Headache Flashcards
What is the key feature of a headache caused by low ICP
Comes on when they stand up and gets better when they lie down
What is the key feature of a headache caused by high ICP
Headache when lying down, gets better when upright
How does a cluster headache present
Extremely severe
One-sided
Lasts around 45-90mins at a time but will get 1-8 per day
These episodes can last weeks to months
People often want to keep moving around
May also have nausea, vomiting, lacrimation, rhinorrhea
What are common associated symptoms of headache that should be asked about
Autonomic features such as nausea and vomiting Photophobia Phonophobia Positive visual symptoms Miosis - constricted pupil Ptosis Nasal stuffiness - sinus
Which demographic tends to get migraines
Young women
Typically teens to 20s
Another peak in the 40s
What are the headache red flags
New onset headache in the over 55s Known or previous malignancy - risk of mets Immunosuppression - risk of infection Early morning headache - wakes you up Exacerbation by the Valsalva manoeuvre
What are the diagnostic criteria for migraine without aura
AT least 5 attacks lasting between 4-72 hours
2 from: moderate/severe pain, unilateral, throbbing or worse on movement
1 from: autonomic features, photophobia or phonophobia
Migraines can be hormonally driven - true or false
True
Can be related to the menstrual cycle in women
Describe the pathophysiology of migraines
Both vascular and neural influences
Stress can trigger changes in the brain which cause release of serotonin
The blood vessels constrict and dilate
Chemicals can irritate the blood vessels and nerves causing pain
Which is more common - migraine with or without aura
Without
Only 20% of people with migraines get auras
What is an aura
A fully reversible visual, sensory, motor or language symptom
e.g. visual disturbance, speech problems, word finding difficulty
Visual is most common
Lasts around 20-60 mins
Does an aura always have to occur alongside the headache
No
Headache can follow the aura - but will be less than one hour between them
Can also occur simultaneously
What can trigger a migraine
Sleep Diet - dark choc, cheese and alcohol are the main ones Hormones - menstrual cycle Physical exertion Stress
What non-pharmacological treatments are available for migraine
Education - what triggers are and how to avoid them
Headache diary to find trigger and monitor symptoms
Relaxation/stress management
Acupuncture
Regular exercise and healthy diet
Hydration
Reduce caffeine intake
What acute treatment is available for migraines
NSAIDs - take ASAP
Paracetamol
Aspirin
Triptans - rizatriptan, sumatriptan
How can triptans be taken
Come as tablets, nasal spray, SC injections and wafers that dissolve in the mouth
Wafers take a while to be absorbed
Ideally given at the start of headache
At which point is migraine prophylaxis considered
If a person has had more than 3 attack per month
If the migraines are particularly severe
How is migraine prophylaxis administered (generally)
Aim to slowly titrate the drug up to the efficient and tolerated dose
Aim for the lowest dose possible
Must trial each drug for at least 3 months
Which drugs can be used for migraine prophylaxis
Amitriptyline- 10-25mg
Propranolol - 80-240mg
Topiramate (carbonic anhydrase inhibitor ) - 25-100mg
Candesartan
Gabapentin, sodium valproate, botox
What are the side effects of amitriptyline
Dry mouth
Postural hypotension
Sedation
When should beta blockers be avoided
In asthmatics, PVD and heart failure
Can affect heart rate and BP
What are the adverse effects of topiramate
Weight loss
Paraesthesia
Impaired concentration
Enzyme induction
Reserved drug as it causes so many issues - start low go slow
How is botox used in the treatment of migraines
32 botox injections in the scalp every month – used for resistant migraines
What is the risk of prescribing sodium valproate
Risky to prescribe to women of child bearing age as it is very teratogenic
What is an acephalgic migraine
Get aura and feel sick but no headache
What is a basilar migraine
Severe form
Get vertigo and loss of balance
What is a hemiplegic migraine
Develop severe issues similar to stroke when they get their migraines, drowsy and unresponsive, speech and limb issues
How might children present with migraine
Recurrent abdominal pain
How does a tension headache present
Mild to moderate pain Pressing or tingling quality Bilateral No nausea or vomiting No photo or phonophobia
How can you treat tension headaches
Relaxation physiotherapy
Antidepressants - amitriptyline
Reassure
What are trigeminal autonomic cephalgia’s
Group of primary headache disorders
Characterised by unilateral trigeminal pain that occurs alongside ipsilateral cranial autonomic features
What are the ipsilateral cranial autonomic features seen in TACs
Ptosis Miosis Nasal Stuffiness Nausea/ vomiting Tearing Eye lid oedema
