Headache Flashcards
what aspects of headache should be covered in a history
SOCRATES unilateral/bilateral timing - morning duration associated with autonomic symptoms, N+V, photophobia worsens with valsalva manoeuvres PMH of cancer
what are red flags to look out for in someone with a headache
>55 yo immunosuppressed previous/current known malignancy worse in the morning associated with N+V, worsens with valsalva
what can headaches be categorised as
primary and secondary headache complexes
list the primary headache complexes
migraine
tension type headache
autonomic cephalgias: cluster headache, paroxysmal hemicrania, SUNCT
list the secondary headache complexes
idiopathic intracranial hypertension
trigeminal neuralgia
sore head upon standing is intracranial hypo/hyper tension
HYPO tension
sore head upon lying down is intracranial hypo/hyper tension
HYPER tension
migraine with/without aura is more common
without aura is more common
IHS criteria is for defining migraine with/without aura
without aura
what is the criteria for defining migraine without aura
at least 5 attacks
each lasting 4-72 hours
2 of: mod/severe, unilateral, throbbing pain, worse with movement
1 of: autonomic features, photo/phonophobia
who gets migraines
females
teens / 40-50s menopausal
menstrually related
what is the pathophysiology of migraines
neurovascular problem in susceptible individuals
serotonin release causes vasoconstriction and dilatation
substance P irritates nerves and vessels causing pain
describe aura associated with migraines
fully reversible symptoms - visual, sensory, motor or language
lasts 20-60 minutes
triggers of migraine
stress sleep diet - dark chocolate, cheese, alcohol hormonal physical exertion
what can be used to help identify triggers of migraine
headache diary
what are the main groups of management in migraine
pharmacological and non-pharmacological
list non-pharmacological Mx of migraine
avoid triggers stress avoidance headache diary hydration - 2L water daily reduce caffiene regular exercise
what is acute management of migraine
NSAIDs +- anti emetic
Triptans
why would you give an anti-emetic with NSAID in acute migraine
if there is gastroparesis
what are triptans and how do they work
serotonin (5HT) agonists
cause vasoconstriction of dilated vessels
how can triptans be administered
PO
SC
sublingual
when would you give someone migraine prophylaxis
if they have had more than 3 attacks per month
or very severe migraines
what prophylaxis can be given for migraines
amitriptyline (tricyclic antidepressant)
propranolol (B blocker)
topiramate (anti-convulsant/carbonic anhydrase inhibitor)
side effects of amitriptyline
postural hypotension
dizziness
sleepiness
dry mouth
side effects of propranolol
bronchoconstriction cold peripheries bradycardia sleep disturbance GI upset tiredness
when is propranolol contraindicated
asthma/COPD
heart failure
peripheral vascular disease
topiramate is teratogenic, true or false
TRUE
side effects of topiramate
weight loss
parasthesia
poor cognition
enzyme inducer
other treatments of migraine
gabapentin pizotifen sodium valproate (teratogenic) botox scalp injection anti CGRP Ab
list some “fancy” types of migraine
acephalgic basilar retinal ophthalmic hemiplegic (familial) abdominal (children)
describe symptoms of tension type headache
bilateral
pressing/tingling pain
absence of autonomic features
management of tension type headache
relaxation physiotherapy
anti-depressants: dothiepin, amitriptyline
reassurance
what are trigeminal autonomic cephalgias (TACs)
group of primary headache complexes with unilateral trigeminal distribution pain along with ipsilateral cranial autonomic features
list cranial autonomic features
nasal stuffiness eye tearing ptosis miosis N+V eyelid oedema
what are the 4 main types of autonomic cephalgias
cluster headache
paroxysmal hemicrania
hemicrania continuum
SUNCT
who gets cluster headaches
men
30-40s
symptoms of cluster headahces
severe unilateral pain
45-90 min
cluster bout
moving makes it better
management of cluster headaches
high flow oxygen 100% for 2 min
SC sumitriptan
steroids reduced over 2 weeks
prophylaxis for cluster headaches
verapamil
who gets paroxysmal hemicrania
females
50-60s
symptoms of paroxysmal hemicrania
severe unilateral headache
10-30 min
more frequent episodes
management of paroxysmal hemicrania
very sensitive to indomethicin
what is SUNCT
Short lived 15-120 sec Unilateral Neuralgiaform headache Conjuctival injections Tearing
management of SUNCT
lamotrigine, gabapentin
what investigations do those with new onset unilateral cranial autonomic features get
MRI brain
MR angiogram
what is idiopathic intracranial hypertension IIH and who gets it
^ICP
females
obese BMI>30
symptoms of IIH
headaches worse in the morning
N+V
visual loss (papilloedema needs to be checked for)
LP is indicated in all cases of IIH, true or false
FALSE
LP is only done if scan is normal
contraindicated in ^ICP
management of IIH
MRI, CSF, visual fields
Weight loss!!!
acetazolamide (carbonic anhydrase inhibitor)
ventricular-peritoneal shunt
who gets trigeminal neuralgia
females
>60 yo
triggers of trigeminal neuralgia
touch chewing swallowing talking eating
symptoms of trigeminal neuralgia
sharp stabbing unilateral pain lasting 1-90 seconds
management of trigeminal neuralgia
MRI - rules out compression
carbamazepine, gabapentin, phenytoin, baclofen
surgery - ablation, decompression
