Headache Flashcards
How common are headaches?
One of the most common symptoms
Symptoms are unpleasant, disabling and common worldwide and have substantial economic impact due to time lost from work
What is a primary headache?
No underlying cause relevant to headache
Migraine, cluster, tension
What is a secondary headache?
A headache with underlying cause
Need to identify underlying cause eg giant cell arteritis
What are the red flags for secondary headache?
HIV/immunosuppressed Fever Thunderclap headache Seizure and new headache Suspected meningitis Suspected encephalitis Red eye - acute glaucoma Headache + new focal neurology eg papilloedema
Give an example of a secondary cause of secondary headache?
Meningitis
SAH
GCA
Medication overuse headache
Name another type of headache
Trigeminal neuralgia
What is a cluster headache?
Most disabling of primary headache disorders
Headache causing excruciating pain around one eye, temple or forehead
How common are cluster headaches?
Distinct from migraines Much rarer than migraines 1 per 1000 More common in men Affects adults between 20-40 Commoner in smokers
What can increase your risk of getting cluster headaches?
Smoker
Male
Autosomal dominant gene has role
What is the pathology of cluster headache?
Unknown
Superficial temporal artery smooth muscle hyper-reactivity to serotonin
Hypothalamic grey matter abnormalities
How do cluster headaches present?
Sudden onset of excruciating pain around on eye, temple or forehead
Ipsilateral cranial autonomic features
- Eye may become watery and bloodshot with lid swelling and lacrimation
- Facial flushing
- Rhinorrhoea
- Miosis +/- ptosis
Pain unilateral and almost always affects same side
Rises to crescendo over minutes lasts 15-160 mins, one/twice per day - usually at same time
Nocturnal/early morning
+/- vomiting
Episodic - clusters last 4-12 weeks and followed by pain-free periods of months or even 1-2 years before next
Can be chronic (last for more than 1 year without remission)
What could be a differential diagnosis of cluster headaches?
Migraine
SAH
How are cluster headaches diagnosed?
Clinical diagnosis
Rule out differentials
At least 5 headache attacks fulfilling above criteria
How can you treat an acute attack of cluster headaches?
Analgesics don’t help
100% 15L for 15mins via non-rebreathable mask
Triptan
How can you prevent cluster headaches?
CCB eg verapamil first line
Avoid alcohol
Corticosteroids can help
What is a migraine?
Recurrent throbbing headache often preceded by aura and associated N&V, and visual changes
What might you get in a migraine aura?
Fortification spectra (zig-zag lines) Shimmering Scotomas (black holes in visual field) Results in pins and needles Dysphasia Weakness of limbs and motor function
How common is migraine?
Most common cause of episodic recurrent headache
More common in women
90% onset before 40
If > 50 then pathology sought
Usually severity decreases with advancing age
What can trigger a migraine?
CHOCOLATE Chocolate Hangovers Orgasms Cheese Oral contraceptives Lie-ins Alcohol Tumult - loud noise Exercise
What might cause a migraine?
Brain chemical imbalance
Changes in brainstem and interactions with trigeminal nerve
What can increase your risk of migraine?
Strong genetic component - FHx
Female
Age - can occur at any age but majority have first migraine in adolescence
What is the pathology of migraine?
Genetic and environmental factors play role
Genetics - neuronal hyper-excitability
Changes in brainstem blood flow lead to unstable trigeminal nerve nucleus and nuclei in basal thalamus
Cortical spreading depression - self-propagating wave of neuronal and glial depolarisation spreading across cerebral cortex thought to cause aura of migraine and leads to release of inflammatory mediators impacting on trigeminal nerve nucleus
Results in release of vasoactive neuropeptides including calcitonin gene related peptide and substance P - results in process of neurogenic inflammation - vasodilation and plasma protein extravasation leading to pain the propagates all over cerebral cortex
What might you get before a migraine and what might it entail?
Prodrome hours/days before - yawning, cravings, mood/sleep changes
Aura
- Visual - chaotic cascading, jumbling, distorting lines, dots, zigzags, scotoma, hemianopia
Somatosensory
- Paraesthesia spreading from fingers to toes
How does a migraine present?
