Headache Flashcards
What is the 1st most disabling conditions in people <50?
Migraines
What points should be asked determined taking a headache history?
- Can I classify the headache?
- Do I need to investigate?
- How do I explain the diagnosis?
- What are the patients expectations?
- What treatment is the most appropriate?
What is a ‘thunderclap’ headache?
Thunderclap headaches strike suddenly like a clap of thunder. The pain of these severe headaches peaks within 60 seconds.
They can warn of potentially life-threatening conditions — usually having to do with bleeding in and around the brain.
When taking a history headache, what questions should be asked regarding the pain?
- Pain onset
- Pain periodicity
- Associated features
Pain onset of headaches can be acute (seconds to minutes), evolving (hours to days) or chronic (weeks to months).
What can an acute onset indicate?
SAH / Intra-cerebral haemorrhage / coital / thunderclap
What is a coital headache?
Sex headaches are brought on by sexual activity — especially an orgasm. You may notice a dull ache in your head and neck that builds up as sexual excitement increases. Or, more commonly, you may experience a sudden, severe headache just before or during orgasm. Most sex headaches are nothing to worry about.
What can an evolving headache indicate?
infection, inflammation, increased ICP
What can a chronic headache indicate?
increased ICP
What are the 2 categories of pain periodicity?
Episodic or chronic
What are examples of episodes vs chronic headaches?
o Episodic: migraine, cluster headache
o Chronic: medication overuse, chronic migraine, hemicrania continua
What is hemicrania continua?
Hemicrania continua is a chronic and persistent form of headache marked by continuous pain that varies in severity, always occurs on the same side of the face and head
What is a 2ary headache?
For this type, another disease or condition is the cause. The headache is a symptom.
What other symptoms can be associated with a headache?
o Diurnal variation o Postural element o Nausea and vomiting o Photophobia and phonophobia o Autonomic features (lacrimation, Horners, red eye)
What are the red flags for a potentially life-threatening headache?
(SNOOP)
S: Systemic symptoms; fever, night sweats, rash, weight loss, vomiting, comorbid systemic disease (e.g. HIV) etc
N: Neurological symptoms; change in mental state or consciousness, abnormal cranial nerve function, loss of sensation, collapse, visual disturbance, seizures etc
O: Onset sudden; sudden or first ever, severe or ‘worst headache of life, thunderclap (pain reaches maximal intensity after onset)
O: Older onset; after 50 years of age e.g. giant cell arteritis
P: Pattern change; progressive headache, postural aggravation etc
What is a cluster headache?
Cluster headaches are excruciating attacks of pain in one side of the head, often felt around the eye.
Other questions to ask:
• Behaviour o Lies down in dark room: migraine o Agitation/pacing: cluster • Family history: migraine • Medication/self-medication
When doing a headache examination, what systemic signs should be looked for?
- Fever, rash, stiff neck, increase BP, organomegaly
- Fundal changes (papilloedema)
- Cranial nerve signs/ Horner’s syndrome
- Focal abnormalities
- Long tract signs
What is organomegaly?
Organomegaly is the abnormal enlargement of organs
What can a fever/rash/neck stiffness indicate?
Meningitis/encephalitis
What is papilloedema?
Optic disc swelling that is caused by increased intracranial pressure due to any cause.
Name 7 primary headaches
- Migraine
- Tension
- Exertional headache
- Ice-pick headache
- Coital headache
- Hypnic headache
- Trigeminal autonomic cephalgias
Migraine:
a) symptoms
b) investigations
c) treatment?
a) Episodic, nausea, dizziness, aura, unilateral, triggered by sleep deprivation, hunger, stress
b) CT/MRI is focal symptoms
c) Avoid caffeine, increase water, avoid tyramine foods, sleep hygiene
Tension headache:
a) symptoms
b) treatment?
A tension headache is the most common type of headache.
a) Bilateral, no aura, tight band
b) Relaxation, massage, amitriptyline, acupuncture, optician check
What is trigeminal autonomic cephalgias?
TACs are primary headaches with a common clinical phenotype consisting of trigeminal pain with autonomic signs, which may include lacrimation, rhinorrhoea and miosis.
Treatment for TACs?
Pain relief (sumatriptan, high low oxygen), prevent with prednisolone, verapamil, indomethasin
Many diseases can cause 2ary headaches. Name some
- Sub-arachnoid haemorrhage
- Stroke
- Meningoencephalitis
- Intracranial venous thrombosis
- Giant cell arteritis
- Tumour with raised ICP
- Cervicogenic headache
- Benign intracranial hypertension
- Raised ICP due to infection
- Temporal arteritis
Sub-arachnoid haemorrhage:
a) symptoms
b) investigations
c) treatment
a) Severe, sudden onset head pains. Vomiting, confusion, impaired ocular movements
b) Angiography
CT
c) Resuscitation, pain relief, refer to neurosurgical team
Tumour with raised ICP:
a) symptoms?
b) investigations?
a) Headache, worse on lying or awakening, vomiting, seizures
b) CT, MRI
Temporal arteritis:
a) symptoms
b) investigations
c) treatment?
a) Temporal headache, general malaise, radiating to jaw, visual disturbance, weight loss
b) Tender, non-pulsatile temporal artery, check Erythrocyte sedimentation rate
c) High dose steroids (prednisolone), temporal artery biospy
Preventative treatments for migraines:
- Propanolol (beta blocker)
- Pizotifen (anti-migraine)
- Topiramate (anti-epilepsy and anti-migraine)
- Valproate
- Amitripitiline
- Botox
Treat otherwise with triptans, naproxen, paracetamol analgesia
What is propanolol? Mechanism behind treating migraines?
