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4th Year Neuro > Headache > Flashcards

Headache Flashcards

1
Q

A 30 year old female sees her GP complaining of a severe, throbbing, left-sided headache. She says the headache came on suddenly over 10 minutes. She describes a strange fluttering of her vision before the headache. Paracetamol has not improved the pain.

What is the most likely diagnosis?

A

Migraine

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2
Q

How are headaches classified?

A

Primary - not caused by an underlying condition

Secondary - caused by an underlying cause

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3
Q

What are the primary causes of headaches?

A
  • Migraine
  • Tension
  • Cluster
  • Other
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4
Q

What are the secondary causes of headaches?

A
  • Vascular
  • Non-vascular
  • Infection
  • Trauma
  • Toxins and medications
  • Disorders of haemostasis
  • Ocular, ear or sinus related
  • Psychiatric
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5
Q

Headache history taking: presenting complaint

A

Site: unilateral, bilateral, occipital, temporal, peri-orbital

Onset: sudden or gradual

Character: throbbing, sharp, tension

Radiation:

Associated symptoms: aura, nausea, lacrimation, seizures, fever, neck stiffness

Timing: hours or days

Exacerbating factors: straining, lying flat, trauma

Severity: 0-10, pain wakes patient up at night, analgesia used

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6
Q

Headache history taking: general principles

A

Past medical history

  • Chronic disease eg HTN, migraine
  • Trauma

Family history

  • Migraine

Drug history

  • Anticoagulants: essential to ask if the patient has a head injury
  • Analgesia: medication overuse
  • COCP: absolute contraindication in those with migraine with aura

Social history

  • Narcotics
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7
Q

Headache examination

A
  • Evidence of trauma
  • Temporal artery palpation
  • Neurologcial deficit
  • Oral cavity examination
  • Eye examination
  • Fundoscpoy
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8
Q

Red flags in headache:

A

Raised ICP:

  • Worse on lying flat
  • Worse at night/morning
  • Exacerbated by Valsava maneuver
  • Vomiting
  • Papilloedema
  • Neurological deficit

Subarachonoid haemorrhage:

  • Sudden-onset thunderclap occipital headache

Infection:

  • Fever, neck stiffness, photophobia
  • Reduced GCS
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9
Q

Raised ICP causes:

A
  • Space occupying lesion
  • Intracranial bleed
  • Congenital malformation
  • Idiopathic intracranial HTN
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10
Q

Headache investigations

A
  • Bedside
    • Observations: Blood pressure, temperature
    • Glucose (hyperglycaemia can be associated with a headache)
    • Pregnancy test (pre-eclampsia)
  • Bloods
    • Inflammatory markers: infection
    • ESR: giant cell arteritis
  • Imaging
    • CT head: non-contrast imaging is first line for an intracranial bleed
    • MRI head: space occupying lesion
  • Special tests:
    • Lumbar puncture: rule out infection and subarachnoid haemorrhage
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11
Q

Definition of migraine

A

Primary headache characterised by severe pain with associated symptoms such as aura and photophobia

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12
Q

Epidemiology of migraine

A
  • Global prevalence of ~15%
  • Often underdiagnosed
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13
Q

Risk factors for migraine

A
  • Age 25-55 years
  • Female 3x more common
  • Family history
  • Obesity
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14
Q

Triggers of migraine

A

Chocolate

Oral Contraceptive

Alcohol

Anxiety

Travel

Exercise

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15
Q

What is aura?

