Headache Flashcards
What percentage of primary care symptoms involve headache?
> 4% GP consultations
What percentage of neurology referals involve headache?
30%
What percentage of headache in primary care are not given a diagnostic label?
70%
WHat percentage of the population have a tension headache at any time?
40%
What are common headache types?
- Tension / muscular
- Migraine
- Analgesia overuse
- Systemic illness
- Cervicogenic
What are the different types of serious headaches?
- Subarachnoid haemorrhage
- Meningitis
- Tumours
- Other SOL
- Temporal arterititis
- Stroke (including CV sinus thrombosis)
What should be included in a history headache history?
SOCRATES as aide memoire
- How long?
- Position on head?
- Character (not intensity)?
- Frequency When?
- Diurnal variation?
- Change in character
- Nausea / vomitting
- Radiation
- Other neurological symtpms
- PMH, FH
- Medicines
What does a tension headache history usually present with?
- Over weeks, months, years
- Tightness, pressure
- Constant, or worse towards evening
- Rarely with nausea
What are the treatments for tension headaches?
- Reassurance
- Explain the muscles around the head
- Reduce analgesia
- Use relaxation exercises
- Low dose amitriptyline
- Won’t go away overnight
How many people in the UK are off work every day due to a migraine?
> 100,000
What are the symptoms of a migraine?
- Headache with nausea
- With or without aura, spreads over minutes
- Unilateral or bilateral, usually hours-days
- Photophobia, phonophobia, gut symptoms
- Pulsating, sharp
What gender are migrains more common in?
Women - especially mid-cycle, at period and menopause (oestrogen)
What is thought to cause migraines?
- Mechanism unclear, vascular and neural theories
- Certain triggers (take diary) - foods, alcohol, beginning or end of working week, periods
- May be exacerbated by physical activity
- Often family history
What are the acute migraine treatments?
- Triptans - agonsists at 5HT- 1b and 5HT-1d receptors (sumatriptan, rizatriptan, naratriptan, zolmitriptan etc)
- Aspirin, paracetamol
- Anti-nausea (prochlorperazine, metoclopramide)
What are the prophylactic treatments of migraines?
- Beta blockers (propranolol)
- Amitriptyline (low dose)
- Pizotifen (5HT-2a and 2c antagonist, antihistamine, anticholenergic)
- Topiramate
- Sodium valproate
- Candesartan
- Flunarazine
- Lisinopril
- Methysergide (retroperitoneal fibrosis)
What are other migraine treatments that are not usually prescribed in primary care?
- Botulinum toxin injection (usually every 90 days)
- Anti-CGRP monoclonal antibodies, erenumab, liscensed in 2018 for >4 migraines / month UK, subcutaneous monthly injection, must have tried at least 3 other prophylactics
- Acupuncture
What category of people should not be prescribed the combined oral contraceptive pill?
Women with migraine and aura due to increased risk of stroke
What are the symptoms of trigeminal neuralgia?
- Shooting pain in one or more division of V
- Extremely painful, maybe triggered by cold or eating
What is considered the cause of trigeminal neuralgia?
- Young people consider demyelination
- Older people, often abberant blood vessel touching V
What are the treatments for trigeminal neuralgia?
- Carbamazepine
- Gabapentin
- Injection
- Surgery
What is trigeminal autonomic cephalagia (TAC)?
- Recurrent pain in trigeminal distribution with autonomic features (eye watering, nasal congestion, redness eye)
- Commonest of these is cluster headache: unilateral (striking circadian rhythm, dame time of day, clustering in periods usually few weeks, around one eye, runny)
- Paroxysmal hemicranias (women>men), shorter, more frequent attacks, response to indomethacin
What is the treatment of Trigeminal Autonomic cephalgia?
- Triptans
- Oxygen
- High dose verapamil (up to 960 mg/day)
- Indomethacin for P Hemicrania
What is a medication overuse headache?
- Present for > 15 days / month
- Worsened while analgesia has been used
- If using simple analgesia > 15 days/month, or > 10 days for other acute e.g. triptans
- No evidence of another type of headache
- Uncertain whether abrupt cessation of gradual stopping is better for treatment
What is a thunderclap headache? How is it treated?
- Instant or rapidly appearing (< 60 seconds)
- Must consider SAH, but can be exertional (coital cephalgia)
- Requires urgent investigation, CT head, LP after 12 hours, look for bilirubin and oxyhaemaglobin
What is associated with raised intracranial pressure?
- Headache usually mild
- Diurnal variation - worse in morning, often gone by lunchtime
- “headache wakes me up in morning”
- May be worse with cough, straining
- Often mild nausea
- Neurological features
- look for papilloedema
- Tumours, absess, CSF blockage
- Urgent referral and scan
What are the classic clinical signs of meningitis?
- Fever
- Photohobia
- Neck stiffness
- Altered conscioussness
- Petechial rash
- Most meningitis is viral, but cannot distinguish clinically, so treat with ceftriaxone/cefotaxime or benzyl penicillin
What are the symptoms / signs of temporal arteritis?
- Never < 50 years of age
- May be features of polymyalgia (proximal myopathy)
- Jaw claudication
- Tendor temporal arteries
- Raised ESR (strong marker of inflammation)
How is temporal arterietis diagnosed / treated?
- Ultrasound or temporal artery biopsy (sample error)
- Danger of blindness, use steroids early - Prednisolone
What group is most likely affected by cerebral venous sinus thrombosis?
Female - oral contraceptive pill
What is associated with cerebral venous sinus thrombosis?
- Headaches, often severe
- May be bilateral, haem
What is used to investigate / diagnose cerebral venous sinus thrombosis?
MRI/MRV
What is a low ICP caused by and what does it involve?
- After lumbar puncture
- Headache on standing, eased with lying
- Can occur spontaneously
How can low ICP be treated?
- May resolve spontaneously
- Blood patch for post lumbar puncture headache
What can cause early morning headaches?
- Raised ICP
- Obesity
- History snoring
- COPD
- Sleep apnoea
What is Transient Global Amnesia?
- Variant of migraine
- Often during stress/exposure to cold
- Period of amnesia, unable to lay down any new memory, keep repeating the same question
- Few minutes to hours
- Usually solitary event that does not reoccur, can be similar to stroke
- Clinical diagnosis
