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HEADACHE AND FACIAL PAIN Flashcards

1
Q

Causes of headaches?

A

Tension headaches
Migraines
Cluster headaches
Secondary headaches
Sinusitis
Giant cell arteritis
Glaucoma
Intracranial haemorrhage
Venous sinus thrombosis
Subarachnoid haemorrhage
Medication overuse
Hormonal headache
Cervical spondylosis
Carbon monoxide poisoning
Trigeminal neuralgia
Raised intracranial pressure
Brain tumours
Meningitis
Encephalitis
Brain abscess
Pre-eclampsia

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2
Q

Headache red flags?

A

Compromised immunity e.g. HIV
Age <20 and Hx of malignancy
History of malignancy known to metastasise to the brain
Vomiting without other obvious cause
Worsening headache with fever
Sudden-onset headache reaching maximum intensity within 5 mins - “thunderclap”
New onset neurological deficit
New-onset cognitive dysfunction
Change in personality
Impaired level of consciousness
Recent head trauma
Headache triggered by cough, vasalva, sneeze or exercise,
orthostatic headache
Symptom suggestive of temporal arthritis or acute narrow-angle glaucoma
Substantial change in characteristics of headache

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3
Q

What are primary vs secondary headaches?

A

Primary headaches — these are not associated with another underlying condition, and include tension-type headache.
Secondary headaches — these are precipitated by another condition or disorder e.g. cancer

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4
Q

What are the 3 categories for tension headaches?

A

Infrequent episodic — less than 1 day of headache per month.
Frequent episodic — at least 10 episodes of headache occurring on fewer than 15 days per month on average, for more than 3 months.
Chronic — this evolves from frequent episodic tension-type headache, with 15 days or more of headache per month, for more than 3 months, in the absence of medication overuse.

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5
Q

Most common type of primary headache disorder?

A

Tension headache

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6
Q

Clinical features of tension type headache?

A

Recurrent episodes of headache lasting from 30 minutes to 7 days which are not associated with nausea or vomiting.
The headache may also be associated with no more than one of photophobia or phonophobia, and…

The headache has at least two of:
- Bilateral location.
- Pressing, tightening, non-pulsating quality (‘like a tight band’)
- Mild/moderate intensity.
- Not aggravated by routine physical activity

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7
Q

What can trigger tension-type headaches?

A

Stress
Sleep problems
Caffeine

Others:
Mood disorders
Poor posture
Neck pain
Alcohol
Skipping meals
Dehydration
Eye strain

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8
Q

Management of tension headaches?

A

Simple analgesia
Manage triggers
If frequent episodic or chronic then avoid excessive use of analgesia
Acupuncture, CBT or PT may be useful
Prophylaxis with amitryptiline can be used

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9
Q

What are trigeminal autonomic Cephalalgias?

A

A group of primary headache disorders characterised by strictly unilateral trigeminal distribution pain occurring in association with ipsilayeral cranial autonomic symptoms

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10
Q

Examples of trigeminal autonomic cephalalgias?

A

Cluster headaches - MC
Paroxysmal hemicrania
Short-lasting neuralgiform attacks with conjunctival injection and tearing or short-lasting neuralgiform attacks with cranial autonomic features
Hemicrania continua

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11
Q

What are episodic vs chronic cluster headaches?

A

Episodic — attacks occur in periods lasting from 7 days to one year and are separated by pain-free periods lasting at least 3 months.
Chronic — attacks occur for one year or longer without remission, or with remission periods lasting < 3 months.

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12
Q

What environmental factors can trigger acute attacks of cluster headaches?

A

Alcohol
Smoking
Histamine
Nitrate-containing foods e.g. cured meats
Smell of volatile substances e.g. paint, nail varnish, petrol

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13
Q

Epidemiology of cluster headaches?

A

Rare
More common in men and smokers

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14
Q

Clinical features of cluster headaches?

A

Intense, sharp, stabbing pain around 1 eye that occurs once or twice a day lasting 15 mins-3 hours
Pt is usually restless and agitated during the attack due to severity
Accompanies with redness, lacrimation, lid swelling, nasal stuffiness and in some, mitosis and ptosis

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15
Q

How long do these clusters of cluster headaches typically last?

