Headache Flashcards
1
Q
What are 2 dangerous causes of headache to rule out?
A
- Subarachnoid haemorrhage
- Meningitis
(contrary to popular belief, brain tumours rarely present with headache only)
2
Q
What are 6 types of benign headaches?
A
- Tension
- Migraine
- Cluster
- Medication overuse
- Post-traumatic
- Trigeminal neuralgia
3
Q
What are 3 features of headaches due to raised intracranial pressure?
A
- Worse in morning
- Associated with vomiting
- Increase with coughing
4
Q
What are 2 examples of serious (but less dangerous) causes of headache?
A
- Idiopathic intracranial hypertension
- Giant cell arteritis
5
Q
In clinical practice, what type of headache is commonly associated with vomiting, worse in mornings and on coughing?
A
Migraine rather than raised ICP
6
Q
What is frequently the character of headaches caused by raised ICP?
A
- New onset, mild and short-lived featureless headaches
- Focal symptoms and signs may or may not be present
7
Q
What is the diagnosis of benign headaches based on?
A
good history taking; examination and scnas rarely help apart from reassuring patient and doctor
8
Q
What is the most common type of headache?
A
Tension headache
9
Q
What is the usual time frame of tension headaches?
A
Daily
10
Q
How do patients typically describe the pain from tension headaches?
A
Generalised, tight band around the head / head feels like it’s in a vice
Pain in neck, upper back, ears and jaw
11
Q
What are 4 additional places the pain may be present in tension headaches?
A
Neck, upper back, ears, jaw
12
Q
What diagnosis may underlie tension headaches?
A
Anxiety or depression
13
Q
What are 6 negative symptoms in tension headaches that may be associated with other causes of headache?
A
- no GI symptoms
- no visual symptoms
- headache doesn’t interfere with sleep
- no aura
- no nausea/ vomiting
- not aggravated by routine physical activity
14
Q
What investigations may be involved in the workup for tension headache?
A
No brain scan indicated but increasingly used for reassurance
15
Q
What are 2 prophylactic treatments against tension-type headaches?
A
- Low-dose amitriptyline (not supported by NICE)
- Up to 10 sessions of acupuncture of 5-8 weeks (NICE)
16
Q
Which groups of people are migraines common?
A
Women and young people
17
Q
What is the typical time frame of migraines?
A
Episodic, usually lasts from several hours to 3 days
18
Q
What is the character of the headache caused by migraine?
A
Unilateral throbbing (thumping, pulsatile, brain moving inside skull)
19
Q
What may precede a migraine and over what time frame?
A
aura - can last for 20-30 minutes
20
Q
What are 4 types of aura that can precede migraine? What may each involve?
A
- Visual aura: flashing lights or zig zag lines, most common
- Sensory: paraesthesia in the hand spreading upwards to involve lips and tongue
- Motor: unilateral weakness
- Speech: dysphasia
21
Q
What are 7 features associated with migraine headaches?
A
- Pain behind eye
- Headache worse with movement
- Nausea and vomiting
- Photophobia
- Phonophobia
- Sleep helps to relieve
- Menstruation common trigger
22
Q
How common are specific triggers for migraine e.g. eating cheese?
A
Not common in clinical practice (contrary to public belief)
23
Q
What explanations/ reassurance can you give to a patient diagnosed with migraines?
A
Full explanation of diagnosis and different treatment strategies; reassure nothing sinister causing headache
24
Q
What investigations are indicated for migraine?
A
brain scan NOT indicated in majority of cases (but increasingly used for reassurance)
25
What are 3 approaches to the treatment of migraine?
1. Avoiding triggers
2. Treating acute attacks
3. Preventative treatment - if \>2 per month
26
When should preventative treatment be considered for migraines?
If patients experince more than 2 migraines a month
27
What are 3 elements of treating acute migraine attacks?
1. Simple analgesia such as paracetamol or aspirin
2. Simple analgesia combined with antiemetics, such as **Migraleve**
3. **Triptans** (5HT1 agonists) available as tablets, nasal spray and subcutaneous injections
28
In what 3 forms do triptans exist to treat acute migraine attacks?
1. Tablets
2. Nasal spray
3. Subcutaneous injections
29
What are 5 options for preventative treatment of migraine?
