Headache: a clinical approach Flashcards
What are primary headaches?
sometimes referred to as tension headaches or migraines
What is trigeminal neuralgia?
primary headache syndrome = agony and disabling
trigeminal nerve becomes demyelinated
What are tension type headaches?
usually last weeks-months
tight band there all the time but you can continue to do your normal things
they tend to be associated with stiffness in the neck but it is important to check they don’t have papilloedema
What factors need to be considered for tension type headaches and what are the treatments?
1) medication overuse? - detox
2) cervicogenic headache (wear and tear in the cervical neck) - physiotherapy
3) need glasses
4) consider migraine - tricyclic antidepressants and SSRIs
What are the rules for migraines?
episodic
better when lying down
associated features
What are the 4 stages of acute migraine?
1) prodrome - hours
2) aura (20%)- minutes to hours
3) headache + associated features = hours to days
4) postdrome - usually 1-2 days
What are the common non-headache manifestations of chronic migraine?
chronic fatigue, autonomic symptoms, myokymia, neck pain, back pain, sensory disturbances, restless legs, reflex syncope, stimulus sensitivity, migraine related dysequilibrium, stuttering
How are migraines managed?
1) lifestyle - detox, no caffeine, look for triggers
2) rescue treatment - NSAIDs and antiemetica
3) triptans
4) prophylaxis - beta blockers, topiramate, candesartan (teratogenic), TCAs, SNRIs
5) BOTOX
6) referral - flunarizine, methysergide, dihydroergotamine, pizotifen, valporate
7) erenumab, fremanexuumab = very very expensive
What are cluster headaches?
comes and goes, period of 3-4 weeks everyday and then period of nothing, there is a kind of hormonal element to them
they can wake you up and there is a diurnal pattern to them
hemicranial and it is always on the same side of the head and they do switch over they don’t switch back
droopy eye, miosis, conjunctivial reddeing, and tears on the same side of head
tend to last about 30 mins to several hours
What is the severity of primary headache syndromes?
worst = SUNCT
paroxysmal hemicrania
cluster headache
hemicrania continus
What are the rules for trigeminal autonomic cephalalgias?
1) strictly side-locked
2) autonomic activation
3) agitiation
What are the treatments for trigeminal autonomic cephalalgias?
1) rescue - fast acting triptan e.g. sub cut sumitriptan, nasal zolmitripta
2) break the cluster - oral prednisolone 60mg OD reduce by 10mg every 3 days
3) prophylaxis - depends on duration
4) indometacin
5) needs MRI
What prophylactic treatments are used for:
- SUNCT
- Paroxysmal hemicrania
- cluster headaches
- hemicrania continua
SUNCT= lamotrigine (rash)
paroxysmal hemicrania = indometacin (kidney injury, ulcer)
cluster headache = verapamil (heart block - can be delayed)
hemicrania continua = indometacin
What are the rules for trigeminal neuralgia?
demyelinated axon - steady flow of sodium into the cell - can be caused in MS
1) one branch of trigeminal nerve
2) stabbing pain
3) triggered (cold wind, eating/drinking, touch sensitive)
4) need to detox to get clear picture
What are the treatments for trigeminal neuralgia?
1) carbamazepine
2) maximum carbamazepine - refer to neurosurgery
3) oxycarbamazepine
4) another AED
need an MRI
What are examples of secondary headaches?
raised ICP
thunderclap headache
vascular problems
sinusitis
How can raised intracranial pressure arise?
increased arterial blood pressure = malignant hypertension, pre-eclampsia, hypercapnia
increased CSF pressure = obstruction to flow(mass, meningitis), failure of re-absorption, overproduction
increased brain pressure - space occupying lesion (blood, cancer, infection)
increased venous blood pressure - cerebral venous sinus thrombosis
meningeal inflammation - infection, autoimmune, cancer
What red flags are there for secondary headaches?
1) papilloedema
2) seizures, focal neurological signs, cancer of HIV
3) visual disturbances
4) postural change (worse on lying down)
5) pregnancy
6) nausea and vomiting
7) previous history of vasculitis
8) diabetes - old man with temp and new onset hearing loss
9) getting progressively worse
10) morning headache or waking from sleep
What are thunderclap headaches?
first presentation of thunderclap headaches = hospital = very sudden onset, gets as bad as its going to be in minutes
- rarely subarachnoid haemorrhage
- sometimes meningitis, CVST or pituitary apoplexy
- sometimes CSF leak
- mostly migraine
What happens in hospital if you have a thunderclap headache?
need a CT within first 6 hours - sensitivity is almost 100%
if CT is negative do a lumbar puncture
What are the symptoms of a carotid artery dissection?
neck pain, facial pain and horner’s syndrome - risk of anterior circulation stroke
What are the symptoms of a vertebral artery dissection?
neck pain, sudden onset, vertigo or ataxia= risk of posterior circulation stroke
What are the rules for temporal arteritis?
1) extremely rare below 60
2) ESR and/or CRP raised
How is temporal arteritis managed?
1) refer immediately to rheumatology
2) steroids
3) US of temporal artery and biopsy within a week
