Headache Flashcards
What are the subclassifications of primary headache?
Migraine
Trigeminal autonomic cephalgias
What are the subclassifications of secondary headache?
Thunderclap headaches High pressure headaches Low pressure Headache Neuralgias
For each headache type which a patient presents with, what questions are important to ask in the history?
Age of onset Chronic headache or episodic Premonitory symptoms Onset - time to peak of headache Progression Location Character Intensity Precipitating factors Exacerbating or relieving factors Associated symptoms How the patient behaves during an attack
What factors are important to ask about when taking a social history from a patient presenting with headache?
Sleep pattern/disturbance Meals Exercise Caffeine Illicit drugs Alcohol Gas appliances
What examinations/investigations should always be done for a patient presenting with headache?
Blood pressure
Fundi examination and assessment for papilloedema
Facial sensation
Cranial and routine neurological examination
In addition to standard examinations and investigations, what further examinations should be conducted when the cause of headache is uncertain or a secondary headache is suspected?
Urine dipstick, pregnancy test, temperature, weight, GCS, mental status examination
Palpation of skull, neck, greater occipital nerves, temporal. arteries and nuchal rigidity
Examination of skin, cervical lymph nodes and tympanic membrane
Examination of visual acuity, visual fields and spontaneous venous pulsation
In addition to standard examinations and investigations, what further investigations should be conducted when the cause of headache is uncertain or a secondary headache is suspected?
ECG Urinalysis Bloods - ESR, CRO, FBC, U&Es, TFTs CT/MRU brain Lumbar puncture CT/ MRI angio/veno gram
Which patients presenting with headache should undergo further investigation?
Systemic symptoms Secondary risk factors Seizures Neurological symptoms Older patients Papilloedema Precipitated by cough, exertion, sleep and valsalva Change in nature of headache Systemic symptoms of signs Focal neurological deficit
What are the diagnostic criteria for a tension type headache?
At least 10 episodes occurring on <1 day a month
Lasts 30mins to 7 days
No nausea or vomiting
No more than one of photophobia or phonophobia
At least two of: bilateral location, pressing or tightening quality, mild or moderate intensity, not aggravated by routine physical activity
Which gene is associated with migraines?
Calcitonin gene related peptide
What is the cause of migraines?
Interaction between primary afferent nociceptive neurone, trigemiovascular system, brainstem, thalamus, hypothalamus and cortex
What are the diagnostic criteria for migraines?
At least 5 attacks which fulfilled other criteria
Headache attacks lasting 4-72 hours
Headache results in at least on of nausea/vomtiing or photobobia/phonophobia
Headache has at least two of: unilateral location, pulsating quality, moderate or severe pain and aggravation by causing avoidance of routine physical activity
Aura are usually visual. T/F?
True
What symptoms might a patient experience in the prodrome phase of a migraine?
Yawning Polyuria Depression Irritability Food cravings Poor concentration Sensitivity to light and sound Poor sleep
How long do aura last for in migraine?
5-60 minutes
What symptoms might a patient experience in the postdrome phase of a migraine?
Depression
Euphoria
Poor concentration
Fatigue
What analgesics should never be used in migraines?
Opiates
When should prophylaxis be used for patients with migraine?
If they are >4 disabling headaches per month
What analgesics can be used to treat migraine?
Ibuprofen and paracetamol
Triptans
What medications can be used as prophylaxis in migraine?
Propranolol Topiramate Amitriptyline Candesartan Flunarazine
What dose of propranolol can be given as prophylaxis in migraine?
start 20mg bd, target 80mg bd
What dose of topiramate can be given as prophylaxis in migraine?
Start 15 or 25 mg daily, target 50mg bd
What dose of amitriptyline can be given as prophylaxis in migraine?
Start 10mg, target 50mg
What dose of candesartan can be given as prophylaxis in migraine?
Start 4mg, target 16mg
What dose of flunarazine can be given as prophylaxis in migraine?
10mg
If prophylaxis is not effective in migraine, what other drugs can be used?
Onabotulinumtoxin A CGRP inhibitors (erenumab)
What are the diagnostic criteria for cluster headache?
At least five attacks which fulfilled other criteroa
Severe or very severe unilateral. orbital, supraorbital and/or temporal pain lasting 15-180 mins
Either of both of a sense of restlessness or agitation and one of the following signs, ipsilateral to the headache: conjunctival injection/lacrimation, nasal congestion/lacrimation, eyelid oedema, forehead and facial sweating/fludhing, sensation of fullness in ear, mitosis, ptosis
Occurring with a frequency between one every other day and 8 a day.
What will exacerbate and alleviate a raised pressure headahce?
Worse when lying flat, in the morning, with physical exertion, with valsalva
Improve on standing or sitting
What associated symptoms are there is raised pressure headaches?
Nausea and vomiting
Transient visual obscurations with a change in posture
What examination findings will be present in a raised pressure headache?
Papilloedema (optic disc swelling) Impaired visual acuity / colour vision restricted visual. fields / enlarged blind spot 3rd nerve palsy 7th nerve palsy Focal neurological signs
Describe the presentation of a thunderclap headache?
‘First and worst’ headache
Severe headache with sudden onset
Typically peaks within one minute but can peak around 5 minutes. Duration greater than one hour
How should a thunderclap headache be investigated?
CT
Lumbar puncture
If both are negative then an MRI, MRI/CT angio/venogram
What are the possible causes of thunderclap headache?
Subarachnoid haemorrhage Intracerebral haemorrhage Arterial dissection Cerebral venous sinus thrombosis Ischaemic stroke Bacterial meningitis Spontaneous intracranial hypotension Pituitary apoplexy
What causes low pressure headache?
CSF leakage causing traction on the meninges, cerebral/cerebellar veins and CN V/IV/X as a result of lumbar puncture or intracranial hypotension
What will exacerbate and alleviate low pressure headaches?
Worse on sitting/standing
Relieved by lying down
