Headache Flashcards
What are the trigeminal autonomic cephalagias?
Group of primary headache disorders characterised by unilateral trigeminal distribution pain and prominent ipsilateral autonomic features
Cluster headaches
Paroxysmal hemicrania
Hemicrania continua
SUNCT
Those with new onset unilateral and cranial autonomic features require
imaging MRI brain and MR angiogram to rule out aneurysm
List some headache red flags?
Any new onset headache in someone over age 55
Anyone with known/ previous malignancy
Immuno-suppressed
Early morning headache
Exacerbation by valsava (suggests increased ICP)
Headache that wakes you up
What is the most common cause of episodic headache?
Migraine
Pathophysiology of migraines?
it’s neurologic and basically results in waves of depolarisation across cortex that activate trigeminal pain receptors
Who are migraines more common in?
women
Criteria for diagnosis of migraine?
• Criteria for migraine without aura: at least five attacks lasting 4-72 hours with
2 of: moderate/ severe, unilateral, throbbing pain, worse with movement
1 of: autonomic features, photophobia, or phonophobia
25% of migraine sufferers have
auras
Describe migraine auras?
can be visual which is most common e.g. scotomas, central fortification, hemianopia
also get sensory and motor auras
these auras usually last 20-60 mins and are followed by the headache phase
Describe some triggers for migraines?
sleep deprivation, skipping meals, alcohol, hormones (oestrogen), physical exertion
Describe some non pharmacologic treatment of migraines?
headache diary, education on avoiding triggers, relaxation, stress management
Describe some acute abortive treatments for migraines?
NSAIDs or triptans (however shouldn’t overuse as can get medication overuse headaches)
Describe prophylactic drugs for migraines?
1st line > amitriptyline
2nd line > propranolol
3rd line > topiramate
What type of headache is the classic everyday headache one might complain of?
tension headache
Describe the features of tension headaches?
Mild to moderate pain, bilateral, tight band sensations, pressure behind the eyes, bursting sensation (absence of photophobia, photophobia, nausea and vomiting)
Treatment of tension headaches?
simple analgesics effective but should avoid overuse
physio to relax the scalp, relaxation, massage and ice packs
tricyclics may be useful for chronic cases
Who are cluster headaches most common in?
males in 20s-40s
Describe the features of a cluster headache?
excruciating unilateral headache with parasympathetic autonomic activation in the same eye causing redness or tearing, nasal congestion or even transient Horner’s syndrome
frequency is about 1-8 a day, lasting 45-90 mins, with bouts lasting 1-2 months
Attacks of cluster headache are most common at ____
night
Describe when bouts of cluster headache occur?
usually recur a year or more later after a previous bout and often at the same time of year
Describe treatment of cluster headaches?
ACUTE: high flow 100% oxygen, sub cutaneous sumatriptan (only drug that works fast enough)
OTHER TREATMENT: verapamil or steroids may terminate a bout of cluster headaches
Who does paroxysmal hemicranial and hemicrania continua occur in
often elderly women
Compare frequency and duration of attacks in hemicrania cluster headaches?
hemicrania attacks are shorter (10-30 mins) than cluster headaches (45-90 mins)
hemicrania attacks are more frequent (1-40 a day) than cluster headaches (1-8 a day)
Describe treatment of paroxysmal hemicrania and hemicrania continua?
rapid and complete response to indometacin
If a headache responds completely to indomethacin it is likely?
hemicrania
Describe SUNCT?
S= short lived U= unilateral N= neuralgiaform headache C= conjunctival injections T= tearing attacks very short, 5 secs to 2 mins and often occur in bouts
Treatment of SUNCT?
lamotrigine or gabapentin
Who does idiopathic intracranial hypertension commonly occur in?
younger, overweight females, many have PCOS
Describe features of idiopathic intracranial hypertension?
headache with red flags, worse in the morning, get nausea and vomiting, often headache with transient visual obscurations due to papilloedema
Describe investigations for idiopathic intracranial hypertension?
MRI is normal
Lumbar puncture shows elevated CSF pressure but normal constituents
Treatment of idiopathic intracranial hypertension?
monitor visual fields, weight loss, acetazolamide, ventricular atrial or lumbar peritoneal shunt may be necessary to protect vision
Who is trigeminal neuralgia most common in and what is the main risk factor?
elderly
hypertension
What is often the cause of trigeminal neuralgia?
Often due to compression of the trigeminal nerve at or near the pons by an ecstatic vascular loop which can be seen on high resolution MRI (can also be caused by MS)
Describe clinical features of trigeminal neuralgia?
severe, sharp, stabbing, unilateral pain in the 5th neve distribution, lasts seconds but there are 10-100 attacks a day
may be caused by trivial stimuli e.g. washing, shaving or chewing
bouts of pain may last weeks to months
Describe treatment of trigeminal neuralgia?
carbamazepine reduces the severity of attacks, may do ablation or decompression of blood vessel if very severe
