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year 2 neuro - Robbie > Headache > Flashcards

Headache Flashcards

1
Q

What are the 2 types of headache?

A

primary

secondary

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2
Q

What is a primary headache?

A

no underlying medical cause

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3
Q

what are some exaples of a primary headahce?

A

Tension Type Headache

Migraine

Cluster Headache

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4
Q

What is a secondary headache

A

has an identifiable structural or biochemical cause

something has happened and you get a headache because of that

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5
Q

what are some exaples of secondary headaches

A

Tumour

Meningitis

Vascular disorders

Systemic infection

Head injury

Drug-induced

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6
Q

Are primary or secondary headaches more common?

A

90% of headaches are primary headaches

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7
Q

What is the most frequent type of primary headache?

A

tension-type headache

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8
Q

Is a tension-type headache disabeling?

A

no and rarley presents to doctors

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9
Q

What is the prevelence of tension-type headache?

A

Lifetime prevalence of 42% in men and 49% in women

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10
Q

What are the symptoms of a tension-type headache?

A

Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity

bilateral pressing

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11
Q

How is a tension-type headache differentiated form being infrequent, frequent and chronic?

A
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12
Q

What are the 2 different types of treatment used for TTH?

A

abortive and preventative

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13
Q

What are some abortive TTH treatments?

A

Aspirin or paracetamol

NSAIDs

Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache

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14
Q

What are some preventative TTH treatments?

A

Rarely required

Tricyclic antidepressants

amitriptyline, dothiepin, nortriptyline

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15
Q

What is the most frequent disabeling primary headache?

A

migraine

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16
Q

WHat is the epidemiology of migraine?

A

6 million people in the UK

Lifetime prevalence: 10% in men and 22% in women

Most sufferers aged 20 to 50

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17
Q

What is migraine?

A

A chronic disorder with episodic attacks

Complex changes in the brain

A migraine is usually a moderate or severe headache felt as a throbbing pain on 1 side of the head.

Many people also have symptoms such as feeling sick, being sick and increased sensitivity to light or sound

There are several types of migraine, including:

migraine with aura – where there are specific warning signs just before the migraine begins, such as seeing flashing lights

migraine without aura – the most common type, where the migraine happens without the specific warning signs

migraine aura without headache, also known as silent migraine – where an aura or other migraine symptoms are experienced, but a headache does not develop

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18
Q

What is experieenced during a migraine attack?

A

Headache

Nausea, photophobia, phonophobia

Functional disability

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19
Q

What is experienced inbetween anxiety attacks?

A

Enduring predisposition to future attacks

Anticipatory anxiety

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20
Q

What are migraine triggers?

A

Normal life events trigger or are associated with attacks in those predisposed

life stress

a neurologic condition in which the brain of predisposed patients is overresponsive to everyday triggers that normally do not initiate attacks

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21
Q

A migraine attack prgoresses through various stages

what are the stages?

A

Starts as a premonitory phase then into an aura phase which only 1/3 of people experience then there is an early and advanced headache phase in which treatment should be done in the early headache phase then finally there is a postdrome phase

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22
Q

What is aura?

A

Affects ~33% of migraineurs

Transient neurological symptoms resulting from cortical or brainstem dysfunction

May involve visual, sensory, motor or speech systems

Slow evolution of symptoms:

Moves from 1 area to next e.g. vision → sensory → speech

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23
Q

How long does aura last?

A

15-60 minutes

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24
Q

What can aura be confused with? and what are the differences?

A

Can be confused with transient ischaemic attack

Loss of function

Sudden onset where as aura comes on over a few mintues

Symptoms all start at same time and can be localised to a specific vascular area

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25
Q

What is a chronic migraine?

A

Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months

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26
Q

Transformed migraine may be the cause for chronic migraine, what is transformed migraine?