A

Neurological deficit which precedes a headache

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16
Q

Classification of migraine

A
  • Migraine with aura
    • Typical aura
    • Atypical aura: brainstem symptoms or hemiplegia
  • Migraine without aura
  • Chronic migraine
    • ≥ 15 days per month for > 3 months
17
Q

Clinical features of migraine

A
  • Severe, unilateral, pulsating headache
    • lasting up to 72 hours
    • Aggravated by exertion
  • Nausea and vomiting
  • Photophobia and phonophobia
  • Aura
18
Q

Describe typical aura

A

Lasts 5-60 minutes and is fully reversible

  • Visual symptoms eg flashing zigzag lines
  • Paraestheia
  • Speech disturbance
19
Q

Describe atypical aura

A

May last more than 60 minutes

  • Motor weakness
  • Diplopia
  • Visual symptoms affecting one eye
  • Vertigo and/or poor balance
20
Q

Management of migraine

A
  • Analgesia
    • Aspirin 900mg or ibuprofen or paracetamol
    • Oral Triptan (nasal if aged 12-17) alone or in combination with paracetamol or NSAID
  • Antiemetic
    • Metoclopramide or prochlorperazine
  • Avoid opiates due to risk of medication overuse headache, dependence and worsening nausea
21
Q

Prophylaxis for migraine

A
  • Propranolol: 80-160mg
  • Topiramate: increased risk of congenital malformation
22
Q

Definition of tension headache

A

Primary headache characterised by mild to moderate, generalised pain, often radiating into the neck.

23
Q

Epidemiology of tension headache

A
  • Most common primary headache
  • Global prevalence 40-50%
24
Q

Risk factors for tension headache

A
  • Age: onset 20-30 years of age
  • Female: 1.5x more common
  • Stress: most common trigger
25
Q

Clinical features of tension headache

1) Site
2) Severity
3) Effect of exertion
4) Duration
5) Associated symptoms
6) Nausea?
7) Photophobia or phonophobia?

A
  1. Bilateral pressure
  2. Mild to moderate in severity
  3. Not affravated by exertion
  4. Lasts for 30 minutes to 7 days
  5. Associated trapezius tenderness
  6. No evidence of moderate or severe nausea
  7. No more than one of photophobia or phonophobia
26
Q

Acute management of tension headache

A
  • Analgesia
    • Ibuprofen or aspirin or paracetamol
    • Avoid opiates: risk of medication overuse headache, dependence, and worsening nausea
27
Q

Chronic management of tension headache

A
  • Acupuncture: up to 10 sessions over 2 months
  • Prophyaxis: low dose amitriptyline may be considered
28
Q

Definition of cluster headache

A

Rare cause of primary headache characterised by severe unilateral periorbital pain and autonomic features.

29
Q

Risk factors for cluster headache

A
  • Age: onset 20-40 years of age
  • Male: 4x more common
  • Alcohol
  • Smoking
  • Head trauma
30
Q

Classification of cluster headache

A
  • Episodic: pain free remission ≥ 3 months
  • Chronic: no remission period or remission period < 3 months
31
Q

Clinical features of cluster headache

A
  • Very severe unilateral periorbital pain
    • Lasts 15 minutes to 3 hours
  • Ipsilateral autonomic symptoms
    • Lacrimation
    • Conjunctival injection
    • Nasal congestion
    • Rhinorrhoea
    • Ptosis
    • Miosis
  • Nausea and vomiting
  • Clusters: frequency between one every day and 8 per day followed by periods of remission
32
Q

Acute management of cluster headache

A
  • Triptans: subcutaneous or intranasal triptal provides symptomatic relief within 15 minutes in 75% of patients
  • High flow oxygen: symptomatic relief within 15 minutes in 70% of patients
33
Q

Prophylaxis for cluster headaches

A

Verapamil

34
Q

A 15-year-old female presents to her GP complaining of a new headache over the last month. She describes it as a pulsating pain in the front of her head on both sides and it usually lasts for over a day. When the headache occurs, she feels sick but denies any visual or auditory symptoms.

The headaches have caused her to come home from school on four occasions, and paracetamol does not seem to help.

A

Migraine

Migraine is a common condition in children. Diagnostic criteria for children are broader than for adults and bilateral headaches are usually seen with children, in comparison to unilateral headaches in adults.

Additionally, a throbbing headache lasting over 24 hours is typical of a migraine. The absence of an aura does not exclude a migraine, as migraine without aura is actually more common.

35
Q

Triptans are which class of drugs?

A

5HT receptor agonists

4th Year Neuro (12 decks)

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