Headache Flashcards
Are most headaches primary or secondary?
Primary
What percentage of headaches are primary and secondary?
Primary - 90%
Secondary - 10%
What are primary headaches?
Ones with no underlying medical cause
What are secondary headaches?
Ones with an identifiable structural or biochemical cause
What are examples of causes of secondary headaches?
- Tumour
- Meningitis
- Vascular disorder
- Systemic infection
- Head injury
- Drug induced
What are examples of primary headaches?
- Tension type headache
- Migraine
- Trigeminal autonomic cephalalgias
- Cluster headache
- Paroxysmal hemicrania
- SUNCT
What is a migraine?
A migraine is a chronic disorder with episodic attacks where complex changes occur in the brain:
- During attacks
- Headaches
- Nausea, photophobia, phonophobia
- Functional disability
- In-between attacks
- Enduring predisposition to future attacks
- Anticipatory anxiety
What is the most frequent primary headache?
Tension type headache
What is a tension type headache?
Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity
What are the different kinds of tension type headache?
- Infrequent ETTH
- <1 day/month
- Frequent ETTH
- 1-14 days/month
- CTTH
- Equal to or more than 15 days/month
When is a tension type headache an infrequent ETTH?
<1day/month
When is a tension type headache a frequent ETTH?
1-14 days/month
When is a tension type headache a CTTH?
Equal to or more than 15 days/month
What is the treatment for tension type headache?
- Abortive treatment
- Aspirin or paracetamol
- NSAIDs
- Limit to 10 days per month (about 2 days per week) to avoid the development of medication overuse headache
- Preventative treatment
- Rarely required
- Tricyclic antidepressants
- Amitrptyline, dothiopin, nortriptyline
What is the most common disabling primary headache?
What changes occur in the between during a migraine attack?
- Headaches
- Nausea, photophobia, phonophobia
- Functional disability
What changes occur in the brain between migraine attacks?
- Enduring predisposition to future attacks
- Anticipatory anxiety
What are examples of migraine triggers?
- Stress
- Hunger
- Sleep disturbances
- Dehydration
- Diet
- Environmental stimuli
- Changes in oestrogen level in woman
How are migraines manifested clinically?
Migraine is manifested clinically as a constellation of symptoms that evolve through the various phases of a migraine attack, the clinical phases of a migraine:
What are the clinical phases of a migraine?
- Premonitory phase
- 70% of patients experience this
- Aura phase
- Involves focal, reversible neurologic symptoms that often precede the headache
- Believed to be due to electrical disturbances called cortical spreading depression (CSD)
- Occurs in 15-30% of migraine attacks
- May involve visual, sensory, motor or speech systems
- Duration is 15-60 minutes
- Slow evolution of symptoms
- Moves from area to the next, for example vision then sensory then speech
- Can be confused with transient ischaemic attack
- Loss of function
- Sudden onset
- Symptoms all start at the same time and can be localised to a specific vascular area
- Headache phase
- Subdivided according to headache pain intensity
- Early headache
- Advanced headache
- Subdivided according to headache pain intensity
- Postdrome
What is the aura phase of a migraine believed to be due to?
- Believed to be due to electrical disturbances called cortical spreading depression (CSD)
Why does the aura phase of a migraine have slow evolution of symptoms?
Moves from one area of the brain to the next
Why can the aura phase of a migraine be confused with a TIA?
- Loss of function
- Sudden onset
- Symptoms all start at the same time and can be localised to a specific vascular area
What can the headache phase of a migraine be divided into?
- Early headache
- Advanced headache
What is a chronic migraine?
Chronic migraine is a headache on 15 or more days per month, of which 8 or more days have to be migraine, for a total of more than 3 months:
What is a transformed migraine?
Migraine condition that initially began as episodic migraine attacks, which then increase in frequency over a period of month to years
What is the clinical presentation of transformed migraine?
- History of episodic migraine
- Increasing frequency of headaches over weeks/months/years
- Migranious symptoms become less frequent and less severe
- Can occur with or without escalation in medication use
What is a medication overuse headache?
- Headache present on 15 or more days/month which has developed or worsened whilst taking regular symptomatic medication
In what kinds of headaches can medication overuse headaches occur in?
- Can occur in any primary headache
- Migraineurs are particular prone to MOH
- Migraineurs taking pain medication for another reason can develop chronic headache
What are medication overuse headaches often caused by?
- Use of triptans, ergots, opiods and combination analgesics more than 10 days/month
- Use of simple analgesics more than 15 days per month
- Caffeine overuse
What is the treatment for migraine?
- Abortive treatment
- Aspirin or NSAIDs
- Triptans
- Limit to 10 days per month (about 2 per week) to avoid the development of medication overuse headache
- Prophylactic treatment
- Propranolol, candesartan
- Anti-epileptics
- Topiramate, valproate, gabapentin
- Tricyclic antidepressants
- Amitryptyline, dothiepin, nortriptyline
- Venlafaxine
What are some specific migraine issues in woman?
