Headache Assessment Flashcards
Migraines are more common in which gender
Women
Which headaches symptoms are classified as dangerous
1- Thunderclap 2- Focal symptoms 3- fever 4- persisting / progressive / provoked 5- new onset headaches
What are the 4 types of new onset dangerous headaches
1- Thunderclap headache
2- Fever
3- Focal symptoms
4- persisted-provoked
What are Thunderclap headaches and what needs to be done if patient comes in with one
MAXIMAL at ONSET
Go from no headache to severe within seconds. Lasts for 20-30 minutes and then disappears completely or lingers for a while. Symptom of SAH, necessary to further investigate must do CT Brian.
What do you think when a patient presents with headache and fever
1- Systemic or viral illness.
2- Sinusitis
3- Meningitis ( viral or bacterial )
4- Encephalitis
Need to exclude bacterial meningitis: progressive, painkillers do not work, getting worse and it’s been 6-12+ hrs.
What do you think when a patient presents with headache and focal symptoms
Most will have migraine with aura , evolving sensory disturbances. Usually due to migraines.
What could be the reason for persistent headaches
1- CO poising : can tell by work or home environment
2- Temporal arteritis
3- Intracranial Hypertension : High BMI and pulsatile tinnitus
4- Cervicogenic / hemicrania : NSAID responsive
6- Paranasal Sinusitis : dental pain
7- Migraine chronic onset
What is temporal arteritis / giant cell arteritis
Patient usually 50+ and ESR is over 50.
Arteries at the side of the head become inflamed , can cause blindness since it can affect retina.
What could be the reasons for provoked headaches and how will they present
1- CSF leak : orthostatic 2- 2- Coital / Exertional : intense and severe , suspect SAH
3- Cluster Headache: nocturnal , autonomic activation, pain around one eye , runny nose , ptosis, goes away
4- Trigeminal neuralgia : electric shock sharp pain and triggered by something
5- Hypnic headache: awakens from sleep ( due to caffeine )
What are orthostatic headaches
when lying down patient is fine but when standing up there’s pressure in head ,and really bad headache that is resolved when lying down again
How can you relieve orthostatic headaches
Epidural Patch in lumbar canal
Will CT brain in orthostatic headache detect the problem
Usually not, usually requires MRI
What are the treatments for cluster headaches
High flow oxygen and Imigran injections. Plus verapamil
How is trigeminal neuralgia treated
Tegretol medication.
Why is trigeminal neuralgia important to diagnose
In younger people could be the first presentation fo MS
What is the classical presentation of Brian tumours
1- Tension type headaches
2- focal neurology / epileptic seizures
3- papilloedema
raised ICP headache in 20%.
What is the presentation of ICP headache
Patient wakes up with headache, vomits and then in a few hours pain goes away
How are recurrent headaches diagnosed
Headache type through History + Normal Neurological exam. Scans are generally not required
What are the symptoms of Migraines
Sickening headaches that make patient what to lie down. Normal neurological exam
1- Disabling level of pain
2- recurrent headaches
3- sensory sensitivity features : usually nausea / light
4- prodromal symptoms ( psychotic )
5- Transient vertigo , brain fog , tingling , heaviness, visual loss, flash , difficulty finding words or concentrating
6- Aura
7- unilateral ( but not always the case )
What are risk factors for migraines
1- Neck stiffness/ injury/ tightness 2- temporal mandibular joint disfunction 3- short sighted ( myopia ) 4- family history of headache 5- female predominant
What senses become sensitive with migraines
Light, noise, smell, movement, touch , nausea
What are possible prodromal symptoms of migraines
1- Depression / anxiety 2- hungry / thirsty / cravings 3- elation/energy 4- diarrhoea/ pleura 5- drowsy / lack of interest
Explain what is the migraine aura symptoms
Depending on the cortical area it is affecting. Visual , hearing, balance, motor , sensory or consciousness
Is a persistent aura due to migraines
no migraine auras go away
What are the symptoms of tension type headaches
1- Tightness/ weight/ pressure / band feeling
2- lasts for hrs, days, weeks
3- nothing makes it worse or better
4- any location on head
What are the symptoms for Ice-Pick Headache
1- Brief neuralgic pain 2- lasts for seconds disappears 3- may increase to migraine 4- may linger like tension-type 5- often around the ye
What is possible treatment for Ice-Pick Headache
NSAIDS , Neck physiotherapy
