headache Flashcards
what is the likely cause of a headache in a woman - onset typically puberty, menstruation, pregnancy, menopause
migraine
outline the Dx criteria for migraine (subdivide into with and without aura)
WITHOUT: at least five attacks of:
a. headache lasting 4-72hrs
b. N.O. at least 1 of N&V / photo/phonophobia
c. P.U.M.A. at least 2 of unilat / pulsatile pain / mod-sev intensity / worsened by normal activities
WITH: at least 2 attacks of
One or more typical aura symptoms (e.g. visual scotoma, zig zag lines, paresthesia, aphasia)
WITH
Each individual aura symptom lasting 5-60 minutes, with aura accompanied, or followed within 60 minutes, by headache.
what is the acute treatment of migraine?
1st line - Oral triptan (eg. sumatriptan) + NSAID / para
(nb - if vomiting - nasal spray / subcut)
Consider antiemetic - Prochlorperazine – if N&V (can give under buccal mucosa)
1st line if pregnant - PARACETAMOL
2nd line if pregnant - ibu / triptan
is it more common to have an aura with migraine or not..?
not
outline the chronic tx (PREVENTION) of migraine if: 1. young woman 2. asthmatic middle aged man 3. pre-menstrual
topiramate (CI teratogenic)
propranolol (CI asthma)
acupuncture / gabapentin 2nd line
zolmitriptan if pre-menstrual
outline your long-term management of GCA
- Pred (stepping down dose whilst monitoring ESR)
- Aspirin 75mg daily
- PPI
- Bisphosphonates
outline the typical presnetation of trigeminal neuralgia
brief unilat shock-like pains
severe
lasting seconds
triggered by light touch
give two key examinations to do in a GP setting when someone presents with a headache
BP (IIH/ SAH / risk of CVA)
papilloedema (IIH / raised ICP)
what is the underlying cause for trigeminal neuralgia?
The vast majority of cases are idiopathic but compression of the trigeminal roots by tumours or vascular problems may occur
what are the red flags in trigeminal neuralgia? (refer to neuro..)
Sensory changes.
Deafness or other ear problems.
History of skin or oral lesions that could spread perineurally.
Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally.
Optic neuritis.
Family history of multiple sclerosis.
Age of onset before 40 years.
what is the tx of trigeminal neuralgia?
Carbamazepine
if doesn’t respond - refer to neuro…
give some causes of a thunderclap headache
SAH
intracranial venous sinous thrombosis (Ix with CT/MR venogram, Tx with LMWH or streptokinase through a catheter
give some differentials for bilateral papillodema
- malignant htn
- BIH - young, overwight woman
- other causes of increased ICP
- cranial venous sinus thrombosis
what might this be?: headache occurs on wakening aggravated by bending / coughing doesn't respond to analgesics 'bursting'
pressure headache - ?colloid cyst causing ball valve obstruction in the ventricles?
what is your first line Mx for a tension headache?
amitryptilline
what 3 treatments do you start in someone with GCA?
- high dose oral pred
- PPI
- bisphosphonates
65 year old man with electric shock like pain from mouth to ear when he shaves
trigeminal neuralgia
Trigeminal neuralgia:
- which two places? and direction
- describe the characteristics of trigeminal neuralgia pain
- list some triggers for trigeminal neuralgia
- mouth-ear (V2/V3) line in 2/3
nose to orbit line in 1/3
travels superior/posteriorly from mouth / nose - electricity/ red hot needles
builds to an excruciating pain felt deep in the face for a few seconds
replaced by an unpleasant ache (red hot poker dragged across face….) - chewing / cutaneous (shaving or brushiing teeth) or motor activity)
how would you investigate trigeminal neuralgia?
MRI to exclude 2y causes - eg. tumour / MS
describe some other features of trigeminal neuralgia (other than the character of the pain)
only during the day (diurnal variation
‘startle’ if attempt to touch the affected side
unkempt / haggard appearance
more than 50 years old usually
how do you treat trigeminal neuralgia?
carbemazapine
2nd line specialist treatments:
lamotrigine
phenytoin
microvascular decompression (often caused by a vessel pressing on a nerve root…)
post herpetic neuralgia:
- presentation?
- treatment?
1. 3-5 days before eruption of vesicles may have an elevated ESR 2. treat the herpes zoster with aciclovir treat the neuralgia with amitriptylline or gabapentin capsaicin / TCNS
