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Y2 CONTROL & MOVEMENT > Headache - Diagnosis & Management > Flashcards

Headache - Diagnosis & Management Flashcards

1
Q

What is the epidemiology of headache like?

How many people are affected by migraines?

A

95% of people are affected by headache in their lifetime

1 in 10 people have migraines

sinister causes of headache are rare (0.1%) in primary care

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2
Q

what is meant by a benign headache?

A

benign headaches, such as migraines, are not caused by structural problems

they can interfere with the patient’s lifestyle and functioning

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3
Q

What questions need to be answered during a consultation when taking a headache history?

A
  • can i classify the headache?
  • do i need to investigate?
  • how do i explain the diagnosis?
  • what are the patient’s expectations?
  • is treatment appropriate?
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4
Q

What 2 areas need to be explored when thinking about the pattern of pain?

A

the onset and periodicity

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5
Q

What are the 3 different types of onset when looking at the pattern of pain?

A

acute:

  • seconds to minutes
  • SAH / intra-cerebral haemorrhage / coital / thunderclap

evolving:

  • hours to days
  • infection / inflammatory / raised intracranial pressure

chronic:

  • weeks to months
  • chronic daily headache / raised ICP
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6
Q

What are the different types of periodicity?

A

episodic:

  • at least a few days free between attacks
  • migraine / cluster headache / trigeminal neuralgia / TACs

chronic:

  • headache present most days
  • medication overuse / chronic migraine / hemicrania continua
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7
Q

What associated features should be asked about during a headache consultation?

A
  • diurnal variation / postural element
  • nausea and vomiting
  • photophobia / phonophobia
  • autonomic features - lacrimation / horners / red eye
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8
Q

What is meant by a postural headache?

A

a type of headache that gets worse when the patient stands up

the pain tends to subside when lying down

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9
Q

What is phonophobia?

A

an anxiety disorder in which the patient has a fear of loud sounds

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10
Q

What are the red flag symptoms for headache?

A
  • cognitive effects
  • seizures
  • fever
  • visual disturbance
  • vomiting
  • weight loss
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11
Q

What is the SNOOP4 mnemonic for remembering the red flags for a potentially life-threatening headache?

A

Systemic symptoms / signs:

  • e.g. fever, rash, chills, myalgia, night sweats, weight loss
  • comorbid systemic disease (e.g. HIV, immunocompromised, malignancy)
  • pregancy or postpartum

Neurologic symptoms / signs:

  • change in mental state or level of consciousness
  • abnormal cranial nerve function
  • weakness, history of seizure, diplopia, etc.

onset sudden:

  • onset sudden or “worst” headache of life, thunderclap headache

older onset:

  • onset after 50 years of age

pattern change:

  • progressive headache (e.g. to daily, continuous pattern)
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12
Q

What other questions should be asked during a headache history?

A

behaviour:

  • lies down in dark room - migraine
  • agitation / pacing - cluster

family history:

  • migraine is often familial

medication / self medication:

  • analgesia - what do they take and how often?
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13
Q

On examination what should you look for signs of?

A
  • fever / rash / neck stiffness / raised blood pressure / organomegaly
  • fundal changes - papilloedema
  • cranial nerve signs / horners syndrome
  • focal abnormalities
  • long tract signs
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14
Q

What is meant by “long tract signs”?

A

symptoms that are attributable to the involvement of the long fibre tracts in the spinal cord

these connect the spinal cord to the brain and mediate spinal and motor functions

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15
Q

What is a cluster headache?

A

recurrent severe headaches on one side of the head (unilateral)

the pain is usually centred over one eye, one temple or the forehead

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16
Q

What are the accompanying symptoms of cluster headaches?

How long do the symptoms tend to last for?

A

there is accompanying eye watering, nasal congestion or swelling around the eye on the affected side

these symptoms typically last 15 minutes to 3 hours

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17
Q

What is a migraine?

A

a primary headache disorder characterised by recurrent headaches that are moderate to severe

the headaches tend to affect one half of the head, are pulsating in nature and last from a few hours to 3 days

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18
Q

What are the associated symptoms of migraine?

What is the secondary headache syndrome?

A

nausea, vomiting and sensitivity to light, sound or smell

secondary headache syndrome is subarachnoid haemorrhage (SAH)

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19
Q

What is a tension headache?

A

a tension headache is generally a diffuse, mild to moderate pain in the head

it is often described as feeling like a tight band around the head

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20
Q

What are the secondary headache syndromes for tension headache?

A

intracranial haemorrhage / stroke

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21
Q

What is the secondary headache syndrome associated with cluster headache?

A

meningoencephalitis

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22
Q

What is paroxysmal hemicrania?

A

a severe debilitating unilateral headache usually affecting the area around the eye

it usually involves multiple, sudden onset, severe, short-lasting attacks affecting one side of the head

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23
Q

What is the secondary headache syndrome associated with paroxysmal hemicrania?