A

4-12 weeks

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16
Q

Investigtaions for ?cluster headaches

A

Neuroimaging - usually MRI with gadolinium contrast
(This is because even when clinical symptoms are typical for cluster headaches, occasionally underlying brain lesions are found)

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17
Q

Acute management of cluster headaches?

A

Sumatriptan
Short burst oxygen therapy high flow

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18
Q

Drug prophylaxis for cluster headaches?

A

Verapamil

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19
Q

What is paroxysmal hemicrania?
What drug does it best respond to?

A

A rare form of trigeminal autonomic cephalgia
Causes severe throbbing and claw-like pain usually on one side of the face near the eye and occasionally around the back of the neck. May also be red and tearing eyes
Responds best to indomethacin

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20
Q

How does ICHD define a medication overuse headache?

A

As a headache occurring on 15 or more days per month in a person with a pre-existing primary headache disorder, which develops as a consequence of regular overuse of 1 or more drugs taken for headache, for more than 3 months

Simple analgesics or aspirin taken on 15 days or more per months
Ergotamines, Triptans, opioids taken on 10 days of more per month

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21
Q

Which medications are most likely to cause a medication overuse headache?

A

Opioids
Triptans

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22
Q

Epidemiology of medication overuse headache?

A

Affects up to 50% of people with chronic headaches
More common in females
Highest in those aged 40-49

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23
Q

Management of medication-overuse headache?

A

Explain diagnosis
Withdraw medications for at least 1 month - stop Triptans, ergotamines and simple analgesics abruptly - exaplin that this may initially worsen headaches
Arrange regular review
Consider use of prophylactic meds for underlying primary headache is appropriate

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24
Q

Episodic vs chronic migraine?

A

Episodic migraine occurs on less than 15 days per month.
Chronic migraine is headache occurring on at least 15 days per month (with features of migraine headache on at least 8 days per month) for more than 3 months.

