Headache Flashcards
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?
Migraine
How are headaches classified?
Primary - not caused by an underlying condition
Secondary - caused by an underlying cause
What are the primary causes of headaches?
- Migraine
- Tension
- Cluster
- Other
What are the secondary causes of headaches?
- Vascular
- Non-vascular
- Infection
- Trauma
- Toxins and medications
- Disorders of haemostasis
- Ocular, ear or sinus related
- Psychiatric
Headache history taking: presenting complaint
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
Headache history taking: general principles
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
Headache examination
- Evidence of trauma
- Temporal artery palpation
- Neurologcial deficit
- Oral cavity examination
- Eye examination
- Fundoscpoy
Red flags in headache:
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
Raised ICP causes:
- Space occupying lesion
- Intracranial bleed
- Congenital malformation
- Idiopathic intracranial HTN
Headache investigations
- 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
Definition of migraine
Primary headache characterised by severe pain with associated symptoms such as aura and photophobia
Epidemiology of migraine
- Global prevalence of ~15%
- Often underdiagnosed
Risk factors for migraine
- Age 25-55 years
- Female 3x more common
- Family history
- Obesity
Triggers of migraine
Chocolate
Oral Contraceptive
Alcohol
Anxiety
Travel
Exercise
What is aura?
Neurological deficit which precedes a headache
Classification of migraine
- Migraine with aura
- Typical aura
- Atypical aura: brainstem symptoms or hemiplegia
- Migraine without aura
- Chronic migraine
- ≥ 15 days per month for > 3 months
Clinical features of migraine
- Severe, unilateral, pulsating headache
- lasting up to 72 hours
- Aggravated by exertion
- Nausea and vomiting
- Photophobia and phonophobia
- Aura
Describe typical aura
Lasts 5-60 minutes and is fully reversible
- Visual symptoms eg flashing zigzag lines
- Paraestheia
- Speech disturbance
Describe atypical aura
May last more than 60 minutes
- Motor weakness
- Diplopia
- Visual symptoms affecting one eye
- Vertigo and/or poor balance
Management of migraine
- 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
Prophylaxis for migraine
- Propranolol: 80-160mg
- Topiramate: increased risk of congenital malformation
Definition of tension headache
Primary headache characterised by mild to moderate, generalised pain, often radiating into the neck.
Epidemiology of tension headache
- Most common primary headache
- Global prevalence 40-50%
Risk factors for tension headache
- Age: onset 20-30 years of age
- Female: 1.5x more common
- Stress: most common trigger
Clinical features of tension headache
1) Site
2) Severity
3) Effect of exertion
4) Duration
5) Associated symptoms
6) Nausea?
7) Photophobia or phonophobia?
- Bilateral pressure
- Mild to moderate in severity
- Not affravated by exertion
- Lasts for 30 minutes to 7 days
- Associated trapezius tenderness
- No evidence of moderate or severe nausea
- No more than one of photophobia or phonophobia
Acute management of tension headache
- Analgesia
- Ibuprofen or aspirin or paracetamol
- Avoid opiates: risk of medication overuse headache, dependence, and worsening nausea
Chronic management of tension headache
- Acupuncture: up to 10 sessions over 2 months
- Prophyaxis: low dose amitriptyline may be considered
Definition of cluster headache
Rare cause of primary headache characterised by severe unilateral periorbital pain and autonomic features.
Risk factors for cluster headache
- Age: onset 20-40 years of age
- Male: 4x more common
- Alcohol
- Smoking
- Head trauma
Classification of cluster headache
- Episodic: pain free remission ≥ 3 months
- Chronic: no remission period or remission period < 3 months
Clinical features of cluster headache
- 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
Acute management of cluster headache
- 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
Prophylaxis for cluster headaches
Verapamil
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.
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.
Triptans are which class of drugs?
5HT receptor agonists
