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Headache Flashcards

1
Q

What are 2 dangerous causes of headache to rule out?

A
  1. Subarachnoid haemorrhage
  2. Meningitis

(contrary to popular belief, brain tumours rarely present with headache only)

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2
Q

What are 6 types of benign headaches?

A
  1. Tension
  2. Migraine
  3. Cluster
  4. Medication overuse
  5. Post-traumatic
  6. Trigeminal neuralgia
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3
Q

What are 3 features of headaches due to raised intracranial pressure?

A
  1. Worse in morning
  2. Associated with vomiting
  3. Increase with coughing
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4
Q

What are 2 examples of serious (but less dangerous) causes of headache?

A
  1. Idiopathic intracranial hypertension
  2. Giant cell arteritis
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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

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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
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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

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8
Q

What is the most common type of headache?

A

Tension headache

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9
Q

What is the usual time frame of tension headaches?

A

Daily

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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

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11
Q

What are 4 additional places the pain may be present in tension headaches?

A

Neck, upper back, ears, jaw

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12
Q

What diagnosis may underlie tension headaches?

A

Anxiety or depression

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13
Q

What are 6 negative symptoms in tension headaches that may be associated with other causes of headache?

A
  1. no GI symptoms
  2. no visual symptoms
  3. headache doesn’t interfere with sleep
  4. no aura
  5. no nausea/ vomiting
  6. not aggravated by routine physical activity
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14
Q

What investigations may be involved in the workup for tension headache?

A

No brain scan indicated but increasingly used for reassurance

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15
Q

What are 2 prophylactic treatments against tension-type headaches?

A
  1. Low-dose amitriptyline (not supported by NICE)
  2. Up to 10 sessions of acupuncture of 5-8 weeks (NICE)
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16
Q

Which groups of people are migraines common?

A

Women and young people

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17
Q

What is the typical time frame of migraines?

A

Episodic, usually lasts from several hours to 3 days

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18
Q

What is the character of the headache caused by migraine?

A

Unilateral throbbing (thumping, pulsatile, brain moving inside skull)

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19
Q

What may precede a migraine and over what time frame?

A

aura - can last for 20-30 minutes

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20
Q

What are 4 types of aura that can precede migraine? What may each involve?

A
  1. Visual aura: flashing lights or zig zag lines, most common
  2. Sensory: paraesthesia in the hand spreading upwards to involve lips and tongue
  3. Motor: unilateral weakness
  4. Speech: dysphasia
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21
Q

What are 7 features associated with migraine headaches?

A
  1. Pain behind eye
  2. Headache worse with movement
  3. Nausea and vomiting
  4. Photophobia
  5. Phonophobia
  6. Sleep helps to relieve
  7. Menstruation common trigger
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22
Q

How common are specific triggers for migraine e.g. eating cheese?

A

Not common in clinical practice (contrary to public belief)

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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

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24
Q

What investigations are indicated for migraine?

A

brain scan NOT indicated in majority of cases (but increasingly used for reassurance)

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25
Q

What are 3 approaches to the treatment of migraine?

A
  1. Avoiding triggers
  2. Treating acute attacks
  3. Preventative treatment - if >2 per month
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26
Q

When should preventative treatment be considered for migraines?

A

If patients experince more than 2 migraines a month

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27
Q

What are 3 elements of treating acute migraine attacks?

A
  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
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28
Q

In what 3 forms do triptans exist to treat acute migraine attacks?

A
  1. Tablets
  2. Nasal spray
  3. Subcutaneous injections
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29
Q

What are 5 options for preventative treatment of migraine?

A
  1. Propranolol
  2. Amitriptyline
  3. Pizotifen
  4. Topiramate
  5. Botox injection - in certain patients with difficult migraine
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30
Q

What kind of time course does a medication overuse headache usually follow?

A

Chronic daily headache

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31
Q

What is the typical character of medication overuse headache?

A

Dull or throbbing

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32
Q

What is the cause of a medication overuse headache?

A

Taking analgesia (especially those containing codeine) almost on a daily basis to treat tension or migraine headache.

Headache is transiently relieved by analgesia

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33
Q

What is the treatment of medication overuse headaches?

