Headache Flashcards
What are the 2 types of headache?
primary
secondary
What is a primary headache?
no underlying medical cause
what are some exaples of a primary headahce?
Tension Type Headache
Migraine
Cluster Headache
What is a secondary headache
has an identifiable structural or biochemical cause
something has happened and you get a headache because of that
what are some exaples of secondary headaches
Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced
Are primary or secondary headaches more common?
90% of headaches are primary headaches
What is the most frequent type of primary headache?
tension-type headache
Is a tension-type headache disabeling?
no and rarley presents to doctors
What is the prevelence of tension-type headache?
Lifetime prevalence of 42% in men and 49% in women
What are the symptoms of a 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
bilateral pressing
How is a tension-type headache differentiated form being infrequent, frequent and chronic?
What are the 2 different types of treatment used for TTH?
abortive and preventative
What are some abortive TTH treatments?
Aspirin or paracetamol
NSAIDs
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
What are some preventative TTH treatments?
Rarely required
Tricyclic antidepressants
amitriptyline, dothiepin, nortriptyline
What is the most frequent disabeling primary headache?
migraine
WHat is the epidemiology of migraine?
6 million people in the UK
Lifetime prevalence: 10% in men and 22% in women
Most sufferers aged 20 to 50
What is migraine?
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
What is experieenced during a migraine attack?
Headache
Nausea, photophobia, phonophobia
Functional disability
What is experienced inbetween anxiety attacks?
Enduring predisposition to future attacks
Anticipatory anxiety
What are migraine triggers?
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
A migraine attack prgoresses through various stages
what are the stages?
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
What is aura?
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
How long does aura last?
15-60 minutes
What can aura be confused with? and what are the differences?
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
What is a chronic migraine?
Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months
Transformed migraine may be the cause for chronic migraine, what is transformed migraine?
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
What is the cause of a transformed migraine and what makes it better?
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
What is a medication overuse headache?
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
What are the 2 different types of migraine treatments?
abortive treatment
prophylactic treatment
What are some abortive migraine treatments?
Aspirin or NSAIDs
Triptans
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
What are some prophylactice migraine treatments?
Propranolol, Candesartan
Anti-epileptics - Topiramate, Gabapentin
Tricyclic antidepressants - amitriptyline, dothiepin, nortriptyline
Venlafaxine
What are some specific issues to do with migraine seen in women?
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
What are Trigeminal Autonomic Cephalalgias (TACs)?
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
What are some exaples of Trigeminal Autonomic Cephalalgias?
cluster headache
paroxysmal hemicrania
SUNCT
What is a cluster headache?
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
What pain is experienced during a cluster headache?
mainly orbital and temporal
Excruciatingly severe (“suicide headache”)
Patients are restless and agitated during an attack
Prominent ipsilateral autonomic symptoms
Are cluster headache attacks unilateral or bilateral?
strickly unillateral
How long do cluster headache attacks last?
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
What migrainous symptoms present often present during a cluster headache attack?
Premonitory symptoms: tiredness, yawning
Associated symptoms: nausea, vomiting, photophobia, phonophobia
Typical aura (often under recognised)
Is a cluster headache attack or a migraine longer
migraine as much longer
Are cluster headaches episodic or chronic?
Episodic in 80-90%
10-20% have chronic cluster
Describe the bout of episodic cluster headache
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
What is the striking circadian rhythmicity of cluster headache?
attacks occur at the same time each day
bouts occur at the same time each year
What are the bouts and temission like in chronic cluster headaches?
Bouts last >1 year without remission or
Remissions last <1 month
What are the different types of treatment for cluster headaches?
abortive (headache)
abortive (headache bout)
preventative
What is Paroxysmal Hemicrania?
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
What pain is experienced in Paroxysmal Hemicrania?
mainly orbital and temporal
Excruciatingly severe
50% are restless and agitated during an attack
Background continuous pain can be present
Are attacks of Paroxysmal Hemicrania bilateral or unilateral?
unilateral
How long are attacks of Paroxysmal Hemicrania?
