flexed) and brudzinski’s sign (flexion of the neck causing involuntary hip and knee flexion)
Number of neurology referrals for headaches?
30%
Migraines in children
Tend to finish faster, 1-12 hours
Chance a headache is sinister?
1%
ETTH
Episodic tension type headache
Treatments for migraine
Non drug treatments - preventing attack, lifestyle
Preventers - propranolol, topiramate (not great,side effects)
Rescue drugs - triptans with NSAIDs,ergotamine,drugs to improve gastric motility
Cerebral blood flow in migraine
Initial vasoconstriction linked to aura
Subsequent vasodilation associated with headache
Not clear causality
Occipital migraine
Migraine with pain localises to back of head
More nausea and dizziness
Can cause collapse
Treatments for tension type headache
Non drug mainly
Massage or stress relief
Patients with confusing symptoms might have
May have multiple superimposed headache types
Chronic tension type headache with migraines or status migrainosus
May also be due to analgesic overload
Chronic migraine
Over 8 days for 3 months
Sufficient migraine symptoms and previous migraine diagnosis
Abdominal pain syndrome
Migraine equivalent
Similar precipitants
Common in children
Often cause unneeded appendectomy
Treating cluster
Lifestyle - alcohol can trigger
Preventatives - verapamil, lithium, gapentin, steroids for a couple of weeks (useful in short clusters)
During attacks - oxygen and injectable triptans