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25
Common triggers for migraines?
Disturbed sleep Irregular meals Excessive caffeine intake Lack of exercise Stress Alcohol COCP Bright lights Cheese, chocolate, red wine, citrus fruits Menstruation
26
Epidemiology migraine?
Common - 1in 7 3:1 women:men Most common age 25-55
27
What are the types of migraines?
Migraine without aura Migraine with aura Silent migraine (migraine with aura but without a headache) Hemiplegic migraine
28
The 5 stages of migraines?
Prodromal stage - several days before headache Aura - lasts up to an hour Headache - 4-72 hours Resolution Postdromal phase
29
Prodromal stage symptoms of migraine?
Fatigue Poor concentration Neck stiffness Yawning
30
Postdromal stage symptoms of migraine?
Fatigue Elated or depressed mood
31
Features of migraine headache?
Unilateral (bilateral in children) Pulsating Moderate-severe intensity Aggravated by routine ADLs and pt characteristically go to a dark quiet room Nausea/vomiting Photophobia and photophobia
32
How long does a migraine headache typically last?
4-72 hours
33
Aura symptoms in migraines?
Visual - zigzag lines, scotoma Sensory - unilateral pins and needles or numbness Speech or language - dysphasia Atypical: Motor weakness Double vision Visual symptoms only affecting 1 eye Poor balance Decreased level of consciousness
34
How long do aura symptoms typically last in a migraine?
5-60 minutes
35
Migraine diagnostic criteria?
At least 5 attacks Headaches last 4-72 hours Headaches have at least 2 of the following characteristics: unilateral, pulsating quality, moderate-severe intensity, aggravated by or causing avoidance of routine physical activity During the headache at least 1 of the following: n&v or photophobia/phonophpobia Not atttributed to another disordr
36
What is a hemiplegic migraine?
A variant of migraine in which motor weakness is a manifestation of aura in at least some attacks Around 50% have a strong FHx This is very rare!! Often mimic a stroke or TIA
37
Management of migraine?
Avoidance of triggers Simple analgesia (NOT opioids) Triptans (oral in adults, nasal in 12-17 YOs) Consider an anti emetic
38
Who should be offered preventive treatment for migraines?
If migraine attacks significantly impact QOL and daily function The person is at risk of medication overuse headaches Acute treatments are contraindicated or not effective
39
What preventative treatmwnt can be offered for migraines?
Propranolol or Topiramate or amitryptiline Consider non-pharmacological therapies too e.g. behavioural interventions, riboflavin or acupuncture
40
Management of predictable menstrual migraines?
Frovatriptan or zolmitroptan
41
How do Triptans work?
They are 5HT receptor agonists = cranial vasoconstriction, inhibit transmission of pain signals and inhibit the release of inflammatory neuropeptides
42
Contraindications for Triptans?
Coronary vasospasm, IHD, hypertension, PVD, previous CV accident or MI or TIA, prinzmetal’s angina
43
Headache diary
A diary that contains the duration, severity, other sympotms, acute medication and comments Helps a doctor make a diagnosis
44
Symptoms of encephalitis?
Fever Headache Psychiatric Sx Seizures Vomiting Focal features e.g. aphasia Changes in personality Confusion LOC
45
Cause of encephalitis?
HSV-1 is responsible for 95% of cases in adults
46
Which areas of the brain does encephalitis most commonly affect?
Temporal and inferior frontal lobes
47
Investigations for encephalitis?
Lumbar puncture Neuroimaging - MRI EEG
48
Management of encephalitis?
IV aciclovir
49
What is meningitis?
Inflammation of the 2 inner meninges the pia and arachnoid mater
50
What is meningococcal disease?
An infection with neisseria meningitidis It can result in meningococcal meningitis or meningococcal septicaemia
51
Most common causative organisms of bacterial meningitis in adults?
Streptococcus pneumoniae - most common Neisseria meningitidis Haemophilus influenzae type b
52
Complications of bacterial meningitis?
Death Cerebral infarction leading to focal neurological deficits - hearing loss, seizures, cognitive impairment, motor deficits, visual impairment Amputations Skin scars Reduced QOL Hydrocephalus Anxiety and emotional & behavioural difficulties Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage)
53
Presentation of meningitis and meningococcal septicaemia?
Fever N&V Headache Non-blanching rash - in meningococcal septicaemia Stiff neck Photophobia Drowsiness
54
What is Kernig’s sign?
When the pt is unable to fully extend at the knee when the hip is flexed - sign of meningitis
55
What is brudzinski’s sign?
When the pt’s knees and hips flex when the neck is flexed - sign of meningitis
56
CSF findings in bacterial meningitis?
Cloudy appearance Low glucose High protein White cells 10-5,000 polymorphs
57
Management of suspected bacterial meningitis with a non-blanching rash or meningococcal septicaemia if in the pre-hospital setting?
Single dose of parenteral benzoyl penicillin
