Headache Flashcards
Most headaches are primary headaches. Name 3 types
Tension type
Migraine
Cluster
Define secondary headache
Identifiable structural or biochemical cause of headache
Six examples of seconday headache
Tumour Meningitis Vascualr disorders Systemic infection Head injury Drug-induced
Most frequent type of primary headache
Tension Type Headache
What type of headache is the 3rd most disabling condition in women under 50 according to WHO
Tension Type headache
Why are tension type headaches common to women in their reproductive years?
Drop in oestrogen can trigger
Describe the severity and spread of tension type headaches
Mild
Bilateral
Symptoms of tension headache that may be described
Pressing
Tightening
No other associated features
Not aggravated by phyical activity
3 categories of Tension type headache
Infrequent Episodic TTH
Frequent ETTH
Chronic TTH
How many days of TTH constitute an infrequent episodic TTH?
1 day per month
How many days of TTH constitute an frequent episodic TTH?
1-14 days per month
How many days of TTH constitute chronic TTH?
More than 15 days in one month`
Two classes of treatment in headache
Abortive
Prophylactic
Abortive treatment for Tension type headache
Aspirin, paracetamol
NSAIDS
What is the limit on abortive treatment for TTH to avoid overuse headache?
10 days per month
2 days in week
Preventative treatment of tension type headache?
Tricyclic antidepressants
- Amitriptyline, dothiepine, nortriptyline
What is the most frequent disabling type of headache?
Migraine
What is the typical age range for migraine sufferers?
20-50
How do migraine attacks present?
Episodic 4-72 hours of headache Unilateral location Pulsating Moderate to severe pain Aggravated by/avoidance of physical activity
What symptoms may be experienced during a migrainous attack?
Headache Nausea Photophobia Phonophobia Functional disability
What symptoms may be experienced between migrainous attacks?
Enduring predisposition to future attacks
Anticipatory anxiety
7 triggers of migraine
Dehydration Diet Sleep disturbance Hunger Environmental stimuli Stress Oestrogen level change in women
5 phases of migraine
Premonitory Aura Early headache Advanced headache Postdrome
Describe features of the premonitory phase in migraine
Mood changes Fatigue Cognitive change Muscle pain Food craving
Describe features of the aura phase of migraine
Mild to moderate headache
Fully reversible, neurological changes, visual somatosensory
Not always followed by headache
What word describes an aura that is not followed by headache?
Acephalgic
Describe features of the early headache phase in migraine
Dull, mild pain
Nasal congestion
Muscle pain
Describe features of the advanced headache pahse in migraine
Moderate to severe pain Unilateral throbbing Nausea Photophobia Phonophobia Osmophobia (smells)
Describe features of the postdrome phase of migraine
Fatigue
Cognitive changes
Muscle pain
What percentage of migraine sufferers experience AURA?
33%
Define aura
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve sensory, visual, motor or speech systems
How do symptoms evolve in aura?
Slowly
Vison precedes sensory, then speech
Wave from occipital lobe
How long may aura last?
15=60 minutes
What condition can aura be mistaken for?
TIA
How to differentiate aura from stroke?
Stroke is sudden
Symptoms will start at once in stroke - localised to specific vascular area
Aura follows wave, occipital forward
How is chronic migraine defined?
Migraine experience for more than 15 days in one month. Migraine can last longer than 8 days
Longer than 3 month history
How else is chronic migraine described?
Transformed migraine
How may chronic migraine evolve from other episodes
History of episodic migraines, increasing frequency of headaches
Migrainous symptoms become less frequent and less severe
Episodes of sever migraine on background of less severe featureless frequent/daily headache
Can occur with/without escalation in medication use
Define medication overuse headache
Headache on more than 15 days in one month
Taking regular symptomatic medication
Can occur from primary headache
Which medications are common to causing medication overuse headache?
Triptans
Ergots
Opioids
Combo analgesics for more than 10 dyas in month
Simple analgesics for over 15 days in month
What other substance can cause ‘medication’ overuse headache>
Caffeine
Abortive migraine treatment
Aspirin
NSIADs
Triptans (limit 10 days per month)
Prophylactic migraine treatment
Propanolol
Candesartan
Antiepileptics ; topiramate, valproate, gabapentin
Tricyclic antidepressants; Amitryptiline, Dothiepin, nortriptyline
Venlafaxine
How does migraine change in pregnancy?
Migraine without aura improves in pregnancy
Migraine with aura will not change
What medication is contraindicated in active migraine with aura?
Combined oral contraceptive pill
Which medication for treating migraine should be avoided in women of child-bearing age?
Anti-epileptics
What treatment can be used in women of child bearing age/pregnant for migraine?