1. Propranolol
2. Amitriptyline
3. Pizotifen
4. Topiramate
5. Botox injection - in certain patients with difficult migraine
30
What kind of time course does a medication overuse headache usually follow?
Chronic daily headache
31
What is the typical character of medication overuse headache?
Dull or throbbing
32
What is the cause of a medication overuse headache?
Taking analgesia (especially those containing **_codeine_**) almost on a daily basis to treat **tension** or **migraine** headache.
Headache is transiently relieved by analgesia
33
What is the treatment of medication overuse headaches?
* **explain** to the patient the harmful effects of overusing analgesia
* preventative treatment for the headache such as **_amitriptyline_** should be introduced
* **analgesia stopped** gradually or abruptly
34
What group of people are predominantly affected by cluster headaches?
* Men, young to middle aged
* Smokers
35
What is the typical time frame/ pattern of cluster headaches?
* Occurs in clusters, once or twice daily, for 4-8 weeks, once every year or two
* Lasts for 30 min to 2 hours, mainly at night or early hours of morning
* typically occur at same time every day e.g. 1am
36
What is the character of cluster headaches?
* Severely painful headache, supposedly worst headache
* Unilateral excruciating pain around the eye
37
What are 4 symptoms associated with cluster headaches?
1. Very agitated, walking up and down
2. Banging head on wall due to pain
3. Watering and redness of eye and nasal blockage (autonomic features)
4. Can occasionally develop Horner's syndrome
38
What are 2 ways to treat acute attacks of cluster headaches?
1. Sumatriptan - subcutaneous injection (5HT1 agonist)
2. High flow 100% oxygen
39
How should preventative treatment be given in cluster headaches?
Give it until the cluster is over (i.e. for the 4-8 weeks when the headaches are occurring)
40
What are 4 options for preventative treatment of cluster headaches?
1. **_Verapamil_ - drug of choice**
2. Pizotifen
3. Topiramate
4. Steroids - tapering dose of prednisolone
41
What age group is usually affected by trigeminal neuralgia?
People above age 40 years
42
What is thought to be the cause of trigeminal neuralgia?
Not clear - perhaps caused by irritation of 5th nerve by an ectatic (dilated) blood vessel that hooks around the root of the 5th nerve (basis of one of the surgical treatments of trigeminal neuralgia)
43
What should you always consider in younger patients who have trigeminal neuralgia?
Could it be a complication of multiple sclerosis
44
What is the character of the pain in trigeminal neuralgia?
Unilateral, severe pain lasting for seconds (like electric shock or needle stabs)
over area supplied by one of the branches of the 5th nerve, usually the maxillary of mandibular
45
What is the time frame of headaches caused by trigeminal neuralgia?
Patient can have several attacks a day, may complain of dull aches between the episodes
46
What is usually the first choice treatment of trigeminal neuralgia?
Carbamazepine
47
In addition to carbamazepine, what are 3 other drugs that can also be used to treat trigeminal neuralgia?
1. Phenytoin
2. Lamotrigine
3. Gabapentin
48
If medical treatment does not work to treat trigeminal neuralgia what are 2 further options for treatment?
Surgical treatment: **glycerol injection** of 5th nerve, and if this fails, **microvascular decompression** of ectactic blood vessel at root (can be demonstrated by MRI brain)
49
Over what time frame might patients experience a post-traumatic headache?
Following any type of head injury (including minor) may occur for weeks or months after
Usually starts within 2 weeks of the injury
50
What could the headache following head trauma be part of?
Post-traumatic (concussion) syndrome: other symptoms such as lack of concentration, poor memory and dizziness
51
What investigations may be needed for post-traumatic headache?
May need reassurance with a brain scan
52
What is widely used as the treatment for post-traumatic headaches?
Amitriptyline
53
What is the typical patient who suffers from idiopathic intracranial hypertension?
Obese young woman
54
What is the typical presentation of IIH?
Blurred vision and headache
55
What 4 examinations should be performed in suspected IIH and why?
* **Fundoscopy**: will show ***_bilateral papilloedema_***
* **CT brain** to exclude brain tumour as cause of papilloema
* **MRV or CTV** to check no cerebral venous sinus thrombosis
* **CSF**: will show high CSF pressure but normal constituents
56
Over what time frame should IIH be treated and why?