58
Should you attempt a lumbar puncture in suspected bacterial meningitis or meningococcal septicaemia?
It considers aseptic technique and is technically diffiuclty so may take time and delay Tx On the other hand, having a CSF sample can be useful to confirm diagnosis and guide antibiotic Tx Lumbar puncture can’t be done if severe signs of sepsis, rapidly evolving rash, severe resp/cardiac compromise, significant bleeding risk or signs of raised ICP
59
Management of pt with suspected meningitis in hospital?
Take bloods and blood culture. Do lumbar puncture if it can be done within the first hour IV antibiotics - <50 give cefotaxime and if >50 give cefotaxime and amoxicillin Consider adjunctive treatment with IV dexamethasone
60
Management of contacts with meningitis?
Prophylaxis to household and close contacts within 7 days before the onset of illness - prophylactic oral ciprofloxacin or rifampicin
61
Is meningitis and meningococcal disease notifiable?
Yes
62
Presentation of temporal arthritis?
A person aged 50 or older with a unilateral temporal headache that came on in a few weeks Tender, thick or nodular temporal artery. Skin overlying it may be read and pulsation may be reduced or absent There may be visual loss, double vision, visual field defects or changes to colour vision May be scalp tenderness May be intermittent jaw claudication May be systemic features e.g. fatigue, fever, anorexia May be features of PMR, neurological features
63
What % of pt with GCA will have PMR?
50%
64
Investigations for GCA?
FBC, ESR and CRP Diagnosis is confirmed with: Duplex USS pr temporal artery biopsy
65
Management of GCA?
Urgent high dose glucocorticoids (before temporal aretry bpspy) Urgent ophthalmology review Bone protection will be required due to long term steroids (Sometimes low dose aspirin is given)
66
Which steroids are given for GCA?
No visual loss - high dose pred Visual loss - IV methylprednisolone prior to starting high-dose pred
67
Normal intracranial pressure?
7-12mmHg
68
How do you calculate cerebral perfusion pressure?
MAP - ICP
69
Causes of raised ICP?
idiopathic intracranial hypertension traumatic head injuries infection e.g. meningitis tumours hydrocephalus
70
Presentation of raised ICP?
headache - constant throbbing which is worse in morning, when coughing.straining/bending forward vomiting reduced levels of consciousness papilloedema - blurred vision, visual field loss, double vision, greyed out vision triggered by coughing/sneezing/bending down Cushing's triad - widening pulse pressure, bradycardia, irregular breathing
71
Investigtaions for raised ICP?
Neuroimaging - CT/MRI to find underlying cause Invasive ICP monitoring can be done where a catheter is placed into the lateral ventricles of the brain to monitor the pressure
72
Maagement of raised ICP?
Tx underlying cause Head elevation to 30 degrees IV mannitol Controlled hyperventilation (causes vasoconstriction of cerebral arteries) Removal of CSF e.g. VP shunt or repeated LP
73
What is a low-pressure headache?
A headache caused by low CSF e.g. spontaneous, following an LP, tear in meninges etc Most commonly following an LP
74
How common are post-lumbar puncture headaches? Who are they most common in?
They occur in 1/3rd of pts Most common in young females with low BMI
75
Presentation of post-lumbar puncture headache?
Develops 24-48 hours following LP usually and lasts several days Worse when upright and improves with recumbent position
76
Presentation of sinusitis?
Frontal pressure facial pain worse on bending forwards + facial tenderness Thick and purulent nasal discharge Nasal obstruction
77
What is a hormonal headache aka? How do they present?
Menstrual migraine Unilateral, pulsation headache associated with nausea that occur 2 days before the the first 3 days of the MP (May also occur in perimenopausal period and early pregnancy as due to low oestrogen)
78
What is cervical spondylosis and how does it usually present?
Extremely common condition resulting from osteoarthritis in the cervical spine in people over 40 Commonly presents as neck pain worse with movement or may refer as a headache
79
Which branches of the trigeminal nerve are most commonly affected in trigeminal neuralgia?
Typically, the maxillary or mandibular branches are affected, either alone or in combination. Involvement of the ophthalmic branch alone is uncommon.
80
What is trigeminal neuralgia?
Severe, episodic, unilateral facial pain in the distribution of 1 or more branches of the trigeminal nerve
81
What can trigger trigeminal neuralgia pains?
Touching the face e.g. shaving Talking Cold wind Vibration Cleaning teeth
82
What is atypical trigeminal neuralgia?
When there is a persistent discomfort between paroxysms, or sensory loss
83
What are the 3 aetiologies of trigeminal neuralgia?
Vascular compression of the trigeminal nerve root (known as classical TN) It can occur as a consequence of major neurological disease e.g. tumour or cerebellopontine angle or MS (known as secondary TN) Idiopathic
