headache Flashcards
are most headaches primary or secondary?
primary
what would be types of secondary headaches?
Tumour Meningitis Vascular disorders Systemic infection Head injury Drug-induced
what would be types of primary headaches?
Tension Type Headache
Migraine
Cluster Headache
what is tension type headache?
Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity
what are tension type headache treatments?
Aspirin or paracetamol
NSAIDs
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
Preventative treatment
Rarely required
Tricyclic antidepressants
amitriptyline, dothiepin, nortriptyline
what is the most frequent dsiabling primary headache?
migraine
what is a migraine?
A chronic disorder with episodic attacks
Complex changes in the brain
what happens during migraine attacks?
Headache
Nausea, photophobia, phonophobia
Functional disability
what happens in between migraine attacks?
Enduring predisposition to future attacks
Anticipatory anxiety
what are migraine triggers?
dehydration diet environmental stimuli changes in oestrogen level in women sleep disturbance hunger stress
what percentage of people does aura affect?
33%
what is aura?
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve visual, sensory, motor or speech systems
how long does aura occur for?
15-60 minutes
how would you define a chronic migraine?
Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months
how does medication overuse in headaches occur?
Headache present on ≥15 days / month which has developed or worsened whilst taking regular symptomatic medication
what is the treatment for migraines?
Abortive treatment
Aspirin or NSAIDs
Triptans
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
Prophylactic treatment Propranolol, Candesartan Anti-epileptics Topiramate, Valproate, Gabapentin Tricyclic antidepressants amitriptyline, dothiepin, nortriptyline Venlafaxine
when are you likely to get your first migraine as a woman?
during pregnancy
what treatment would you use for someone that is haveing an acute attack of migraines but is pregnant?
paraceamol
what preventatives would you give a pregnant person with migraines
Propranolol or Amitriptyline
what are Trigeminal Autonomic Cephalalgias
group of headache disorders characterised by attacks of moderate to severe unilateral pain in the head or face, with associated ipsilateral cranial autonomic features such as lacrimation, conjunctival injection, rhinorrhoea, nasal congestion, eyelid oedema and ptosis.
where would the pain most likely be due to a cluster headache?
mainly orbital and temporal
how long would a cluster headache be?
15 mins to 3 hours
what are the different types of Trigeminal Autonomic Cephalalgias
Paroxysmal Hemicrania
SUNCT
cluster headache
which of the TAC’s attack the most frequent
Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing
(SUNCT)
which os the TAC’s last the longest?
cluster headache
which of the TAC’s have a burning sensation?
SUNCT
where would the pain be due to paroxysmal hemicrania?
mainly orbital and temporal
how long would a paroxysmal hemicrania attack last?
2-30 mins
what are cutaneous triggers for SUNCT?
Wind , cold
Touch
Chewing
what type of a pain is trigeminal neuralgia?
stabbing
how long does trigeminal neuralgia last?
5-10 seconds
what are the treatments for cluster headache?
Abortive (Headache)
Subcutaneous sumatriptan 6mg or nasal zolmatriptan 5mg
100% oxygen 7-12 l/min via a tight fitting non-rebreathing max is effective and safe
Abortive (Headache bout)
Occipital depomedrone injection (same side as the headache)
Or tapering course of oral prednisone
Preventative Verapamil (high doses may be required) Lithium Methysergide (risk of retroperitoneal fibrosis) Topiramate
what are the treatments for paroxysmal hemicrania?
No abortive treatment
Prophylaxis with indometacin
Alternatives – COX-II inhibitors, Topiramate
what are the treatments for SUNCT?
No abortive treatment
Prophylaxis: Lamotrigine Topiramate Gabapentin Carbamazepine / Oxcarbazepine
what are the treatments for trigeminal neuralgia?
No abortive treatment
Prophylaxis:
Carbamazepine
Oxcarbazepine
Surgical intervention:
Glycerol ganglion injection
Steriotactic radiosurgery
Decompressive surgery
what are presentations of a secondary headache?
Associated head trauma First or worst Sudden (thunderclap) onset New daily persistent headache Change in headache pattern or type Returning patient
what are red flags for a secondary headache?
new onset headache
new or change in headache
aged over 50
Immunosupression or cancer
change in headache frequency, characteristics or associated symptoms
focal neurological symptoms
non-focal neurological symptoms
abnormal neurological examination
what is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than 1 minute
Majority peak instantaneously
what are differential diagnosis for thunderclap headaches?
Primary (migraine, primary thunderclap headache, primary exertional headache, primary headache associated with sexual activity) Subarachnoid haemorrhage Intracerebral haemorrhage TIA / stroke Carotid / vertebral dissection Cerebral venous sinus thrombosis Meningitis / encephalitis Pituitary apoplexy Spontaneous intracranial hypotension
who is likely to get a subarachnoid haemorrhage?
All patients presenting with a sudden severe headache that peaks within a few minutes and lasts for at least 1 hour Examination is often normal! Never consider a patient ‘too well’ for SAH
what are features suggestive of a space occupying lesion or raised intracranial pressure?
Progressive headache with associated symptoms and signs
Headache worse in morning or wakes patient from sleep
Headache worse lying flat or brought on by valsalva (cough, stooping, straining)
Focal symptoms or signs
Non-focal symptoms e.g. cognitive or personality change, drowsiness
Seizures
Visual obscurations and pulsatile tinnitus
what is intracranial hypotension
a condition in which there is negative pressure within the brain cavity
causes of intracranial hypotension?
Dural CSF leak
investigations for intracranial hypotension
MRI brain and spine
treatment of intracranial hypotension
Bed rest, fluids, analgesia, caffeine (e.g. 1 can red bull qds)
i.v. caffeine
Epidural blood patch
when would you consider someone with arteritis of large arteries?
in any patient over the age of 50 years presenting with new headache
what are specific features of giant cell arteritis?
include scalp tenderness, jaw claudication and visual disturbance
Prominent, beaded or enlarged temporal arteries may be present
An elevated ESR supports the diagnosis
(usually >50, often much higher, rarely normal)
Raised CRP and platelet count are other useful markers