What are the 4 types of trigeminal autonomic cephalgia’s
Cluster headaches
Paroxysmal hemicrania
Hemicrania continua
SUNCT
Who gets cluster headaches
Most commonly young men
30s-40s
When do cluster headaches occur
Seem to have circadian and seasonal variation
Bouts will last weeks to months
How do you treat cluster headaches
High flow oxygen 100% for 20 mins
Sub cut sumatriptan 6mg
Steroids- reducing course over 2 weeks
Verapamil for prophylaxis
Who gets paroxysmal hemicrania
Older people - 50-60
Women more commonly than men
What are the features of paroxysmal hemicrania
Severe unilateral headache
Unilateral autonomic features
Lasts 10-30 mins
Can get 1-40 attacks per day
How do you treat paroxysmal hemicrania
Indomethacin
Has an absolute response
What is hemicrania continuum
Severe unilateral headache which is present all the time during an exacerbation
Also get the autonomic symptoms
What is SUNCT
Primary headache syndrome Short lived (15-120 secs) Unilateral Neuralgiaform headache Conjunctival injections Tearing
How do you treat SUNCT
Lamotrigine
Gabapentin
What investigations are needed if there is new onset of cranial autonomic symptoms
MRI brain
MR angiogram
Who gets idiopathic intracranial hypertension
More common in women
Overweight - getting more common as obesity rises
How does idiopathic intracranial hypertension present
Headache that is worse in the morning - diurnal variation
Morning N&V
Gets better when they stand up
Visual loss
What investigations need to be done if you suspect idiopathic intracranial hypertension
MRI brain - rule out more sinister causes
Should be normal
If normal do a LP - will show elevated pressure
Visual fields examination
When should you not do a LP
In someone with signs of raised ICP
Unless they have a brain scan and it is normal
How do you treat idiopathic intracranial hypertension
Weight loss - can be the cure
Acetazolamide - carbonic anhydrase inhibitor
VA or LP shunt - if at risk of blindness
Monitor the visual fields and CSF pressure
Who gets trigeminal neuralgia
Elderly - over 60
More common in women
What triggers trigeminal neuralgia
Aggravated by touch – shooting pain when touch their face
e.g. on shaving, applying makeup, brushing teeth
Also made worse by chewing, wind etc
How does trigeminal neuralgia present
Severe, stabbing pain - excruciating, some commit suicide it is so bad Unilateral Aggravated by touch Lasts 1-90secs Can get 10-100 attacks per day Bouts may last from weeks to months
How do you treat trigeminal neuralgia
Carbamazepine
Gabapentin
Phenytoin
Baclofen
Surgical:
Microvascular decompression
Decompression better in young patients
Percutaneous injection - need repeated
- glycerol
- ballon compression of the nerve
- thermocoagulation (high risk of numbness)
Good for elderly or those not fit for surgery
Which other structures (non-neurological) can cause facial pain
Eyes Ears Sinuses Teeth TMJ
How does migraine present
Unilateral, throbbing
headache
Autonomic symptoms include photophobia
Aura
Which conditions may present with acute headache
Sub-arachnoid haemorrhage Meningitis Other serious intra-cranial pathology i.e. post-trauma Cluster headache Eye issues - glaucoma, optic neuritis
Which conditions may present with chronic headache
Tension headache - most common
Migraine
Brain tumour
How can you treat recurrent vomiting in migraine
Prochloperazine
What are the most common types of headache seen in practice
Tension headache
Migraine
Which other symptoms may be associated with headache caused by sinusitis
Preceding cold or nasal discharge
Which other symptoms may be associated with headache caused by glaucoma
Misting of vision
Haloes around objects
Which other symptoms may be associated with headache caused by optic neuritis
Loss of vision
Which other symptoms may be associated with headache caused by haemorrhage
Instant onset
Vomiting
Neck stiffness
Which other symptoms may be associated with headache caused by hydrocephalus
Impaired conscious level
Impaired up gaze
Which other symptoms may be associated with headache caused by infections
Impaired conscious level
Acute onset
Neck stiffness
Fever
Which other symptoms may be associated with headache caused by tumours
Vomiting
Disc oedema
Which other symptoms may be associated with headache caused by sub-dural haematoma
Impaired conscious level
Focal neurological signs
Which other symptoms may be associated with headache caused by benign intracranial hypertension
Disc oedema
Visual symptoms
Which other symptoms may be associated with headache caused by temporal arteritis
Scalp tenderness
Jaw claudication
Thickened temporal artery
Which other symptoms may be associated with headache caused by chronic tension
Anxiety and depression
Which other symptoms may be associated with headache caused by cervical spondylosis
Neck and arm pain