Can people with migraines get other types of headaches
Yes they usually do
How to tell difference between focal seizure and migraine aura
Focal seizure : maximal at onset
migraine aura: maximal over minutes
What are the risk factors of a very one sided headache
1- TMJ joint dysfunction on that side
2- cervical spine abnormality on that Side
Does a one sided headache automatically mean migraine
No
What are the risk factors for SAH ( 6 ) that would show that severe headache needs more investigations
1- 40 + years 2- neck pain / stiffness 3- onset during exertion 4- thunderclap onset 5- neck stiffness on examination 6- Loss of consciousness
What is Horner’s syndrome and how does it present
Loss of sympathetic innervation to the eye , causing partial upper eye lid drooping ( ptosis) , pupil is constricted due to parasympathetic overactivity ( myosis )
Horner’s syndrome could be a sign of what
ipsilateral internal carotid artery dissection which could give thunderclap heading
What are the differential diagnosis for thunderclap headache
1- SAH 2- Meningitis 3- Venous sinus thrombosis 4- Pituitary apoplexy 5- spontaneous intracranial hypotension
What investigations could be done for thunderclap headaches
1- CT Brian
2- lumber puncture ( for bilirubin peak )
3- check CSF glucose & protein
4- CSF cultures for infection
When are angiograms done with thunderclap headache presentations
If arterial dissection , vasoconstriction are suspected and if CT&LP are inconclusive for SAH
When are Venography’s does for thunderclap headache presentation
Suspected Cerebral Venous Sinus Thrombosis
When are MRI’s with contrast does for thunderclap headache presentation ? what about normal MRI
contrast : Suspected spontaneous intracranial hypotension
normal : suspected stroke , infarction
Stimulation or pain in the neck causes referred pain in what
In the head. The higher up the neck the more forward the pain is referred in the head
What examinations are done if migraine is suspected
1- Cervical flexion-rotation test
2- palpation of upper cervical muscles . sub occipital insertions
3- palpate ROM TMJIs
4- visual acuity
5- Neuro screening exam
6- BP, pulse, Heart sounds ( check atria )
How to manage Migraines
1- Lifestyle - Hydration - avoid hunger - sleep well - walk / exercise 2- modifiable Risk factors - medication overuse - neck/ posture - jaw intervensions - eye vision correction - BMI , reduces overweight 3- Psychology of pain - explain to patient the pain is normal 4- Acute Medication 5- Prophylaxis
What is the Acute management of migraine
1- NSAIDS/ paracetamol - aspirin / ibuprofen 2- Anti-emetics - buccastem / metoclopramide 3- Triptans - sumatriptan / injection
NICE recommend early triptan and combinations with others
What is the window of treatment for migraines
Take medication before it is too severe. if head is too sore to touch then unlikely medication will treat the migraine
What is the prophylaxis treatment for migraines
1- Beta-blockers - propranolol
2- Anti-convulsants - topiramate
3- Anti-depressants - amitriptyline/
Give for 3 months to see if they work
What are the types of constant headaches
1- chronic migraine
2- chronic tension type headache
3- idiopathic intracranial hypertension
4- cervicogenic headache
What is a sign of idiopathic intracranial hypertension
Papillodema
How to diagnose Chronic migraine
1- 6 months + 2- more than 50% of days with headache 3- 50% of headaches have migraine features 4- no other reason 5- normal examination
What investigations are done for chronic migraines
1- FBP / TSH/ cortisol / LFT
2- ask about sleep apnoea
no need for scans
What is the prophylaxis treatment for chronic migraines
Medications with randomized trial evidence
1- Topiramate
2- Botulinum Toxin A
3- Anti-CGRP Abs
When are you able to get botox for chronic migraines
if any of the 3 prophylactic drugs fail
How does Botox work for migraines
31 different injection points, botox works to desensitize C fibres
When migraines are building , level of what antibodies rises
CGRP, driving inflammatory process that gives pain
What medication was just approved in 2020/2021 for chronic migraines
Monoclonal Ab which block CGRP pathways.
Have minimal side effects but very expensive
If the botox doesn’t work for chronic migraine what do you do next
Prescribe the Monoclonal Ab
What is new daily persistent headache s
Headaches post vaccines
What is Hemicrania Continua and what medication is prescribed
a headache causing constant pain on one side of the head, treated via NSAIDS
