Headache: A Clinical Approach Flashcards
What are the commenest headache conditions
migraine, tension headache, medication overuse headache
What are the more serious conditions that cause headache?
cluster headache, tumour, CNS infection
What is the commonest theory for the pathogenesis of migraine?
- neuro-vasuclar theory, activation of trigeminovascular system
How can an aura present in a migraine?
- visual auras are the most common, flashing lights, zizzag lines, certification spectre, paracentral scotoma
- hemianopia
- sensory parasthesia
- hemiparesis
- ompthalmoparesis
What are the features of migraine without aura?
- headaches are often longer and more frequent, with the pain typically spreading bilaterally
- more common in females from 30-50 who have generally experienced aura through their teens and twenties
What are the associated symptoms during the headache phase of migraine?
nausea, vomiting, photophobia, phonophobia
What is migraine pain like?
- the headache is usually severe enough to put people to bed and typically is a throbbing, unilateral pain that become worse on activity
What is the first treatment of migraine?
- removal of any triggers such as chocolate, cheese, alcohol, dehydration, fasting
- also menstruation, exercise, travelling, stres
What is the acute treatment for mirgraine
- analgesics (NSAIDs, paracetamol)
- anti-emetics (domperidone or metoclopramide), and triptans (5-HT antagonists e.g. sumitriptan)
What are prophylactic drugs for migraine?
- beta blockers e.g. propanolol
- antiepileptics e.g. topiramate
- TCA’s, but sedative effects
- acupuncture and botox
When are prophylactic treatments used?
- only in severe ceases where there are >4 migraines a month
- the does are built up to avoid side effects and then titrated up until symptoms are controlled
How do tension headaches present?
- bilateral pressure, band like
- can be episodic or continuous
- may go along features of anxiety, such as panic attacks
How are tension headaches managed?-
stress management and reassurance
- lifestyle changes
- analgesia (never codeine!)
- psych referral
- prophylaxis, TCAs and SSRIs
How can a diagnosis of a medication overuse headache be made?
- the headaches attenuate after 3 months of drug withdrawal
which drugs cause medication overuse headache
codeine
ergotaline
triptans
What is the presentation of cluster headache?-
cluster of headaches which only last 30-60 minutes around 4-5 times a day, more often at night.
- typically they cause incredibly severe unilateral pain in the ocular or frontal regions, the patient will be incredibly agitated, and it is coupled with autonomic syndrome
- typically one eye will water, and the conjunctiva will go red
- there will be unilateral nasal discharge
How can cluster headaches be investigated?
MRI , as there may be evidence of pituitary lesion that can irritate the trigeminal nerve
How are cluster headaches managed?
- acute treatment, subcutaneous or nasal sumatriptan alongside oxygen
- prophylaxis includes verapamil, lithium and prednisone
Cluster headaches are a form of ……….
Terminal autonomic cephalgias (TACs)
What does temporal arteritis affect?
0 the branches of the external carotid arteries
What are they features of temporal arteritis?
headache, scalp tenderness, jaw claudication, fever, weight loss, anaemia, increased ALP, proximal muscle weakness (polymyalgia rheumatica)
What is the age group affected by temporal arteritis?
- over 50
What are the investigations for temporal arteritis?
- blood tests, particularly ESR, which will be raised
- temporal artery biopsy can be performed under local but has poor sensitivity
What are the complications of temporal arteritis?
- blindness, if the internal carotid arteries are affected
- TIA or stroke
What is the treatment for temporal arteritis?
- treatment takes 2-3 years before symptoms are eradicated
- involves high does (60mg daily) of prednisolone to give an immediate response, and then dose is titrated down
How does idiopathic intracranial hypertension present?
- non-specific featureless chronic headache
- visual obscurations can occur leading to temporary blinding and there may be VI nerve palsies
What is the main clinical sign in IIH?
papilloedema
What are the precipitating factors for IIH?
- hormonal: obesity, OCP, pregnancy, steroid therapies
- some antibiotic treatments
How is IIH diagnosed?
- lumbar puncture, demonstrating raised pressure of >40
- CT and MRI should be used to exclude venous sinus thrombosis and tumour
How IIH managed?
- neuro-opthalmology
- closely monitoring visual fields to ensure vision is not impaired
- remove any precipitating agents
- weight loss encouraged
- acetazolamide and other diuretics can be useful
- surgical therapy includes limbo-peritoneal shouting or optic nerve sheath re-fenestration to permanently relieve pressure
How does trigeminal neuralgia present?
- sever stabbing pain triggered by factors such as touch and chewing
- most commonly felt in the maxillary division of the trigeminal nerve unilaterally
How is TN managed?
- oral pregabaline or gabapentin
- can be treated with the injection of alcohol at the foramen rotundum, however this runs the risk of nerve damage
How does headache associated with tumours present?
- meningiomas will cause constant headache, usually in the right fronto-temporal region, and other symptoms such as slurred speech, arm weakness, and facial spasm
- if there are focal symptoms and signs on one sign of the body, this is a red flag for a tumour