A

History of episodic migraine

Increasing frequency of headaches over weeks / months / years

Migrainous symptoms become less frequent and less severe

Many patients have episodes of severe migraine on a background of less severe featureless frequent or daily headache

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27
Q

What is the cause of a transformed migraine and what makes it better?

A

Transformation can occur with or without escalation in medication use

In patients with medication overuse, discontinuing the overused medication often (but not always) dramatically improves headache frequency

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28
Q

What is a medication overuse headache?

A

Headache present on ≥15 days/month which has developed or worsened whilst taking regular symptomatic medication

Can occur in any primary headache

Migraineurs are particularly prone to MOH

Migraineurs taking pain medication for another reason can develop chronic headache

Can also be caffeine overuse

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29
Q

What are the 2 different types of migraine treatments?

A

abortive treatment

prophylactic treatment

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30
Q

What are some abortive migraine treatments?

A

Aspirin or NSAIDs

Triptans

Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache

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31
Q

What are some prophylactice migraine treatments?

A

Propranolol, Candesartan

Anti-epileptics - Topiramate, Gabapentin

Tricyclic antidepressants - amitriptyline, dothiepin, nortriptyline

Venlafaxine

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32
Q

What are some specific issues to do with migraine seen in women?

A

Migraine without aura gets better in pregnancy but migraine with aura usually does not change

First migraine can occur during pregnancy - particularly migraine with aura

Avoid anti-epileptics in women of child bearing age

Treatment is more difficult in pregnancy

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33
Q

What are Trigeminal Autonomic Cephalalgias (TACs)?

A

a group of headache disorders characterised by attacks of moderate to severe unilateral pain in the head or face, with associated ipsilateral cranial autonomic features

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34
Q

What are some exaples of Trigeminal Autonomic Cephalalgias?

A

cluster headache

paroxysmal hemicrania

SUNCT

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35
Q

What is a cluster headache?

A

Cluster headaches are excruciating attacks of pain in 1 side of the head, often felt around the eye

Cluster headaches are rare. Anyone can get them, but they’re more common in men and tend to start when a person is in their 30s or 40s

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36
Q

What pain is experienced during a cluster headache?

A

mainly orbital and temporal

Excruciatingly severe (“suicide headache”)

Patients are restless and agitated during an attack

Prominent ipsilateral autonomic symptoms

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37
Q

Are cluster headache attacks unilateral or bilateral?

A

strickly unillateral

38
Q

How long do cluster headache attacks last?

A

Attacks are strictly unilateral

Rapid onset (max within 9 mins in 86%)

Duration: 15 mins to 3 hours (majority 45-90 mins)

Rapid cessation of pain

39
Q

What migrainous symptoms present often present during a cluster headache attack?

A

Premonitory symptoms: tiredness, yawning

Associated symptoms: nausea, vomiting, photophobia, phonophobia

Typical aura (often under recognised)

40
Q

Is a cluster headache attack or a migraine longer

A

migraine as much longer

41
Q

Are cluster headaches episodic or chronic?

A

Episodic in 80-90%

10-20% have chronic cluster

42
Q

Describe the bout of episodic cluster headache

A

Attacks “cluster” into bouts typically lasting 1-3 months with periods of remission lasting at least 1 month

Attack frequency: 1 every other day to 8 per day

May be continuous background pain between attacks

Alcohol triggers attacks during a bout, but not in remission

43
Q

What is the striking circadian rhythmicity of cluster headache?

A

attacks occur at the same time each day

bouts occur at the same time each year

44
Q

What are the bouts and temission like in chronic cluster headaches?

A

Bouts last >1 year without remission or

Remissions last <1 month

45
Q

What are the different types of treatment for cluster headaches?

A

abortive (headache)

abortive (headache bout)

preventative

46
Q

What is Paroxysmal Hemicrania?

A

Paroxysmal hemicrania is a rare form of headache that usually begins in adulthood. Patients experience severe throbbing, claw-like, or boring pain usually on one side of the face; in, around, or behind the eye; and occasionally reaching to the back of the neck

47
Q

What pain is experienced in Paroxysmal Hemicrania?