A

intracranial venous thrombosis

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24
Q

What is an exertional headache?

A

a group of headache syndromes, which are associated with some physical activity

they become severe very quickly after a strenous activity such as weight-lifting or sexual intercourse

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25
Q

What is the secondary headache syndrome associated with exertional headache?

A

giant cell arteritis

this is the most common form of vasculitis which can cause headache

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26
Q

what is an ice-pick headache?

A

short, stabbing, extremely painful and intense headaches that feel like a stabbing blow, or a series of stabs, from an ice pick

they have no warning before striking and can be excruciatingly painful

they are brief and tend to only last a few seconds

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27
Q

What is the secondary headache syndrome associated with ice-pick headache?

A

tumour with raised intracranial pressure

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28
Q

What is a coital headache?

A

an intense, searing headache that is brought on by sexual activity

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29
Q

What is the secondary headache syndrome associated with coital headache?

A

cervicogenic headache

this is a pain that develops in the neck, but feels like it is in the head

30
Q

What is a hypnic headache?

A

a rare type of headache that wakes people from sleep

they only affect people when they are sleeping and tend to occur around the same time several nights a week

31
Q

What are the secondary headache syndromes associated with hypnic headache?

A

benign intracranial hypertension

32
Q

What is a secondary headache?

A

headaches that are due to an underlying medical condition

e.g. a neck injury or a sinus infection

33
Q

What is shown here?

new onset headache after motorcycle accident

A

Horner syndrome - there is pupillary asymmetry

MRI angiography confirms a left ICA occlusion due to a carotid dissection

34
Q

What can a ruptured berry aneurysm in the brain lead to?

A

a sudden agonising headache

onset within seconds (sudden)

pain at the back of the head reaching a maximal intesity pain in seconds

35
Q

How may someone with a headache due to ruptured berry aneurysm present?

A
  • vomiting
  • confused (around 14/15 on GCS)
  • clinically apyrexial and hyperreflexic
  • ocular movements may be impaired
36
Q

If someone with an intense headache (from suspected ruptured berry aneurysm) has a normal CT, what should be done?

A

CT is 95% sensitive if done within 48 hours of onset

if it is normal, then lumbar puncture is performed to look for xanthochromia

37
Q

What is xanthochromia?

What does it indicate?

A

it describes the yellowish appearance of cerebrospinal fluid that occurs several hours after bleeding into the subarachnoid space

this is indicative of subarachnoid haemorrhage

38
Q

Why does xanthochromia occur?

A

due to bilirubin released from in vivo macrophages digesting red blood cells

39
Q

If lumbar puncture and CT are normal, but a patient has a history suggestive of subarachnoid haemorrhage, what may be causing the headache?

A

cervical artery dissection, cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome and pituitary apoplexy may present with isolated thunderclap headache

40
Q

What may raised intracranial pressure be due to?

A
  • mass effect - brain tumour / abscess
  • brain swelling (hypertensive encephalopathy)
  • increased venous pressure
  • CSF outflow obstruction (hydrocephalus)
  • increased CSF production (meningitis / SAH)
41
Q

What are the symptoms of raised intracranial pressure?

A
  • headache (worse on lying or awakening)
  • vomiting
  • seizures
42
Q

What are the signs of raised intracranial pressure?

A
  • papilloedema
  • lateralising signs
43
Q

What is the equation for cerebral perfusion pressure (CPP)?

What is the normal value?

A

CPP = MAP - ICP

cerebral perfusion pressure = mean arterial pressure - intracranial pressure

normal value is 7 - 18 cm H2O

CPP affected > 40 cm H2O

44
Q

What investigation is important in suspected streptococcus pneumoniae meningitis?

A

streptococcal pneumoniae will be grown in blood cultures

45
Q

What is the acute management for streptococcus pneumoniae meningitis?

A
  • resuscitation
  • broad spectrum IV antibiotics
  • think about other bugs in immunocompromised patients
  • steroids in patients with streptococcus pneumoniae meningitis
46
Q

What is invovled in the long-term management of streptococcus pneumoniae meningitis?

A
  • cognitive / psychological sequelae
  • ENT for assessment of hearing loss
47
Q

What are the signs and symptoms of temporal arteritis?

A
  • weight loss
  • myalgia
  • transient loss of vision
  • jaw claudication
  • tender non-pulsatile temporal artery
48
Q

What is temporal arteritis?

A

a disease which causes the arteries to become inflamed

it affects the temporal arteries that carry blood to the brain

49
Q

What is temporal arteritis associated with?

Which patients should it be considered in?

A

think this diagnosis in patients > 50 years old

more common in females than males

associated with polymyalgia rheumatica

ESR (erythrocyte sedimentation rate) is often elevated, but not always

50
Q

What is involved in the management of suspected temporal arteritis?