- Migraine without aura gets better in pregnancy
- Migraine with aura usually does not change
- First migraine can occur during pregnancy
- The combined OCP is contraindicated in active migraine with aura
- Avoid if anti-epileptics in woman of child bearing age
- Treatment is more difficult in pregnancy
- Acute attack is paracetamol
- Preventative is propranolol or amitriptyline
What is the acute attack and preventative medication for migraine in pregnant woman?
Acute attack - paracetamol
Preventative - propranolol or amitriptyline
What are different kinds of trigeminal autonomic cephalalgias?
Cluster headache
Paroxysmal hemicrania
SUNCT
SUNA
Trigeminal neuralgia
What can cluster headaches be seperated into?
- The attack
- Pain, mainly orbital and temporal
- Strictly unilateral
- Rapid onset
- Duration is 15 mins to 3 hours
- Rapid cessation of pain
- Excruciatingly severe (known as suicide headache)
- Migrainous symptoms often present
- Tiredness, yawning, nausea, vomiting, photophobia, phonophobia
- The bout
- Episodic in 80-90%
- Attacks cluster into bouts typically lasting 1 to 3 months with periods of remission lasting at least 1 month
- Attack frequency is 1 every other day to 8 per day
- May be continuous background pain between attacks
- Alcohol triggers attacks during a bout, but not in remission
- Striking circadian rhythmicity
- Attacks occur at the same time every day
- Bouts occur at the same time each year
- 10-20% have chronic cluster
- Bouts last >1 year without remission or remission lasts <1 month
- Episodic in 80-90%
What occurs during the attack of a cluster headache?
- Pain, mainly orbital and temporal
- Strictly unilateral
- Rapid onset
- Duration is 15 mins to 3 hours
- Rapid cessation of pain
- Excruciatingly severe (known as suicide headache)
- Migrainous symptoms often present
- Tiredness, yawning, nausea, vomiting, photophobia, phonophobia
What are some migrainious symptoms?
- Tiredness, yawning, nausea, vomiting, photophobia, phonophobia
Is the attack of a cluster headache unilateral or bilateral?
Strictly unilateral
Describe the bout of cluster headaches?
- Episodic in 80-90%
- Attacks cluster into bouts typically lasting 1 to 3 months with periods of remission lasting at least 1 month
- Attack frequency is 1 every other day to 8 per day
- May be continuous background pain between attacks
- Alcohol triggers attacks during a bout, but not in remission
- Striking circadian rhythmicity
- Attacks occur at the same time every day
- Bouts occur at the same time each year
- 10-20% have chronic cluster
- Bouts last >1 year without remission or remission lasts <1 month
Where is the pain located due to paroxysmal hemicrania?
Mainly orbital and temporal
Is paroxysmal hemicrania unilateral or bilateral?
Strictly unilateral
What is the onset of paroxysmal hemicrania?
Rapid onset
What is the onset of the attack of a cluster headache?
Sudden onset
What is the duration of an attack of cluster headache?
15 minutes to 3 hours
What is the duraiton of paroxysmal hemicrania?
2 to 30 minutes
Describe the cessation of pain due to an attack of cluster headache?
Rapid cessation
Describe the cessation of pain due to paroxysmal hemicrania?
Rapid cessation of pain
What is the clinical presentation of paroxysmal hemicrania?
- Pain is mainly orbital and temporal
- Strictly unilateral
- Rapid onset
- Duration is 2 to 30 minutes
- Rapid cessation of pain
- Excruciatingly severe
- Prominent ipsilateral autonomic symptoms
- Migrainous symptoms may be present
- Background continuous pain can be present
- 80% have chronic, 20% have episodic
- Frequency is 2-40 attacks per day (no circadian rhythm)
- Absolute response to indometacin
What is the treatment for paroxysmal hemicrania?
- Absolute response to indometacin
What is SUNCT?
- Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing
Describe the pain due to SUNCT?
- Unilateral orbital, supraorbital or temporal pain
- Stabbing or pulsating pain
What is the duration of SUNCT?
10-240 seconds
What triggers SUNCT?
- Cutaneous triggers
- Wind, cold, touch, chewing
What is the frequency of SUNCT?
- Frequency 3-200/day, no refractory period
What is the frequency of paroxysmal hemicrania?
- Frequency is 2-40 attacks per day (no circadian rhythm)
What is the frequency of cluster headache?
- Attack frequency is 1 every other day to 8 per day
What kind of pain does trigeminal autonomic cephalalgias present as?
Presents as unilateral head pain predominantly V1, which is very severe/excruciating
What are some cranial autonomic symptoms due to trigeminal autonomic cephalalgias?
