Headache Flashcards
what is the exam usually like in headache
normal
expect in tumours
name the ha:
visual disturbance, sub acute onset headache, dark rooms make it better
migraine
name the ha:
Headache every time you stood up and fine when you sat down
low ICP
name the ha:
Every time you lie down heachache and when stand up fine, wakes you up in morning
high ICP
name the ha:
Make, smoker, one sided headache v sore that lasts half an hour
cluster ha
name the ha:
non specific, pain 2 on scale
stress ha
what are the associated factors you should ask about
Autonomic features (N+V), photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness
what are the ha exacerbating factor you should ask about
Posture, valsalva (sneezing, coughing, straining etc). Diurnal variation.
who does a migraine most commonly affect
young females
worse in teenage years/ early 20s then worse again in 40s/50s
what are the red flags for headaches
new onset >55
known/ previous malignancy
immunosuppressed (worry about intracranial infection)
early morning ha
exacerbated by valsalva (coughing, sneezing= raised ICP)
what past medical history is important in has
previous cancer
predisposition to thrombosis
why is social history important in ha
as problems can manifest as pain
how often do people usually get migrinaes
once a month
what are the diagnostic (IHS criteria) features for a migraine without aura
at least 5 attacks
lasts 4-72 hours
2 of:
-moderate/ severe, unilateral, throbbing pain, worse on movement
1 of:
-autonomic features, photo/phono phobia
when is migraine pain worse
evolves from on set, not worse at start
reaches 6/7 out of 10 pain
what is the pathophysiology of a migraine
both vascular and neural influences
have to be susceptible patient
stress trigger changes in brain- release of serotonin
blood vessels constrict and dilate
chemical including substance P irritate nerves and blood vessels causing pain
what is the pathophysiology of a migraine with aura
- cortical spreading depolarisation
- activation trigeminal vascular system - dilation of cranial blood vessels
- release of substance P, neurokinin A, CGRP
where is the migraine centre
dorsal raphe nucleus and the locus coeruleus
how many migraines have an aura
20%
what is an ‘aura’
fully reversible visual, sensory, motor or language symtoms
visual most common
what language symptoms can you get with migraine
speech problems
word finding difficulties
how long does an aura usually last
20-60 mins, headache follows < 1 hour later (but can occur simultaneously)
what types of visual aura can you get
central scotomata
central fortification
hemianopic loss
what are the migraine tiggers
sleep dietary (chocolate, cheese, alcohol) stress hormonal (menstrual) physical exertion
(ha diary helpful to identify)
what are the non pharmological treatments for migraines
education- avoid triggers ha diary relaxation/ stress management healthy diet hydration reduce caffeine exercise
what are the acute/ abortive pharmalogical treatments for migraines
NSAID: -aspirin 900mg, -naproxen 250mg, -ibruprofen \+/- anti emetic if gastroparesis take asap
Triptans
-5HT agonist (Rizatriptan= eletriptan > sumatriptan)
Oral, sub-lingual, subcutaneous- consider method of administration in those with N+V
treat at start of headache
similar efficacy to NSAIDS
what are the prophylaxic treatments for migraines
amitriptyline (10-25mg)
propanalol (80-240mg)
topiramate (25-100mg)
titrate drug as tolerated to achieve efficacy at the lowest dose possible
Must trial each for minimum of 3 months
Consider non-pharmacological methods such as acupuncture, relaxation exercises
others inc- gabapentin, pizotifen, Na valporate, botox (given if 3 failed medicines), monoclonal antibodies
when do you gove migraine prophylaxs
3 attacks per month or if very severe
what are the side effecrts of amitriptyline
dry mouth
postural hypotension
sedation
light headedness
who do you not give a beta blocker to
asthmatics, PVD, heart failure
what is topiramate and what are its side effects
carbonic anhydrase inhibitor
nasty drug
weight loss, paraesthesia, impaired concentration, enzyme inducer, probably teratogenic
what are the rarer types of migraine
acephalgic- aura basilar- vertigo,, get unsteady retinal ophthalmic hemiplegic (familial/ sporadic)- get symptoms similar to stroke, encephalopathic abdominal- children, recurrent abdo pain
is migraine unilateral or bilateral
unilateral
what are the features of a tension headache
can be episodic or chronic pressing tingling sensation bilateral mild to moderate pain absence of N&V absence of photophobia or phonophobia
what is the treatment for tension type headaches
relaxation physio
antidepressant
-dothiepin or amitriptyline
-3 month review
reassure
what causes tension headaches
often stressors
what are the trigeminal autonomic cephalgias (TACs)
a group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features
(is a primary headache complex)
what is a primary headache
one not caused by a tumour
what are the ispilateral autonomic features seen in trigeminal autonomic cephalgias
ptosis miosis nasal stuffiness N/V tearing eye lid oedema
what are the four main types of trigeminal autonomic cephalgias
cluster
paroxsymal hemicrania
hemicrania continua
SUNCT (short lived unilateral neuralgiaform headache, conjunctival injections, tearing)
who gets cluster has
young (30-40s)
men> women
what are the features of a cluster ha
circadian (around sleep) and seasonal variation
severe unilateral headache
lasts 45-90 mins
get 1-8 a day
cluster bout may last few weeks to months
severe pain, dont like to lie still
what is the treatment for a cluster ha
high for oxygen 100% for 20 mins (home canisters)
sub cut sumatriptan 6mg
steriods (reducing course over 2 weeks)
verapamil for prophylaxis
(all have MRI to make sure nothing there)
who gets paroxysmal hemicrania
older (50s-60s)
women> m3n
what are the features of paroxysmal hemicrania
severe unilateral headache
unilateral autonomic features
lasts 10-30 mins
1-40 a day
(shorter duration and more frequent than cluster has)
what is the treatment for paroxysmal hemicrania
responds v well to indomethicin (used to diagnose)
what is SUNCT
short lived (15-120 seconds) unilateral neuralgiaform headache conjunctival injections tearing
what is the treatment for SUNCT
lamotrigine
gabapentin
what investigations for those with new onset unilateral cranial autonomic features
always do MRI brain and MR angiogram
who gets idiopathic intracranial hypertension
F>m
obese
what are the symptoms of idiopathic intracranial hypertension
headache (diurnal variation, worse when they wake up, morning N&V)
visual loss- enlarged blind spot
what investigations do you do into idiopathic intracranial hypertension
MRI with MRV sequence (should be normal)
cerebrol spinal fluid (elevated pressure, normal constituents)
visual fields
when is the only time you do a lumbar puncture in raised ICP
IIH- do scan of brain first to make sure its normal
what is the treatment for IIH
weight loss acetazolamide ventricular atrial/ lumbar peritoneal shunt (only if patient going blind as problematic) monitor visual fields and CSF pressure
who gets trigeminal neuralgia
elderly (>60)
women> men
what are the features of trigeminal neuralgia
triggered by touch, usually V2/3 severe stabbing unilateral pain duration 1-90 seconds 10 to 100 times a day bouts of pain may last weeks to months before remission chewing makes it worse
what is the treatment for trigeminal neuralgia
carbamazepine
gabapentin
phenytoin
baclofen
surgically:
- abalation
- decompression
what investigations in trigeminal neuralgia
MRI brain
what other than trigeminal neuralgia should you consider in facial pain
eyes, ears, sinuses, teeth, TMJ etc
what is the 1st line for uncomplicated migraines
symptomatic NSAIDs