Treatment should be **_prompt_** to avoid ***permanent loss of vision*** due to _infarction fo the optic nerve_ (10% of patients can go blind)
57
What is the management of IIH? 4 aspects
1. Full and regular **visual assessment** including visual fields
2. **_Weight loss = main treatment_**
3. Diuretics such as **_acetazolamide_** (no clear evidence it works)
4. If vision deteriorates, neurosurgical intervention: **_lumboperitoneal shunting aka IPS_**
58
What age group is affected by giant cell (temporal) arteritis?
Elderly people, typically \>60 years
59
What is the typical presentation of patients with GCA?
* Pain and tenderness on temple
* Difficulty brushing hair, jaw claudication
* Weight loss, malaise, myalgias, pyrexia of unknown origin
60
What will examination show in GCA?
Tenderness around temple, **lack of pulsation** of temporal artery, **palpable** artery
61
What are the 2 investigations of choice in GCA?
1. ESR: usually \>60
2. Temporal artery biopsy
62
What is the treatment for GCA?
* **_Immediate_** treatment with **oral steroids** to avoid permanent loss of vision due to infarction of optic nerve (before biopsy result)
* (Headache settling within a day of starting treatment is diagnostic)
* Maintenance dose of steroid normally needed for some years
63
With what disease is GCA associated and in what proprtion of patients is it present?
Polymyalgia rheumatica: 50% of GCA patients also have PR
64
What is the typical time frame of development of GCA?
Rapid onset (\< 1 month)
65
What are 7 possible causes of acute single episode headaches?
1. Meningitis
2. Encephalitis
3. Subarachnoid haemorrhage
4. Tropical illness e.g. malaria
5. Acute angle-closure glaucoma
6. Sinusitis
7. Head injury
66
What is meant by the term trigeminal autonomic cephalgia? What are 3 examples of things it encompasses?
* Group of conditions including:
1. cluster headache
2. paroxysmal hemicrania
3. short-lived unilateral neuralgiform headache with conjunctival injection and tear (SUNCT)
67
What is the recommended management of trigeminal autonomic cephalgias?
Referral for specialist assessment as specific treatment may be required, e.g. paroxysmal hemicrania responds very well to indomethacin (NSAID)
68
What is the trend in genders being affected by headache in children?
Equal between boys and girls until puberty then strong (3:1) female preponderance
69
What is the most common cause of primary headache in children?
Migraine without aura
70
What are 4 criteria for paediatric migraine **without** aura?
1. A: **\>=5** attacks fulfilling features B to D
2. B: Headache attack lasting **4-72 hours**
3. C: Headache has at least 2 of the following 4 features:
1. bilateral or unilateral (frontal/temporal) **location**
2. **pulsating** quality
3. moderate to severe **intensity**
4. aggravated by routine physical **activity**
4. At least one of the following accompanies headache:
1. nausea and/or vomiting
2. photophobia and phonophobia (may be inferred from behaviour)
71
What is teh acute management of migraine without aura in children? 3 features
* **_Ibuprofen_** - more effective than paracetamol for paediatric migraine
* **_Triptans_** may be used in **children \>= 12** years but follow up required (not licensed \<18)
* **_Sumatriptan nasal spray_** (licensed) is only triptan with proven efficacy. Poorly tolerated by young people who don't like the taste in the back fo the throat
72
What is the suggested prophylaxis for migraine without aura in children?
First line: **Pizotifen** and **propranol**
Second line: **valproate, topiramate, amitryptiline**
73
What is the second most common cause of headache in children?
Tension-type headache
74
What are the 4 IHS (International Headache Society) criteria for tension type headache in children?
1. A: at least **10 previous headache episodes** fulfilling features B to D
2. B: headache lasting from **30 minutes to 7 days**
3. C: At least two of following pain characeristics:
1. **pressing/tightening (non-pulsating) quality**
2. **mild or moderate intensity (may inhibit but does not prohibit activity)**
3. **Bilateral location**
4. **No aggravation by routine physical activity**
4. D: Both of the following:
1. **no nausea or vomiting**
2. **photophobia and phonophobia,** or one, but not the other is present
75
What are 15 red flags in headache?
