Headache Flashcards
Name the different types of headache syndromes:
- primary headache syndromes? [4]
- secondary headache syndromes? [4]
- Primary Headache Syndromes
- migraine
- trigeminal autonomic cephalgia
- tension headaches
- cluster headaches
- Secondary Headache Syndromes
- thunderclap headache
- high pressure headache
- low pressure headache
- neuralgias
What history of presenting compliant questions should be asked to a patient coming in with a headache? [11]
- Age of onset
-
Pattern:
- chronic headache,
- episodic (define pattern)
- constant/recurrent
-
Onset — time to peak:
- thunderclap or gradual onset
-
Progression/Periodicity:
- frequency/duration
- is the patient headache-free between attacks?
-
Location:
- facial/retro-orbital/frontal/occipital/parietal
- unilateral/bilateral
- radiation of pain
-
Character: Aura
- typically reversible visual, sensory or language symptoms
-
Intensity:
- use visual analogue scale 0-10
-
Precipitating factors:
- what were they doing when they got the headache?
-
Exacerbating or relieving factors:
- (features of high or low pressure)
-
Associated symptoms:
- nausea/vomiting
- photophobia (fear of light)
- phonophobia (fear of sound)
- Concerns about headaches: what do they think it is?
What other questions should be asked to a patient coming in with a headache?
- PMHx? [9]
- DH? [2]
- FM? [2]
- SH? [6]
- Others? [3]
- PMH
- Immunosuppression
- Cancer
- Foreign travel
- Cardiac, cerebrovascular renal, hepatic, psychiatric, gastric disease
- DH
- Medications that cause HA
- Drug-drug interactions for potential therapy
- FM
- Migraine
- Tumour
- SH
- Sleep
- Meals
- Exercise
- Caffeine
- Illicit drugs, alcohol (falls??)
- Gas appliances
- Others
- impact
- concerns
- expectations
What examinations should you carry out on a patient with a headache? [9]
- Blood pressure, urine dipstick, pregnancy test, temperature, weight
- GCS, mental status examination
- Palpation — skull, neck, greater occipital nerves, TMJ, temporal arteries, nuchal rigidity?
- Eyes
- Acuity, visual fields, (blind spot), fundi, assessment for papilloedema and spontaneous venous pulsation, movements
- Presence or absence of Horner’s 3rd, 6th nerve palsies
- Facial sensation
- Autonomic features if during an attack
- Cranial nerves, routine neurological examination
- Skin exam (rashes), cervical lymphadenopathy, tympanic examination
What investigations should you do on a patient with a headache? [8]
(depends on circumstance)
- Blood pressure
- ECG
- Urinalysis
- Bloods (e.g. ESR, CRP, FBC, UEs, thyroid function)
- CT Brain/MRI Brain
- Lumbar puncture (opening pressure, blood products, other constituents)
- CT angiogram/MR angiogram
- CT venogram/MRI venogram
Which headache patients should you do imaging on? [9]
- Systemic symptoms
- Secondary risk factors
- Seizures
- Neurological symptoms/Focal neurological deficit
- Depending on onset and progression (incl. change in attack frequency, nature)
- Older
- Presence of papilloedema
- Precipitated by cough, exertion, sleep, valsalva
- Change in nature of headache (or new headache)
What is the diagnostic criteria for a tension type headache? [8]
- At least 10 episodes of headache occurring on <1 day/month on average (<12 days/year) and fulfilling criteria B-D (2-4)
- Lasting from 30 minutes to 7 days
- At least two of the following four characteristics:
- bilateral location
- pressing or tightening (non-pulsating) quality
- mild or moderate intensity
- not aggravated by routine physical activity such as walking or climbing stairs
- Both of the following:
- no nausea or vomiting
- no more than one of photophobia or phonophobia
Describe the basic pathophysiology of a migraine [3]
- Interaction between primary afferent nociceptive neurons/trigeminovascular system/brainstem/thalamus/hypothalamus/cortex - i.e. brain disorder
- Calcitonin gene related peptide (CGRP)
- NOT a primary vascular problem
What is the ICHD-3 diagnostic criteria for a migraine? [8]
- At least five attacks fulfilling criteria B-D
- Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated)
- Headache has at least two of the following four characteristics:
- unilateral location
- pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
- During headache at least one of the following:
- nausea and/or vomiting
- photophobia and phonophobia
What are the 4 phases of a migraine? [4]
- Prodrome
- Aura
- Headache
- Postdrome
Prodrome phase of a migraine:
- when does it occur? [1]
- what are the symptoms? [8]
- Occurs hours-days before the headache
- Symptoms:
- Yawning
- Polyuria
- Depression
- Irritability
- Food cravings
- Poor concentration
- Sensitivity to light and sound
- Poor sleep
Aura phase of a migraine:
- when does it occur? [1]
- visual disturbance symptoms? [3]
- somatosensory symptoms? [2]
- motor symptoms? [4]
- speech/language symptoms? [2]
- Occurs 5-60mins before the headache
- Visual disturbance symptoms:
- chaotic distorting
- “melting”
- jumbling of lines, dots, or zigzags, scotomata
- hemianopia
- Somatosensory symptoms:
- paraesthesia, spreading from fingers to face
- Motor symptoms:
- dysarthria
- ataxia
- ophthalmoplegia
- hemiparesis
- Speech/Language:
- dysphasia
- paraphasia
Headache phase of a migraine:
- how long does it last? [1]
- symptoms? [5]
- Lasts 4-72 hours
- Symptoms:
- throbbing headache
- nausea
- vomiting
- photophobia
- worse with activity
Postdrome phase of a migraine:
- how long does it last? [1]
- symptoms? [4]
- Lasts 24-48hrs after headache
- Symptoms:
- depression
- euphoria
- poor concentration
- fatigue
What is the acute treatment of a migraine? [3]
- Restrict acute medication to 2 days a week:
- Simple analgesics: aspirin or ibuprofen
- Triptans
- Sumatriptan
- Only work once headache starts
- General efficacy is to work for 2 out of 3 attacks