Attacks lasting 4-72 hours Two of the following - Unilateral - Pulsing - Moderate/severe pain - Aggravated by routine physical activity During headache at least one of - Nausea and/or vomiting - Photophobia and phonophobia Not attributable to another disorder
How might a migraine with aura present?
At least 2 attacks
Aura precedes attack by minutes and may persist during it
Unilateral, pulsatile headache
What could be a differential diagnosis of migraine?
Tension headache Cluster headache Medication over-use headache Meningitis/SAH if sudden Thromboembolic TIA Brain tumour Temporal arteritis
How do you diagnose migraine?
Clinical diagnosis
What might you examine to rule out other differentials?
Eyes - papilloedema and other eye issues
BP
Head and neck (scalp, neck muscle and temporal arteries)
What tests might you do to rule out other differentials?
CRP and ESR
MRI/CT if red flags
LP
When would you do an LP?
Worst headache of life
Severe rapid onset headache
Progressive headache
Unresponsive headache
How do you treat migraine?
Reduce triggers Acute - Triptans - NSAIDs - +/- anti-emetic Prevention - Beta-blocker/tricyclic antidepressant/anti-convulsant if > 2 attacks per month or acute treatment required > 2x per week
What are the side effects of triptans?
Arrhythmias
Angina
MI
When are triptans CI?
IHD
Coronary spasm
Uncontrolled high BP
What is a tension headache?
Most chronic daily and recurrent headaches are tension headaches
How common are tension headaches?
Commonest primary headache
Can be episodic < 15 days/month or chronic > 15 days/month for at least 3 months
No organic cause
What can cause tension headaches?
Stress Sleep deprivation Bad posture Hunger Eyestrain Anxiety Noise
How do tension headaches present?
Usually has one of the following - bilateral, pressing/tight non-pulsatile, mild/moderate pain, +/- scalp muscle tenderness No vomiting/sensitivity to head movement No aura Not aggravated by physical activity Tight band-like sensation Pressure behind eyes Last from 30 mins to 7 days Not attributed to another disorder
What could be a differential diagnosis for tension headaches?
Migraine
Cluster
GCA
Drug-induced
How are tension headaches diagnosed?
Clinical
How can you treat tension headaches?
Reassurance and lifestyle advice Stress relief Symptomatic treatment - Aspirin/paracetamol/NSAIDs Limit analgesia to prevent medication overuse
When might you get medication over-use headaches?
Worsens whilst on regular analgesics espec opioids
Other causes are mixed analgesics
What is trigeminal neuralgia?
Chronic, debilitating condition resulting in intense and extreme episodes of pain
What are the branches of the trigeminal nerve?
1 - ophthalmic
2 - maxillary
3 - mandibular
How common is trigeminal neuralgia?
Peak incidence between 50-60 More common in women Prevalence increases with age May be due to genetic predisposition Almost always unilateral
What is the cause of trigeminal neuralgia?
Compression of trigeminal nerve by a loop of vein or artery
Local pathology - aneurysms, meningeal inflammation, tumours eg vestibular schwannoma - local pathology more common in younger people as cause of compression
5th nerve lesion due to pathology
- With brainstem - tumour, multiple sclerosis, infarction
- At cerebellopontine angle - acoustic neuroma, another tumour
- Within petrous bone - spreading middle ear infection
- Within cavernous sinus - aneurysm of internal carotid, tumour or thrombosis of cavernous sinus
What can increase your risk of trigeminal neuralgia?
Hypertension
Triggers - washing affected area, shaving, eating, talking, dental prothesis
What happens when the nerve is compressed in trigeminal neuralgia?
Demyelination and excitation of nerve resulting in erratic pain signalling
How does trigeminal neuralgia present?
Almost always unilateral
At least 3 attacks of unilateral facial pain
Facial pain occurring in one or more distribution of trigeminal nerve, with no radiation beyond trigeminal distribution
Pain has at least 3 of the following
- Reoccurring in paroxysmal (sudden and frequent) attacks from a fraction of a second to 2 minutes
- Severe intensity
- Electric shock like, shooting, stabbing, or knife-like
- Precipitated by innocuous stimuli by affected side of face eg washing or shaving
What are the differential diagnoses of trigeminal neuralgia?
GCA/temporal arteritis Dental pathology Temporomandibular joint dysfunction Migraine Cluster headaches