Rapid onset
Duration: 2-30 mins
Rapid cessation of pain
What other symptoms may be present in a Paroxysmal Hemicrania attack?
Prominent ipsilateral autonomic symptoms
Migrainous symptoms may be present
Is Paroxysmal Hemicrania chronic or episodic?
80% have chronic PH
20% have episodic PH
How frequent are attacks of paroxysmal hemicrania and is there a cricadian rhythm?
2-40 attacks per day
no circadian rhythm
What is the treatment of Paroxysmal Hemicrania?
No abortive treatment
Prophylaxis with indometacin
Alternatives – COX-II inhibitors, Topiramate
What is SUNCT?
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
Where is pain felt in SUNCT?
Unilateral orbital, supraorbital or temporal pain
WHat type of pain is experienced in SUNCT?
Stabbing or pulsating pain
What is the duration of a SUNCT attack?
10-240 seconds duration
What are the cutaneous triggers of a SUNCT attack?
Wind, cold
Touch
Chewing
How often do SUNCT attacks occur?
Attack frequency from 3-200/day, no refractory period
What is the treatment of SUNCT?
- No abortive treatment
- Prophylaxis:
Lamotrigine
Topiramate
Gabapentin
Carbamazepine/Oxcarbazepine
What is Trigeminal Neuralgia?
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
What pain is felt in Trigeminal Neuralgia?
Unilateral maxillary or mandibular division pain > ophthalmic division
Stabbing pain
What is the duration of Trigeminal Neuralgia?
5 - 10 seconds duration
What are the cutaneous triggers of Trigeminal Neuralgia?
Wind, cold
Touch
Chewing
How frequent are attacks of Trigeminal Neuralgia?
Attack frequency similar to SUNCT (3-200/day), has a refractory period
Are autonomic features common in trigeminal neuralgia?
Autonomic features are uncommon
What is the treatment of trigeminal neuralgia
- No abortive treatment
- Prophylaxis:
Carbamazepine
Oxcarbazepine
• Surgical intervention:
Glycerol ganglion injection
Steriotactic radiosurgery
Decompressive surgery
Onto secondary headache now
Serious intracranial pathology is very unlikely in longstanding _______ headache
Serious intracranial pathology is very unlikely in longstanding episodic headache
What presentations are more likely to have a sinister cause?
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 to look out for?
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
What is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than 1 minute
Majority peak instantaneously
Is a thunderclap headache a primary or seconday headache?
May be primary or secondary - no reliable differentiating features!
What are some differential diagnosis of thunderclap headache?
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
1 in 10 patients with thunderclap headache will have a ___________
subarachnoid haemorrhage
What is the prognosis of a subarachnoid haemorrhage?
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!
Who may have 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
How do you determine if someone has a subarachnoid haemorrhage?
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
____ infection should be considered in any patient presenting with headache and fever
CNS
e.g. Meningitis and Encephalitis
What would be seen in a patient with Meningism?
nausea +/- vomiting, photo/phono phobia, stiff neck
What would be seen in a patient with encephalitis?
altered mental state/consciousness, focal symptoms/signs, seizures
What should you look for in patients with suspected meningitism
a rash
Raised ______ pressure, due to many reasons, may also be the cause of headache
intracranial
What is papilloedema?
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
What are features suggestive of a space occupying lesion and/or raised intracranial pressure?
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
What is intracranial hypotension due to?
Dural CSF leak
Spontaneous or iatrogenic (post lumbar puncture)
What would be the trigger of intracranial hypotension?
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
What investigations would be used for intracranial hypotension?
MRI brain and spine
What is the treatment for intacranial hypotension?
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
What is giant cell arteritis?
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
What are the symptoms of giant cell arteritis?
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
What is the diagnosis and management of giant cell arteritis?
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