1. Compromised immunity e.g. HIV or immunosuppresive drugs
2. Age under 20 years and **history of malignancy** - brain mets
3. Malignancy known to **metastasise to brain** - brain mets
4. **Vomiting** without other obvious cause - raised ICH
5. **Worsening** headache with **fever** - meningitis
6. Sudden-onset headache reaching **maximum intensity within 5 minutes** - thunderclap, SAH
7. New-onset **neurological deficit**
8. New-onset **cognitive** dysfunction
9. Change in **personality**
10. Impaired level of **consciousness**
11. Recent (typically within past 3 months) head **trauma**
12. Headache triggered by **cough, valsalva** (trying to breathe out with nose and mouth blocked), **sneeze** or **exercise**
13. **Orthostatic** headache (changes with posture)
14. **GCA** symptoms or acute-narrow angle **glaucoma**
15. Substantial change in characteristics of headache
76
What is the gender ratio of cluster headache sufferers?
Male : female 3:1
77
What eye signs might be present in a minority of patients with cluster headaches?
Miosis and ptosis
78
What is the response rate to 100% oxygen as a treatment for cluster headaches?
80% response rate within 15 minutes
79
What is the response rate to subcutaneous triptan to treat an acute cluster headache?
75% response rate within 15 minutes
80
Should you seek specialist advice for cluster headaches? What for?
Yes - with respect to neuroimaging
81
What is tension type headache a form of?
Episodic primary headache
82
What defines a chronic tension-type headache?
Tension headaches that occurs on 15 or more days per month
83
In what proportion of patients undergoing lumbar puncture does headache occur?
1/3
84
What is thought to be the pathophysiology of post-lumbar puncture headache?
Pathophysiology unclear, may relate to 'leak' of CSF following dural puncture
85
In what group of patients is post-lumbar puncture headache most common?
young females with low body mass index
86
What is the typical time frame of a post-lumbar puncture headache?
Develops within 24-48 following LP but may occur up to one week later
May last several days
87
What exacerbates/ improves post-lumbar puncture headache?
Worse when upright, improves in recumbent position
88
What are 4 factors that increase the likelihood of a post-lumbar puncture headache?
1. Increased needle size
2. Direction of bevel
3. Not replacing the stylet
4. Increased number of LP attempts
89
What are 5 features that reduce likelihood of post-lumbar puncture headache?
1. Increased volume of CSF
2. Bed rest following procedure
3. Increased fluid intake post-procedure
4. Opening pressure of CSF
5. Position of patient
90
What is the initial treatment for post-lumbar puncture headache and what should be done if it does not improve?
* Supportive initially: analgesia, rest
* If continues for \>72 hours: specific treatment to prevent subdural haematoma
* blood patch, epidural saline, IV caffeine
91
When should specific treatment be pursued for post-lumbar puncture headache and why?
If pain continues for logner than 72 hours, to prevent subdural haematoma
92
What are 3 treatment options for a post-lumbar puncture headache lasting \>72 hours?
1. Blood patch
2. Epidural saline
3. IV caffeine
93
What are 2 examples of the typical visual auras that occur before a migraine?
1. transient hemianopic disturbance
2. spreading scintillating scotoma
94
What is the prevalence of migraine in a) men and b) women?
a) 6%
b) 18%
95
What are 7 common triggers for migraine attacks?
1. Tiredness, stress
2. Alcohol
3. COCP
4. Lack of food or dehydration
5. Cheese, chocolate, red wines, citrus fruits
6. Menstruation
7. Bright lights
96
What are the 5 diagnostic criteria for migraines?
1. A: at least 5 attacks fulfilling criteria B-D
2. B: Headache attacks lasting 4-72 hours (untreated or successfully treated)
3. C: headache has at least 2 of the following:
1. unilateral location
2. pulsating quality - varying with heartbeat
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity e.g. walking, climbing stairs
4. D: During headache at least one of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
5. E: Not attributed to another disorder - based on history, exam, appropraite investigations, don't occur for first time in close temporal relation to other disorder
97
What are 3 ways that migraines in children differ from those in adults?
1. may be shorter lasting in children
2. headache more commonly bilateral in children
3. GI disurbance more prominent in children
98
what is another way to describe the spreading scintillating scotoma?
Jagged crescent