A
  • 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
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34
Q

What group of people are predominantly affected by cluster headaches?

A
  • Men, young to middle aged
  • Smokers
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35
Q

What is the typical time frame/ pattern of cluster headaches?

A
  • 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
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36
Q

What is the character of cluster headaches?

A
  • Severely painful headache, supposedly worst headache
  • Unilateral excruciating pain around the eye
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37
Q

What are 4 symptoms associated with cluster headaches?

A
  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
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38
Q

What are 2 ways to treat acute attacks of cluster headaches?

A
  1. Sumatriptan - subcutaneous injection (5HT1 agonist)
  2. High flow 100% oxygen
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39
Q

How should preventative treatment be given in cluster headaches?

A

Give it until the cluster is over (i.e. for the 4-8 weeks when the headaches are occurring)

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40
Q

What are 4 options for preventative treatment of cluster headaches?

A
  1. Verapamil - drug of choice
  2. Pizotifen
  3. Topiramate
  4. Steroids - tapering dose of prednisolone
41
Q

What age group is usually affected by trigeminal neuralgia?

A

People above age 40 years

42
Q

What is thought to be the cause of trigeminal neuralgia?

A

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
Q

What should you always consider in younger patients who have trigeminal neuralgia?

A

Could it be a complication of multiple sclerosis

44
Q

What is the character of the pain in trigeminal neuralgia?

A

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
Q

What is the time frame of headaches caused by trigeminal neuralgia?

A

Patient can have several attacks a day, may complain of dull aches between the episodes

46
Q

What is usually the first choice treatment of trigeminal neuralgia?

A

Carbamazepine

47
Q

In addition to carbamazepine, what are 3 other drugs that can also be used to treat trigeminal neuralgia?

A
  1. Phenytoin
  2. Lamotrigine
  3. Gabapentin
48
Q

If medical treatment does not work to treat trigeminal neuralgia what are 2 further options for treatment?

A

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
Q

Over what time frame might patients experience a post-traumatic headache?

A

Following any type of head injury (including minor) may occur for weeks or months after

Usually starts within 2 weeks of the injury

50
Q

What could the headache following head trauma be part of?

A

Post-traumatic (concussion) syndrome: other symptoms such as lack of concentration, poor memory and dizziness

51
Q

What investigations may be needed for post-traumatic headache?

A

May need reassurance with a brain scan

52
Q

What is widely used as the treatment for post-traumatic headaches?

A

Amitriptyline

53
Q

What is the typical patient who suffers from idiopathic intracranial hypertension?

A

Obese young woman

54
Q

What is the typical presentation of IIH?

A

Blurred vision and headache

55
Q

What 4 examinations should be performed in suspected IIH and why?

A
  • 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
Q

Over what time frame should IIH be treated and why?

A

Treatment should be prompt to avoid permanent loss of vision due to infarction fo the optic nerve (10% of patients can go blind)

57
Q

What is the management of IIH? 4 aspects

A
  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
Q

What age group is affected by giant cell (temporal) arteritis?

A

Elderly people, typically >60 years

59
Q

What is the typical presentation of patients with GCA?

A
  • Pain and tenderness on temple
  • Difficulty brushing hair, jaw claudication
  • Weight loss, malaise, myalgias, pyrexia of unknown origin
60
Q

What will examination show in GCA?

A

Tenderness around temple, lack of pulsation of temporal artery, palpable artery

61
Q

What are the 2 investigations of choice in GCA?

A
  1. ESR: usually >60
  2. Temporal artery biopsy
62
Q

What is the treatment for GCA?

A
  • 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
Q

With what disease is GCA associated and in what proprtion of patients is it present?

A

Polymyalgia rheumatica: 50% of GCA patients also have PR

64
Q

What is the typical time frame of development of GCA?

A

Rapid onset (< 1 month)

65
Q

What are 7 possible causes of acute single episode headaches?

A
  1. Meningitis
  2. Encephalitis
  3. Subarachnoid haemorrhage
  4. Tropical illness e.g. malaria
  5. Acute angle-closure glaucoma
  6. Sinusitis
  7. Head injury
66
Q

What is meant by the term trigeminal autonomic cephalgia? What are 3 examples of things it encompasses?

