Headache Flashcards
important points to explore in a history?
SOCRATES
triggers
auras, visual disturbances
red flags
red flags for headache?
new onset HA >55 new/ previous Hx of malignancy immunosuppressed early morning HA which wakes you up exacerbated by valsalva manouvre persistent severe headache, worse at night associated weight loss
what ees dees?
a common cause of headache which occurs intermittently characterised by recurrent
episodes of headache lasting a few hours to a few days.
migraine
attacks of migraine can usually be associated with known triggers e.g.
stress skipping meals binge eating menstruation or ovulation oral contraceptive bright sunshine
clinical features of migraine?
at least 5 attacks in 5-72hrs:
- unilateral throbbing headache
- worse on movement
- photo/phonophobia (require dark room)
- N&V
how may migraine present differently in children?
shorter, may be bilateral, more prominent GI symptoms
T/F: most migraines occur with aura
false - 20%
what is an aura? (with migraine)
reversible visual, auditory, motor or language symptoms inc zigzag lines, central or hemianopic scotoma, aphasia and muscle weakness occurring before or at the start of the headache
which medication is completed contraindicated in pts with migraine with aura and why?
COCP- significantly increased risk of ischaemic stroke
diagnosis of migraine?
no other physical symptoms: clinical
weakness, aphasia, other Sx: CT scan (rule out stroke)
treatment of migraine?
trigger avoidance
mild: high dose NSAID +/- antiemetic
severe: oral triptan (rizatriptan, sumatriptan) +/- NSAID +/- antiemetic (even w/o N&V)
SEs of triptans?
dizzy, drowsy, altered temperature sensation, tingling sensations, chest/ throat tightness or heaviness
contraindications of triptans?
coronary vasospasm
ischaemic heart disease
previous cerebrovascular accident
what can be used as migraine prophylaxis? indications for this?
> 3 attacks/ month or severe
- propranolol or topiramate
how is a tension type headache often described?
tight band around head often radiating to neck
triggers of tension type headache?
stress, depression, anxiety
believed to be caused by stiffening of muscles of face and neck
clinical features of tension type headache?
band like pressure around head radiating to neck
tingling sensation in head
absence of what clinical features is important for a diagnosis of tension headache?
N&V or photo/phonophobia
treatment of tension type headache?
reassurance
relaxation
amitriptyline in chronic refractory tension type HA
what are Trigeminal autonomic cephalgias?
a group of HA disorders categorised by unilateral pain (often severe) in distribution of trigeminal nerve. Often associated with autonomic symptoms on ipsilateral side
3 types of TAC?
cluster HA
trigeminal neuralgia
paroxysmal hemicrania
where did cluster headache get its name?
tends to occur in clusters during the day (1-8 times) and for a certain period of the year (weeks-months) before ceasing for a long period of time
demographic for cluster HA?
men 20-55
clinical features of cluster HA?
1) symptoms
2) timing
3) how often/ day
severe unilateral stabbing retro-orbital, supra-orbital or temporal region pain
ipsilateral autonomic features: ptosis, miosis lacrimation, nasal stuffiness, chemosis
cicardian rhythm of onset (often night or early morning)
last 10 minutes - 3 hours, 1-8 times/ day
diagnosis of cluster HA?
usually clinical
MRI + MR angiogram to rule out secondary cause
treatment of cluster HA?
1) acute
2) prophylaxis
1) high flow oxygen + SC sumatriptan
2) verapamil
how to differentiate paroxysmal hemicrania from a cluster HA?
- shorter (10-30 mins)
- more frequent (1-40/ day)
- more common in females, older age of onset (50-60)
treatment of paroxysmal hemicrania?
indomethicin (complete response)
what does SUNCT stand for? (a type of TAC)
short-lived
unilateral (temporal, retroorbital and supraorbital regions)
neuralgiaform (single stabs, series of stabs or saw-tooth pattern)
conjunctival injection
tearing
treatment of SUNCT?
lamotrigine, gabapentin
what causes trigeminal neuralgia?
disorder of the trigeminal nerve, most commonly due to compression of vascular origin. Can also be demyelinating disease/ neoplastic compression
Trigeminal neuralgia
The __ and __ divisions of the nerve are most commonly affected and symptoms tend to be UNILATERAL/ BILATERAL
maxillary and mandibular
unilateral
clinical features of trigeminal neuralgia?
electric shock-like pain usually around the nose or mouth
pain lasts up to 90 seconds and can go on for weeks-months
exacerbated by touching, cold wing, shaving/ brushing teeth, talking, eating, drinking
Ix in trigeminal neuralgia?
MRI brain
Rx of trigeminal neuralgia?
1) carbamazepine
2) neurosurgical debulking or radiofrequency ablation
HAs caused by increased intracranial pressure may be due to benign causes e.g. … or ore sinister aetiologies e.g. …
IIH
brain tumours
what is a medication HA?
headache lasting 15 days which started/ got worse while the patient was on regular medication and improved within 2 months of discontinuation
name 3 types of activity-related HA?
primary cough HA
primary exertional HA
primary sexual HA
describe the HA in the following vascular disorders
1) subarachnoid haemorrhage
2) carotid dissection
3) giant cell arteritis
1) sudden onset occipital thunderclap, signs of meningism
2) spontaneous or due to hyperextension neck injury. Pain in head/ neck and symptoms of ischaemia distal to the dissection with horner syndrome
3) scalp tenderness, jaw claudication
HAs caused by increased intracranial pressure may be due to benign causes e.g. … or ore sinister aetiologies e.g. …
IIH
intracranial neoplasm, abscess
what is idiopathic intracranial hypertension? (IIH)
idiopathic process of chronically raised CSF pressures in the brain occurring w/o any discernible SOL
who does IIH tend to occur in?
young obese females
clinical features of IIH?
HA: throbbing type, worse in morning, relieved
on standing.
Bilateral papilloedema.
N&V
Less commonly, CNVI palsy due to increased ICP
Ix in IIH
- MRI/ CT
- visual field testing
- LP
MRI/CT: slit like ventricles
VF: papillodeoma > enlarged blind spot
LP: high opening pressure
treatment of IIH?
1) weight loss (usually sufficient)
2) acetazolamide (decreases CSF production)
3) lumboperitoneal shunt
what Ix must be carried out in all patients with TACs?
MRI and MR angiogram to rule out secondary causes
describe the features of primary cough HA. Cause?
occurs on coughing
sharp, bilateral pain lasting short duration
most have underlying cause (Chiari malformation, aneurysm)
describe the features of primary exertional HA.
occurs with exercise
bilateral, pulsating
describe the features of primary sexual HA.
early coital cephalgia: dull occipital aching, worsens with sexual excitement
post-coital cephalgia: severe and maximal during orgasm
Migraine triggers?
CHOCOLATE: chocolate hangovers orgasms cheese/caffeine oral contraceptives lie-ins alcohol travel exercise
Migraine triggers?
CHOCOLATE: chocolate hangovers orgasms cheese/caffeine oral contraceptives lie-ins alcohol travel exercise
