Headache - Diagnosis & Management Flashcards
What is the epidemiology of headache like?
How many people are affected by migraines?
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
what is meant by a benign headache?
benign headaches, such as migraines, are not caused by structural problems
they can interfere with the patient’s lifestyle and functioning
What questions need to be answered during a consultation when taking a headache history?
- 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?
What 2 areas need to be explored when thinking about the pattern of pain?
the onset and periodicity
What are the 3 different types of onset when looking at the pattern of pain?
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
What are the different types of periodicity?
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
What associated features should be asked about during a headache consultation?
- diurnal variation / postural element
- nausea and vomiting
- photophobia / phonophobia
- autonomic features - lacrimation / horners / red eye
What is meant by a postural headache?
a type of headache that gets worse when the patient stands up
the pain tends to subside when lying down
What is phonophobia?
an anxiety disorder in which the patient has a fear of loud sounds
What are the red flag symptoms for headache?
- cognitive effects
- seizures
- fever
- visual disturbance
- vomiting
- weight loss
What is the SNOOP4 mnemonic for remembering the red flags for a potentially life-threatening headache?
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)
What other questions should be asked during a headache history?
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?
On examination what should you look for signs of?
- fever / rash / neck stiffness / raised blood pressure / organomegaly
- fundal changes - papilloedema
- cranial nerve signs / horners syndrome
- focal abnormalities
- long tract signs
What is meant by “long tract signs”?
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
What is a cluster headache?
recurrent severe headaches on one side of the head (unilateral)
the pain is usually centred over one eye, one temple or the forehead
What are the accompanying symptoms of cluster headaches?
How long do the symptoms tend to last for?
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
What is a migraine?
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
What are the associated symptoms of migraine?
What is the secondary headache syndrome?
nausea, vomiting and sensitivity to light, sound or smell
secondary headache syndrome is subarachnoid haemorrhage (SAH)
What is a tension headache?
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
What are the secondary headache syndromes for tension headache?
intracranial haemorrhage / stroke
What is the secondary headache syndrome associated with cluster headache?
meningoencephalitis
What is paroxysmal hemicrania?
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
What is the secondary headache syndrome associated with paroxysmal hemicrania?
intracranial venous thrombosis
What is an exertional headache?
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
What is the secondary headache syndrome associated with exertional headache?
giant cell arteritis
this is the most common form of vasculitis which can cause headache
what is an ice-pick headache?
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
What is the secondary headache syndrome associated with ice-pick headache?
tumour with raised intracranial pressure
What is a coital headache?
an intense, searing headache that is brought on by sexual activity
What is the secondary headache syndrome associated with coital headache?
cervicogenic headache
this is a pain that develops in the neck, but feels like it is in the head
What is a hypnic headache?
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
What are the secondary headache syndromes associated with hypnic headache?
benign intracranial hypertension
What is a secondary headache?
headaches that are due to an underlying medical condition
e.g. a neck injury or a sinus infection
What is shown here?
new onset headache after motorcycle accident
Horner syndrome - there is pupillary asymmetry
MRI angiography confirms a left ICA occlusion due to a carotid dissection
What can a ruptured berry aneurysm in the brain lead to?
a sudden agonising headache
onset within seconds (sudden)
pain at the back of the head reaching a maximal intesity pain in seconds
How may someone with a headache due to ruptured berry aneurysm present?
- vomiting
- confused (around 14/15 on GCS)
- clinically apyrexial and hyperreflexic
- ocular movements may be impaired
If someone with an intense headache (from suspected ruptured berry aneurysm) has a normal CT, what should be done?
CT is 95% sensitive if done within 48 hours of onset
if it is normal, then lumbar puncture is performed to look for xanthochromia
What is xanthochromia?
What does it indicate?
it describes the yellowish appearance of cerebrospinal fluid that occurs several hours after bleeding into the subarachnoid space
this is indicative of subarachnoid haemorrhage
Why does xanthochromia occur?
due to bilirubin released from in vivo macrophages digesting red blood cells
If lumbar puncture and CT are normal, but a patient has a history suggestive of subarachnoid haemorrhage, what may be causing the headache?
cervical artery dissection, cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome and pituitary apoplexy may present with isolated thunderclap headache
What may raised intracranial pressure be due to?