A
  • Group of conditions including:
  1. cluster headache
  2. paroxysmal hemicrania
  3. short-lived unilateral neuralgiform headache with conjunctival injection and tear (SUNCT)
67
Q

What is the recommended management of trigeminal autonomic cephalgias?

A

Referral for specialist assessment as specific treatment may be required, e.g. paroxysmal hemicrania responds very well to indomethacin (NSAID)

68
Q

What is the trend in genders being affected by headache in children?

A

Equal between boys and girls until puberty then strong (3:1) female preponderance

69
Q

What is the most common cause of primary headache in children?

A

Migraine without aura

70
Q

What are 4 criteria for paediatric migraine without aura?

A
  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
Q

What is teh acute management of migraine without aura in children? 3 features

A
  • 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
Q

What is the suggested prophylaxis for migraine without aura in children?

A

First line: Pizotifen and propranol

Second line: valproate, topiramate, amitryptiline

73
Q

What is the second most common cause of headache in children?

A

Tension-type headache

74
Q

What are the 4 IHS (International Headache Society) criteria for tension type headache in children?

A
  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
Q

What are 15 red flags in headache?

A
  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
Q

What is the gender ratio of cluster headache sufferers?

A

Male : female 3:1

77
Q

What eye signs might be present in a minority of patients with cluster headaches?

A

Miosis and ptosis

78
Q

What is the response rate to 100% oxygen as a treatment for cluster headaches?

A

80% response rate within 15 minutes

79
Q

What is the response rate to subcutaneous triptan to treat an acute cluster headache?

A

75% response rate within 15 minutes

80
Q

Should you seek specialist advice for cluster headaches? What for?

A

Yes - with respect to neuroimaging

81
Q

What is tension type headache a form of?

A

Episodic primary headache

82
Q

What defines a chronic tension-type headache?

A

Tension headaches that occurs on 15 or more days per month

83
Q

In what proportion of patients undergoing lumbar puncture does headache occur?

A

1/3

84
Q

What is thought to be the pathophysiology of post-lumbar puncture headache?

A

Pathophysiology unclear, may relate to ‘leak’ of CSF following dural puncture

85
Q

In what group of patients is post-lumbar puncture headache most common?

A

young females with low body mass index

86
Q

What is the typical time frame of a post-lumbar puncture headache?

A

Develops within 24-48 following LP but may occur up to one week later

May last several days

87
Q

What exacerbates/ improves post-lumbar puncture headache?

A

Worse when upright, improves in recumbent position

88
Q

What are 4 factors that increase the likelihood of a post-lumbar puncture headache?

A
  1. Increased needle size
  2. Direction of bevel
  3. Not replacing the stylet
  4. Increased number of LP attempts
89
Q

What are 5 features that reduce likelihood of post-lumbar puncture headache?

A
  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
Q

What is the initial treatment for post-lumbar puncture headache and what should be done if it does not improve?

A
  • Supportive initially: analgesia, rest
  • If continues for >72 hours: specific treatment to prevent subdural haematoma
    • blood patch, epidural saline, IV caffeine
91
Q

When should specific treatment be pursued for post-lumbar puncture headache and why?

A

If pain continues for logner than 72 hours, to prevent subdural haematoma

92
Q

What are 3 treatment options for a post-lumbar puncture headache lasting >72 hours?

A
  1. Blood patch
  2. Epidural saline
  3. IV caffeine
93
Q

What are 2 examples of the typical visual auras that occur before a migraine?

A
  1. transient hemianopic disturbance
  2. spreading scintillating scotoma
94
Q

What is the prevalence of migraine in a) men and b) women?

A

a) 6%
b) 18%

95
Q

What are 7 common triggers for migraine attacks?

A
  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
Q

What are the 5 diagnostic criteria for migraines?

A
  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
Q

What are 3 ways that migraines in children differ from those in adults?

A
  1. may be shorter lasting in children
  2. headache more commonly bilateral in children
  3. GI disurbance more prominent in children
98
Q

what is another way to describe the spreading scintillating scotoma?

A

Jagged crescent

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