Acute - paracetamol
Prophylactic - propanolol
Four types of headache categorised as Trigeminal Autonomic Cephalgias
Cluster
Paroxysmal hemicrania
SUNCT
SUNA
Features of a trigeminal autonomic cephagia
Unilateral head pain V1
Very sever, excruciating
Cranial autonomic symptoms
List 6 cranial autonomic syptoms
Conjunctival injection/lacrimation Nasal congestion.rhinorrhoea Eyelid oedema Forehead and facial swelling Misosis/ptosis (Horner's)
What region of the head is painful in cluster headaches
Orbital and temporal
What is the distribution of pain in cluster headaches?
Unilateral
How long do cluster headaches tend to last?
15 minutes to 30 minutes
Rapid cessation
What term is given to the severe pain experienced in cluster headaches?
Suicide headache
How do autonomic symptoms coincide with a cluster headache?
Ipsilateral autonomic symptoms
What migrainous symptoms are experienced in cluster headache?
Premonitory - tiredness, yawning
Assoicated - nausea, vomiting, photophobia, phonophobia
Typical Aura
What percentage of patients with cluster headache experience epsiodic attacks?
80-90%
In episodic cluster headache, how long do bouts and remission tend to last?
1-3 months
1 month remission
How often can attacks occur in cluster headache?
Varies 1 every other day up to 8 attacks in a day
Continuous background of pain may be experienced
What substance can trigger an attack during a bout of cluster headache, but typically has no effect in remission?
Alcohol
Is there a pattern of timing in cluster headache?
Yes
Striking circadian rhythmicity - same time each day, same time of year
How many people with cluster headache suffer chronically?
10-20%
How long does chronic cluster headache last?
Bouts must last longer than 1 year without remission or with remission of less than a month
Which region of the head is painful in paroxysmal hemicrania?
Orbital, temporal
Distribution of pain in paroxysmal hemicrania
Unilateral
Describe severity and time period of headache in paroxxysmal hemicrani
Rapid onset, rapid cessation - 2 to 30 minutes
Excruciatingly severe - 50% restless, agitated
How do autonomic symptoms coincide with pain in paroxysmal hemicrania?
Ipsilateral autonomic symptoms
10% of attacks in paroxysmal hemicrania are precipitated by…
bending/rotation of head
What percentage of sufferers of paroxysmal hemicrania are chronic and episodic?
80% chronic
20% episodic
How many attacks can occur daily in paroxysmal hemicrania?
2-40 attacks
Paroxysmal hemicrania has an absolute repsonse to what drug?
Indometacin
What does SUNCT stand for?
Short-lasting Unilateral Neuralgiform headache with Conjunctival Injection and Tearing
Describe the regions headache is present in SUNCT
Unilateral
Orbital, supraorbital, temporal
Describe the character of the headache in SUNCT
Stabbing, pulsating at V1
Name cutaneous triggers of SUNCT
Wind
Touch
Cold
Chewing
How many headache attacks can be experienced daily with SUNCT
3-200, no refractory period
Describe the region of pain in trigeminal neurallgia
Unilateral
MAXILLARY OR MANDIBULAR -moreso than opthalmic
Describe the character of pain in trigeminal neuralgia
Stabbing pain - 5-10 seconds
Electric SHock
What can trigger trigeminal neuralgia?
Cutaneous triggers - wind, cold, touch, chewing
What is the attack frequency of Trigeminal neuralgia?
Similar to SUNCT 3-200
How does trigeminal neuralgia differ from SUNCT?
Pain in maxillary, mandible region
Refractory period between attacks
Autonomic features in trigeminal neuralgia
UNCOMMON
Abortive treatment of cluster headache?
Subcutaneous sumatriptan 6mg
or
nasal zolmatriptan
100% oxygen
Abortive treatment of bout of cluster headache?
Occipital injection
Oral prednisolone
Prophylactic treatment of cluster headache
Verapimil
Lithium
Methysergide (ERGOMETRINE TARTRATE)
Topiramate
Abortive treatment of paroxysmal hemicrania>
NO ABORTIVE TREATMENT
Prophylactic treatment of paroxysmal hemicrania
Indometacin
Alternatives to indometacin
COX II inhibitors
Topiramate
Abortive treatment for SUNCT
NO ABORTIVE
Prophylactic treatment for SUNCT
Lamotrigine
Topiramate
Gabapentin
Carbamazepine/Oxcarbazepine
Abortive treatment of trigeminal neuralgia
NO ABORTIVE
Prophylactic treatment of trigeminal neuralgia
Carbamazepine
Oxcarbazepine
Surgical intervention for trigeminal neuralgia
Glycerol ganglion injection
Steriotactic radiosurgery
Decompressive surgery
Likely presentations of secondary headache
Assoicated head trauma Sudden onset New daily persistent headache Change in pattern/type of headaches Returning patient from primary
Red Flag Headache symptoms
New onset
New/change in headache - over 50, immunosupressed, cancer
Focal neurological symptoms
Non-focal symptoms
Abnormal neurological examination
Neck stiffness
Fever
High pressure ; worsens lying down, on wakening, on exertion, valsalva (RF for cerebral venous sinus thrombosis)
Low pressure - headache precipitated by sitting/standing up
Giant cell arteritis - jaw claudication, visual disturbance, prominent/headed temporal arteries
Describe onset of thunderclap headache
High intensity headache reaches max intensity in less than 1 minute.