- mass effect - brain tumour / abscess
- brain swelling (hypertensive encephalopathy)
- increased venous pressure
- CSF outflow obstruction (hydrocephalus)
- increased CSF production (meningitis / SAH)
What are the symptoms of raised intracranial pressure?
- headache (worse on lying or awakening)
- vomiting
- seizures
What are the signs of raised intracranial pressure?
- papilloedema
- lateralising signs
What is the equation for cerebral perfusion pressure (CPP)?
What is the normal value?
CPP = MAP - ICP
cerebral perfusion pressure = mean arterial pressure - intracranial pressure
normal value is 7 - 18 cm H2O
CPP affected > 40 cm H2O
What investigation is important in suspected streptococcus pneumoniae meningitis?
streptococcal pneumoniae will be grown in blood cultures
What is the acute management for streptococcus pneumoniae meningitis?
- resuscitation
- broad spectrum IV antibiotics
- think about other bugs in immunocompromised patients
- steroids in patients with streptococcus pneumoniae meningitis
What is invovled in the long-term management of streptococcus pneumoniae meningitis?
- cognitive / psychological sequelae
- ENT for assessment of hearing loss
What are the signs and symptoms of temporal arteritis?
- weight loss
- myalgia
- transient loss of vision
- jaw claudication
- tender non-pulsatile temporal artery
What is temporal arteritis?
a disease which causes the arteries to become inflamed
it affects the temporal arteries that carry blood to the brain
What is temporal arteritis associated with?
Which patients should it be considered in?
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
What is involved in the management of suspected temporal arteritis?
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
How many people are affected by migraine?
What are the typical symptoms?
- 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
What % of people with migraine have prodrome?
What does this mean?
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
What are triggers of migraine?
- sleep deprivation
- hunger
- stress
- oestrogens
What is meant by aura in migraine?
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
What are the 3 subtypes of migraine?
- basilar - cranial neuropathies / cerebellar signs
- hemiplegic
- acephalgic migraine
What is responsible for aura and pain in migraine?
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
What neurotransmitters are involved in migraine?
What is involved in prodromal and postdromal symptoms?
CGRP, serotonin, substance P
prodromal and postdromal symptoms controlled by hypothalamus and pons
What are the stages involved in the management of migraine?
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
What is erenumab?
a CGRP receptor antagonist specifically designed to prevent migraine across the spectrum
it binds potently and selectively to the CGRP receptor, blocking its activation
What causes trigeminal autonomic cephalgias?
What are the characteristics?
activation of the trigeminal / parasympathetic systems
characterised by short-lasting headaches and variable autonomic features
What are the differet types of trigeminal autonomic cephalgias?
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
What is used in the management of pain relief for trigeminal autonomic cephalgias?
- sumatriptan (class a)
- high flow 100% oxygen
- neurostimulation - GAMMACORE vagal nerve stimulation
What is involved in the prevention of trigeminal autonomic cephalgias?
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
What is involved in the management of tension headache?
- relaxation and massage
- small dose of amitriptyline if headache is frequent
- acupuncture
- ensure the patient has recently had optician check
What is a tension headache?
a constricting tight band around the head
it is a featureless headache but may be a form of mild/moderate migraine
What is a new daily persistent headache?
it is similar to a tension headache
it is rarely sinister and there is no previous history of episodic headache
What are the causes of new daily persistent headache?
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
What is idiopathic intracranial hypertension?
a disorder related to high pressure in the brain
it causes signs and symptoms of a brain tumour
What is the definition of a chronic daily headache?
a headache lasting for >4 hours on >15 days per month for >3 months
What are the causes of chronic daily headache?
de novo:
- new daily persistent headache
previous episodic headache:
- transformed migraine
- chronic tension type headache
- hemi-crania continua
What are the treatment options for chronic daily headache?
treatment options are limited
withdraw analgesia if there is a history of overuse
consider amitriptyline / topiramate for transformed migraine