Beta blockers –> Block effects of catecholamines at the B1-adrenergic receptors, decreasing sympathetic activity on heart
Beta-blockers have been used to alleviate some symptoms of anxiety; probably patients with palpitation, tremor, and tachycardia respond best. Beta-blockers are also used in the prophylaxis of migraine
What are the causes of a new daily persistent headache?
- Raised ICP
- Low ICP
- Chronic meningitis (infective and noninfective)
- Post head injury
What defines a chronic headache?
Headache lasting over 4 hours on over 15 days per month for over 3 months
Causes of a chronic headache?
o Transformed migraine o Chronic tension type headache o Hemi crania continua o Transformed migraine o Medication overuse
Treatment of chronic headache?
o Withdraw analgesia if history of overuse
o Consider amitriptyline/topiramate for transformed migraine
What is Erenumab? Mechanism in treating migraines?
• CGRP receptor antagonist designed to prevent migraine
The CGRP receptor is located at sites that are relevant to migraine pathophysiology, such as the trigeminal ganglion.
• Binds to the CGRP receptor, blocking its activation
Potent and selective but not yet on NHS
How can an internal carotid artery dissection cause Horner’s syndrome?
Horner syndrome caused by compression of ascending sympathetic supply within the carotid sheath.
Causes of thunderclap headache?
Cervical artery dissection Stroke Brain aneurysm Head injury that causes a brain bleed. Vasculitis Infection in the brain such as encephalitis or meningitis.
Causes of raised ICP?
- Mass Effect (brain tumour, abscess)
- Brain swelling (Hypertensive encephalopathy)
- Increased venous pressure
- CSF outflow obstruction (hydrocephalus)
- Increased CSF production (meningitis/SAH)
Symptoms of raised ICP?
- Headache (worse on lying or awakening)
- Vomiting
- Seizures
Signs of raised ICP?
- Papilloedema
* lateralising signs
What is temporal arteritis/giant cell arteritis?
Arteries, particularly those at temples, become inflamed
In which age group should you particularly consider temporal arteritis?
Over 50 (F>M)
What condition is temporal arteritis associated with?
Polymyalgia rheumatica (PMR) - an inflammatory disorder that causes widespread aching, stiffness and flu-like symptoms.
Symptoms of temporal arteritis?
a severe headache that develops suddenly (your scalp may also feel sore or tender)
pain in the jaw muscles when eating
problems with sight, such as double vision or loss of vision
Others: o Weight loss o Myalgia o Transient loss of vision o Jaw claudication o Tender non-pulsatile temporal artery
Treatment for suspected temporal arteritis?
Commence immediate high dose steroids: Prednisolone
What is a migraine ‘aura’?
An aura is a collection of symptoms that occur before or along with a migraine attack e.g. visual and physical disturbances or sensations
Can also occur without a following migraine.
What is a basilar migraine?
migraine that begins in brainstem
What is a hemiplegic migraine?
Very rare (<0.1%) –> weakness on one side of body in addition to headache
What is a acephalgic migraine?
‘silent migraine’, aura without headache
Triggers for a migraine?
o Sleep deprivation
o Hunger
o Stress
o Oestrogens etc
Is a migraine unilateral or bilateral?
The pain is often unilateral but may be bilateral
What are the possible causes of migraines?
- Cortical spreading depression
- Vasodilation
- Trigeminal nerve
What is cortical spreading depression?
- During cortical spreading depression, the electrical activity of neurons in a certain brain area is silenced.
- Once a certain threshold of depression occurs, this silencing spreads throughout the brain like a ripple in a pond.
- Often begins in sensory associated brain areas such as those involved in vision
How is the trigeminal nerve involved in migraines?
- Upon the onset of headache in migraines, the trigeminal nerve will release CGRP
- CGRP will relax the blood vessel walls causing vasodilation.
What is CGRP?
CGRP is a neuropeptide that has been implicated in migraines. CGRP functions as a vasodilator – a cause of migraines.
What are triptans?
Triptans are a group of medicines used to treat migraine or headache. Are serotonin receptor agonists.
When would you request brain imaging in headache patients?
Brain imaging in patients with abrupt onset headache or secondary headache syndromes
What should you consider if headaches change from episodic to chronic?
Consider analgesia overuse
How does a tension headache present?
- Commonly described as ‘constricting’ ‘tight band’
- Increasingly held view that it is a form of mild/moderate migraine
- Intermittent BILATERAL headache