Majority peak instantaneously
SUDDEN, SEVERE, INSTANTANEOUS
Diferrentials for thunderclap headache
Primary - migraine, exertional, sexual activity Subarachnoid haemorrhage Intracerebral haemorrhage TIA/Stroke Catorid/vertebral dissection Cerebral venous sinus thrombosis Meningitis/encephalitis Pituitary apoplexy Spontaneous intracranial hypotension
How many people with thunderclap headache are diagnosed with subarachnoid haemorrhage?
1 in 10
What percentage of SAH cases are aneurysmal?
85%
Mortality of SAH
50%
Risk of rebleed in SAH
4-6% in first 48 hours
40% in first month
Treatment of SAH
Coiling
Clipping
How does SAH present
Sudden headache, peaks within minutes, lasts at least 1 hour
Examination normal
Investigations for SAH
CT brain
Lumbar puncture
Beyond 2 weeks - angiography
In what time frame must a lumbar puncture be carried out in SAH?
within 12 hours of onset
Symptoms of meningitis
Nausea with or without vomiting Photophobia Phonophobia Neck stiffness RASH
Symptoms of encephalitis
Altered mental state or consciousness
Focal symptoms and signs
Seizures
Causes of raised intracranial pressure
Glioblastoma multiforme Cerebral abscess Venous infarct with focal area of haemorrhage Meningioma Hydrocephalus Papilloedema
Symptom of gliobastoma multiforme
Weeks to months of high pressure headache
Features suggesting space occupying lesion
Progressive headache with associated signs and symptoms
Warning - headache worse in morning/wakes patient from sleep
Worse lying flat or valsalva
Focal signs and symptoms
Seizures
Non-focal ; cognitive, personality change, drowsiness
Visual obscurations
Pulsatile tinnitus
What causes intracranial hypotension?
Dural CSF leak - spontaneous or iatrogenic (post LP)
What features of headache indicate intracranial hypotension?
Clear postural component - upright; lessens/resolves when lying down
When headache becomes chronic loses postural component
Investigation of intracranial hypotension
MRI brain and spine
Treatment for intracranial hypotension
Bed rest Fluid Analgesia Caffeine - IV Epidural blood patch - injects blood into widened epidural space, seal to make space tighter
Purpose of IV caffeine in treatment of intracranial hypotension?
Raise CSF pressure
Describe the onset and character of the headache in Giant Cell Arteritis
NEW Diffuse Persistent May be severe PATIENT MAY BE SYSTEMICALLY UNWELL
Symptoms of giant cell arteritis
Scalp tenderness
Jaw claudication
Visual disturbance
Prominent, headed, enlarged temporal arteries
Signs of giant cell arteritis
Prominent, headed, enlarged temporal arteries
Elevated ESR (>50 - much higher)
Raised CRP
Raised platelets
Treatment of Giant Cell arteritis
High dose prednisolone
Temporal artery biopsy - behind eye, stroke, constricted RV
Risk factors trigeminal neuralgia
Multiple Sclerosis Age - 50-60 Female Family history Stroke and hypertension
Complications of trigeminal neuralgia
Impact on daily living
Depression/isolation
Weight loss - inability to eat; cutaneous triggers
Red flag symptoms in trigeminal neuralgia - may suggest underlying cause
Sensory changes.
Deafness or other ear problems.
History of skin or oral lesions that could spread perineurally.
Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally.
Optic neuritis.
Family history of multiple sclerosis.
Age of onset before 40 years.
TTH differentials
Headache not associated with an underlying condition – primary headache:
Migraine.
Trigeminal autonomic cephalgias for example cluster headache and paroxysmal hemicranias.
Other primary headache disorders such as primary cough headache and cold-stimulus headache.
Secondary headaches — headache attributed to an underlying condition including:
Trauma or injury to the head and/or neck.
Cranial or cervical vascular disorders for example intracerebral haemorrhage, central venous thrombosis or giant cell arteritis.
Non-vascular intracranial disorders for example idiopathic intracranial hypertension or neoplasm.
Exposure to, or withdrawal from, a substance such as carbon monoxide, cocaine or alcohol — medication over use headache (which can be due to ergotamines, triptans, simple analgesics and opioids) is included in this category.
Infection for example intracranial infection (including meningitis, encephalitis and cerebral abscess) or systemic infection.
Disorders of homeostasis for example hypoxia or hypertension including pre-eclampsia and eclampsia.
Disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structure such as angle closure glaucoma, temporomandibular disorder, dental problems, otitis media or sinusitis.
Psychiatric disorders such as somatization disorder.
Painful cranial neuropathies and other facial pains such as trigeminal neuralgia, post-herpetic neuralgia and optic neuritis.