A

commence immediate high dose steroids:

  • prednisolone 60 mg once daily for 1st week
  • slow taper over 6 weeks to 15-20 mg once daily

arrange temporal artery biopsy:

  • this can be negative even is ESR is high

in patients >55 where diagnosis is uncertain, check ESR as part of diagnostic work up

51
Q
A
52
Q

How many people are affected by migraine?

What are the typical symptoms?

A
  • affects 10% of the population
  • more common in females than males
  • unilateral headache
  • nausea / photophobia / dizziness
  • 30% of patients will have aura lasting up to 60 minutes
53
Q

What % of people with migraine have prodrome?

What does this mean?

A

10% experience prodrome

this is a set of signs and symptoms which indicate the onset of a disease

this includes fatigue and changes in mood

54
Q

What are triggers of migraine?

A
  • sleep deprivation
  • hunger
  • stress
  • oestrogens
55
Q

What is meant by aura in migraine?

A

migraine with aura is a recurring headache that strikes after or at the same time as sensory disturbances (aura)

these disturbances are usually visual

can include flashes of light, blind spots, vision changes or tingling in the hand or face

56
Q

What are the 3 subtypes of migraine?

A
  • basilar - cranial neuropathies / cerebellar signs
  • hemiplegic
  • acephalgic migraine
57
Q

What is responsible for aura and pain in migraine?

A

cortical spreading depression leads to aura

this releases chemically active irritants that trigger sensory fibres in the meninges which can be felt as pain

the trigeminovascular system is responsible for pain

58
Q

What neurotransmitters are involved in migraine?

What is involved in prodromal and postdromal symptoms?

A

CGRP, serotonin, substance P

prodromal and postdromal symptoms controlled by hypothalamus and pons

59
Q

What are the stages involved in the management of migraine?

A

brain imaging:

  • focal symptoms / signs lasting 24 hours or more
  • new onset of daily migraine

conservative measures:

  • avoid caffeine / increase water intake
  • avoid tyramine foods (cheese / chocolate / red wine)
  • sleep hygiene and regular meals

analgesia:

  • triptans / naproxen / NSAIDs
60
Q

What is erenumab?

A

a CGRP receptor antagonist specifically designed to prevent migraine across the spectrum

it binds potently and selectively to the CGRP receptor, blocking its activation

61
Q

What causes trigeminal autonomic cephalgias?

What are the characteristics?

A

activation of the trigeminal / parasympathetic systems

characterised by short-lasting headaches and variable autonomic features

62
Q

What are the differet types of trigeminal autonomic cephalgias?

A

cluster headache:

  • attacks last 30-180 minutes
  • only 1 per 24 hours

paroxysmal hemicrania:

  • attacks last 2-30 minutes
  • there are >5 per 24 hours

SUNCT:

  • very rare
  • lasts for seconds
  • up to 200 attacks per 24 hours
63
Q

What is used in the management of pain relief for trigeminal autonomic cephalgias?

A
  • sumatriptan (class a)
  • high flow 100% oxygen
  • neurostimulation - GAMMACORE vagal nerve stimulation
64
Q

What is involved in the prevention of trigeminal autonomic cephalgias?

A

treatment should be started at the beginning of the cluster

  • prednisolone (60 mg/day) and taper after 2-3 weeks
  • verapamil - up to 240 mg/day
  • indomethacin - 25-75 mg TDS
65
Q

What is involved in the management of tension headache?

A
  • relaxation and massage
  • small dose of amitriptyline if headache is frequent
  • acupuncture
  • ensure the patient has recently had optician check
66
Q

What is a tension headache?

A

a constricting tight band around the head

it is a featureless headache but may be a form of mild/moderate migraine

67
Q

What is a new daily persistent headache?

A

it is similar to a tension headache

it is rarely sinister and there is no previous history of episodic headache

68
Q

What are the causes of new daily persistent headache?

A

raised ICP:

  • unlikely to be tumour if there is only a headache
  • idiopathic intracranial hypertension

low ICP:

  • spontaneous intracranial hypotension
  • post lumbar puncture headache

chronic meningitis (infective & non-infective)

post head injury

69
Q

What is idiopathic intracranial hypertension?

A

a disorder related to high pressure in the brain

it causes signs and symptoms of a brain tumour

70
Q

What is the definition of a chronic daily headache?

A

a headache lasting for >4 hours on >15 days per month for >3 months

71
Q

What are the causes of chronic daily headache?

A

de novo:

  • new daily persistent headache

previous episodic headache:

  • transformed migraine
  • chronic tension type headache
  • hemi-crania continua
72
Q

What are the treatment options for chronic daily headache?

A

treatment options are limited

withdraw analgesia if there is a history of overuse

consider amitriptyline / topiramate for transformed migraine

Y2 CONTROL & MOVEMENT (69 decks)

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