A

mainly orbital and temporal

Excruciatingly severe

50% are restless and agitated during an attack

Background continuous pain can be present

48
Q

Are attacks of Paroxysmal Hemicrania bilateral or unilateral?

A

unilateral

49
Q

How long are attacks of Paroxysmal Hemicrania?

A

Rapid onset

Duration: 2-30 mins

Rapid cessation of pain

50
Q

What other symptoms may be present in a Paroxysmal Hemicrania attack?

A

Prominent ipsilateral autonomic symptoms

Migrainous symptoms may be present

51
Q

Is Paroxysmal Hemicrania chronic or episodic?

A

80% have chronic PH

20% have episodic PH

52
Q

How frequent are attacks of paroxysmal hemicrania and is there a cricadian rhythm?

A

2-40 attacks per day

no circadian rhythm

53
Q

What is the treatment of Paroxysmal Hemicrania?

A

No abortive treatment

Prophylaxis with indometacin

Alternatives – COX-II inhibitors, Topiramate

54
Q

What is SUNCT?

A

Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT) is a syndrome predominant in males, with a mean age of onset around 50 years. The attacks are strictly unilateral, generally with the pain persistently confined to the ocular/periocular area

55
Q

Where is pain felt in SUNCT?

A

Unilateral orbital, supraorbital or temporal pain

56
Q

WHat type of pain is experienced in SUNCT?

A

Stabbing or pulsating pain

57
Q

What is the duration of a SUNCT attack?

A

10-240 seconds duration

58
Q

What are the cutaneous triggers of a SUNCT attack?

A

Wind, cold

Touch

Chewing

59
Q

How often do SUNCT attacks occur?

A

Attack frequency from 3-200/day, no refractory period

60
Q

What is the treatment of SUNCT?

A
  • No abortive treatment
  • Prophylaxis:

Lamotrigine

Topiramate

Gabapentin

Carbamazepine/Oxcarbazepine

61
Q

What is Trigeminal Neuralgia?

A

Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. If you have trigeminal neuralgia, even mild stimulation of your face - such as from brushing your teeth or putting on makeup - may trigger a jolt of excruciating pain

62
Q

What pain is felt in Trigeminal Neuralgia?

A

Unilateral maxillary or mandibular division pain > ophthalmic division

Stabbing pain

63
Q

What is the duration of Trigeminal Neuralgia?

A

5 - 10 seconds duration

64
Q

What are the cutaneous triggers of Trigeminal Neuralgia?

A

Wind, cold

Touch

Chewing

65
Q

How frequent are attacks of Trigeminal Neuralgia?

A

Attack frequency similar to SUNCT (3-200/day), has a refractory period

66
Q

Are autonomic features common in trigeminal neuralgia?

A

Autonomic features are uncommon

67
Q

What is the treatment of trigeminal neuralgia

A
  • No abortive treatment
  • Prophylaxis:

Carbamazepine

Oxcarbazepine

• Surgical intervention:

Glycerol ganglion injection

Steriotactic radiosurgery

Decompressive surgery

68
Q

Onto secondary headache now

A
69
Q

Serious intracranial pathology is very unlikely in longstanding _______ headache

A

Serious intracranial pathology is very unlikely in longstanding episodic headache

70
Q

What presentations are more likely to have a sinister cause?

A

Associated head trauma

First or worst

Sudden (thunderclap) onset

New daily persistent headache

Change in headache pattern or type

Returning patient

71
Q

What are red flags to look out for?

A

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

neck stiffness / fever

high pressure

<span>- </span>headache worse lying down

- headache wakening the patient up

- headache precipitated by physical exertion

- headache precipitated by valsalva manoeuvre

- risk factors for cerebral venous sinus thrombosis

low pressure

- headache precipitated by sitting/standing up

GCA (giant cell arteritis)

- jaw claudication or visual disturbance

- prominent or beaded temporal arteries

72
Q

What is a thunderclap headache?