84
RF for trigeminal neuralgia?
Advancing age -50-60 Female MS FHx - rarer RF
85
Prognosis of trigeminal neuralgia?
Episode sof TN can occur daily for weeks/months and there can be months/years of remission 50% get remission of at least 6 months 65% of pt with newly diagnosed TN will have a second episode within 5 years Periods of remission tend to get shorter with time and attacks of pain get longer
86
Complications of trigeminal neuralgia?
Impairment of activities of daily living. Depression/isolation. Weight loss caused by inability to eat.
87
Presentation of trigeminal neuralgia?
Severe, electric shock-like, sharp, shooting pain Unilateral Lasts a few seconds-minutes and stops suddenly Many attacks a day Episodic - pain free periods tend to gradually shorter between episodes Provoked by factors such as light touch to face, taking, exposure to cold air
88
What are some serious conditions that can lead to compression of the trigeminal nerve and cause symptoms similar to trigeminal neuralgia?
Tumours MS Epidermoid, dermoid or arachnoid cysts Aneurysms or AVMs
89
Red flag symptoms or signs to ask about in ?trigeminal neuralgia that may suggest a serious underlying cause…
Sensory changes Deafness/ear problems Pain in only ophthalmic division Bilateral pain Optic neuritis FHx of MS Age of onset before 40
90
Management of trigeminal neuralgia?
Carbamazepine 100mg TD (titration up) Once pain is in remission gradually reduce dosage Failure to respond to Tx or atypical features -> refer to neurology
91
Causes of facial pain?
Trigeminal neuralgia TMJ disorders - TMJD, bruxism, arthritis of TMJ Sinusitis Dental problems - caries of abscesses Tension headaches or cluster headaches Migraines Ophthalmic or ear disorders GCA Shingles Trauma e.g. facial fractures Referred pain
92
What is chronic orofacial pain defined as?
Pain lasting >12 weeks
93
What is mid facial segment pain?
Similar to a tension headache with a bilateral T-shaped distribution over the nose and frontal areas Constant pain Aetiology is unknown and its considered a diagnosis of exclusion
94
What is bruxism?
Teeth grinding
95
What forms the temporomandibular joint?
Articulation of the head of the mandible and 2 surfaces of the temporal bone (mandibular fossa and Radicular tubercle) Note that the articular bones are lined by fibrocartilage and separated by an articular disc which splits the joint into 2 synovial joint cavities
96
What are temporomandibular joint disorders?
A group of MSK conditions affecting the mastication muscle, temporomandibualr joint and associated structures E.g. masticatory muscle disorders, degeneration of TMJ or disc displacement
97
Cause of temporomandibular joint disorders?
Anatomical - disc displacement Macrotraumas Microtraumas e.g. bruxism Stress, anxiety, depression Co-morbidities e.g. fibromyalgia
98
Presentation of temporomandibular joint disorder?
Pain in or around the TMJ or muscles of mastication - usually pre-auricular region and may radiate to temple/teeth/cheek/angle of jaw Pain may be provoked by palpation of masseter, temporalis muscle or TMJ, or jaw movement Joint noise - clicking, popping, crepitus Headache in temporal region May be locking of the jaw
99
Management of temporomandibular joint disorder?
Reassure pt and educate about condition Encourage self-management e..g soft diet, rest jaw if acute pain, avoid parafunctional activis e.g. yawning, apply ice or heat, massage muscles Consider analgesia short term Consider referral to surgery if persistent or worsening
100
Who typically gets idiopathic intracranial hypertension?
Young, obese females Pregnant women
101
Which drugs can increase the risk of idiopathic intracranial hypertension?
COCP Steroids Tetracyclines Retinoids Lithium
102
Presentation of idiopathic intracranial hypertension?
headache blurred vision papilloedema (usually present) enlarged blind spot sixth nerve palsy may be present and double vision Pulsatile tinnitus
103
Management of idiopathic intracranial hypertension?
Weight loss - meds may be used to help with this e.g. topiramate (also added benefit of being a CA inhibitor) Carbonic anhydrase inhibitors e.g. acetazolamide Repeated LP as a temporary measure Surgery e.g. optic nerve sheath decompression and fenestration to prevent damage / lumboperitoneal or VP shunt
104
How is idiopathic intracranial hyopertension diagnosed?
Typical symptoms + normal neurological exam except for papilloedema and visual field defect CT or MRI is normal LP with higher than normal pressure for defintive diagnosis
105
How does acetazolamide work to treat idiopathic intracranial hypertension?
It’s a carbonic anhydrase inhibitor which decreases CSF production and therefore decreases ICP
106
Complications of idiopathic intracranial hypertension?
Optic neuropathy Loss of vision Strokes Seizures Coma Respiratory arrest

NEUROLOGY (16 decks)

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