- Conjunctival injection/lacrimation
- Nasal congestion/rhinorrhoea
- Eyelid oedema
- Forehead and facial sweating
- Miosis/ptosis (Horner’s syndrome)
What is the treatment for cluster headache?
What is the treatment for paroxysmal hemicrania?
What is the treatment for SUNCT?
What is the treatment for SUNA?
What is the treatment for trigeminal neuralgia?
What is the attack frequency (daily) of cluster headache, paroxysmal hemicrania and SUNCT?
What is the duration of attack of cluster headache, paroxysmal hemicrania and SUNCT?
Describe the pain quality of cluster headache, paroxysmal hemicrania and SUNCT?
Describe the pain intensity of cluster headache, paroxysmal hemicrania and SUNCT?
What are some features that predict a sinister secondary headache?
- Serious intracranial pathology is very unlikely in longstanding episodic headache
- Presentation more likely to have sinister cause
- Associated head trauma
- First or worst
- Sudden (thunderclap) onset
- New daily persistent headache
- Change in headache pattern or type
- Returning patient
What are some red flags for a sinister secondary headache?
- New onset headache
- New or change in headache
- Age over 50
- Immunosuppression or cancer
- Change in headache frequency, characteristic or associated symptoms
- Focal neurological symptoms
- Non-focal neurological symptoms
- Abnormal neurological examination
- Neck stiffness/fever
- High pressure
- Headache worse lying down
- Headache wakening the patient up
- Precipitated by physical exertion
- Precipitated by Valsalva manoeuvre
- Risk factors for cerebral sinus thrombosis
- Low pressure
- Headache precipitated by sitting/standing up
- GCA
- Jaw claudication or visual disturbance
- Prominent or breaded temporal arteries
What are some indicators that a headache is caused by high pressure?
- Headache worse lying down
- Headache wakening the patient up
- Precipitated by physical exertion
- Precipitated by Valsalva manoeuvre
- Risk factors for cerebral sinus thrombosis
What are some different causes of secondary headaches?
- Thunderclap headache
- Meningitis and encephalitis
- Raised intracranial pressure
- Intracranial hypotension
- Giant cell arteritis
What is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than 1 minute
Is a thunderclap headache primary or secondary?
May be primary or secondary, no reliable differentiating features
What is the differential diagnosis for thunderclap headache?
What dangerous thing is thunderclap associated with?
1 in 10 patients with thunderclap headache will have a subarachnoid haemorrhage (SAH):
- 85% aneurysmal
- 50% mortality
What investigations are done for thunderclap headache?
- Same day hospital assessment
- CT brain
- LP must be done >12 hours after headache onset
- CT with or without LP is unreliable beyond 2 weeks and angiography is required beyond this time
What should be considered in any patient presenting with headache and fever?
CNS infection should be considered in any patient presenting with headache and fever:
- Meningism
- Nausea with or without vomiting
- Photo/phonophobia
- Stiff neck
- Encephalitis
- Altered mental state/consciousness
- Focal symptoms
- Signs, seizures
Compare the presentations of meningism and encephalitis?
- Meningism
- Nausea with or without vomiting
- Photo/phonophobia
- Stiff neck
- Encephalitis
- Altered mental state/consciousness
- Focal symptoms
- Signs, seizures
What are warning features that the cause of the headache is raised intracranial pressure?
- Headache is worse in morning or wakes patient from sleep
- Headache worse lying flat or brought on by Valsalva (cough, stooping, straining0
- Focal symptoms or signs
- Non-focal symptoms such as cognitive or personality change, drowsiness
- Seizures
- Visual obscuration’s and pulsatile tinnitus
What is intracranial hypotension often due to?
Dural CSF leak
What is the presentaiton of intracranial hypotenison?
Clear postural component to the headache
Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down
Once the headache becomes chronic it often lose its postural component
What investigation is done for intracranial hypotension?
- MRI brain and spine
What is the treatment for intracranial hypotension?
- Bed rest, fluids, analgesia, caffeine
- IV caffeine
- Epidural blood patch
What is giant cell arteritis?
Arteritis of large arteries
When should giant cell arteritis be considered as the cause for a headache?
Should be considered in any patient over the age of 50 presenting with new headache
Describe the headache due to giant cell arteritis?
Headache is usually diffuse, persistent and may be severe
What is the presentation of a headache due to giant cell arteritis?
Headache is usually diffuse, persistent and may be severe
Patient is systemically unwell
Specific features include scalp tenderness, jaw claudication and visual disturbance
Prominent, beaded or enlarge temporal arteries may be present
What does ESR stand for?
Erythrocyte sedimentation rate
What blood finding supports giant cell arteritis being the cause of a headache?
An elevated ESR supports the diagnosis:
- Usually >50, often much higher, rarely normal
- Raised CRP and platelet count are other useful markers
What is the treatment for giant cell arteritis?
If the diagnosis is considered likely high dose prednisolone should be started and a temporal artery biopsy arranged