A

A high intensity headache reaching maximum intensity in less than 1 minute

Majority peak instantaneously

73
Q

Is a thunderclap headache a primary or seconday headache?

A

May be primary or secondary - no reliable differentiating features!

74
Q

What are some differential diagnosis of thunderclap headache?

A

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

75
Q

1 in 10 patients with thunderclap headache will have a ___________

A

subarachnoid haemorrhage

76
Q

What is the prognosis of a subarachnoid haemorrhage?

A

85% aneurysmal

50% mortality, 20% of survivors remain dependant

Risk of re-bleed 4-6% in first 24-48 hours, 40% in first month

Early coiling (or clipping) of the aneurysm saves lives!

77
Q

Who may have a subarachnoid haemorrhage?

A

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

78
Q

How do you determine if someone has a subarachnoid haemorrhage?

A

SAME DAY hospital assessment

Does the patient have SAH or another secondary cause

CT brain (3% negative at 12 hrs, 7% negative at 24 hrs)

LP (must be done >12hrs after headache onset)

CT +/- LP is unreliable beyond 2 weeks and angiography is required beyond this time

79
Q

____ infection should be considered in any patient presenting with headache and fever

A

CNS

e.g. Meningitis and Encephalitis

80
Q

What would be seen in a patient with Meningism?

A

nausea +/- vomiting, photo/phono phobia, stiff neck

81
Q

What would be seen in a patient with encephalitis?

A

altered mental state/consciousness, focal symptoms/signs, seizures

82
Q

What should you look for in patients with suspected meningitism

A

a rash

83
Q

Raised ______ pressure, due to many reasons, may also be the cause of headache

A

intracranial

84
Q

What is papilloedema?

A

optic disc swelling that is caused by increased intracranial pressure due to any cause

the swelling is usually bilateral and can occur over a period of hours to week

85
Q

What are features suggestive of a space occupying lesion and/or raised intracranial pressure?

A

Progressive headache with associated symptoms and signs - headache is a common 1st presenting feature, but other symptoms and signs are usually present

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

86
Q

What is intracranial hypotension due to?

A

Dural CSF leak

Spontaneous or iatrogenic (post lumbar puncture)

87
Q

What would be the trigger of intracranial hypotension?

A

Clear postural component to the headache

Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down

Once the headache becomes chronic it often loses its postural component

88
Q

What investigations would be used for intracranial hypotension?

A

MRI brain and spine

89
Q

What is the treatment for intacranial hypotension?

A

Bed rest, fluids, analgesia, caffeine (e.g. 1 can red bull qds)

i.v. caffeine

Epidural blood patch - a surgical procedure that uses autologous blood in order to close one or many holes in the dura mater of the spinal cord, usually as a result of a previous lumbar puncture

90
Q

What is giant cell arteritis?

A

Arteritis of large arteries (on spectrum with polymyalgia rheumatica)

Should be considered in any patient over the age of 50 years presenting with new headache

an inflammatory disease affecting the large blood vessels of the scalp, neck and arms. Inflammation causes a narrowing or blockage of the blood vessels, which interrupts blood flow. The disease is commonly associated with polymyalgia rheumatica

91
Q

What are the symptoms of giant cell arteritis?

A

Headache is usually diffuse, persistent and may be severe

The patient may be systemically unwell

Specific features include scalp tenderness, jaw claudication and visual disturbance

Prominent, beaded or enlarged temporal arteries may be present

92
Q

What is the diagnosis and management of giant cell arteritis?

A

An elevated ESR supports the diagnosis (usually >50, often much higher, rarely normal)

Raised CRP and platelet count are other useful markers

If the diagnosis is considered likely high dose prednisolone should be started and a temporal artery biopsy arranged

year 2 neuro - Robbie (48 decks)

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