Headache II Flashcards
What are the 3 most common types of headaches?
Migraine
Tension
Cluster
What is a Migraine?
A headache disorder - repeated attacks of stereotypes headaches
Usually hemicranial - persistent unilateral headache
Triggered
Common features - easily hungover, visual vertigo and motion sickness
What are the 3 attack forms of a migraine?
Pain
Focal symptoms - speech arrest, aphasia, pins and needles and weakness
Pain and focal symptoms
What are the 5 phases of a migraine?
- Prodome
- Aura
- Headache
- Resolution
- Recovery
How do these 5 phases of a migraine present and progress?
- Prodome
- Aura
- Headache
- Resolution
- Recovery
- Prodome - changes in mood, urination, fluid retention, food craving (cheese, chocolate), yawning
- Aura - visual, sensory (numbness / paraesthesia), weakness (hemiplegic migraine - looks like they have had a stroke), speech arrest (difficulty finding and speaking words)
- Headache - head and body pain, nausea, photophobia, phonophobia
- Resolution - lighter / softer pain allowing patient to rest and sleep
- Recovery - mood disturbed, food intolerance, feeling hungover
How long is the cycle?
Avg = 48hrs
Range from 1-5 days
What are the 2 types of symptoms for migraine auras?
Give examples for each.
Positive or negative symptoms
Positive = flashes, zigzags, bright starbusts Negative = blackness, loss of vision
What happens if positive and negative symptoms of a migraine aura combine?
Scintillations
Blindspots
Shimmering border with centre of darkness in their vision
Small blindspot slowly getting larger
Why doe the scintillations and blindspots expand? What causes a migraine?
Spreading electrical depression across the cerebral cortex, as it goes across visual cortex = expansion of visual image
What is the treatment for acute migraine attacks?
Aspirin/ibuprofen and paracetamol
Anti-emetic - e.g. metoclopramide (stimulates peristalsis, gut slows down during migraines, hence helps nausea symptoms and absorption of other medications)
Soluble preparations to aid absorption
Triptans-tablets (painkillers for migraines - treat the headache not aura): melts, nasal sprays, s/c injections
Act as vasoconstrictors and synergise with NSAIDS
Take it as soon as headache starts - doesn’t work if the headache has progressed too far
Opiates - although have analgesic abuse potential
A short nap
TMS - interrupts complex networks that trigger and perpetuate migraine, which is caused by spreading electrical depression across the cerebral cortex
Why do migraine sufferers get recurrent headaches?
Genetic pre-disposition - sensitive head
Trigger - overreaction to stimulation
What long term treatment options are there for migraine sufferers?
Lifestyle adjustments -
Look for triggers and avoid them:
dietary, environmental, hormonal, weather, dehydration, stress, alcohol (esp. containing sulphites)
Drink 2 litres water/day
Avoid caffeinated drinks
Don’t skip meals. Fresh food. Avoid ready meals & take-aways
Don’t oversleep or have late nights, keep electronics downstairs
Analgesic abuse
How are chronic migraines classified clinically?
> 14 headaches / month
What medications (migraine prophylaxis) are given to chronic migraine sufferers?
Over-the-counter preparations: feverfew, coenzyme Q10, riboflavin, magnesium, EPO, nicotinamide
Tricyclic antidepressants (TCAs): amitriptyline 7pm
Beta-blockers - Propranolol, Atenolol
Serotonin antagonists: pizotifen, methysergide
Calcium channel blockers: flunarazine, verapamil
Anticonvulsants: valproate, topiramate, gabapentin (must not get pregnant while taking this medication)
Greater occipital nerve blocks
Botox: crown of thorns
Suppress ovulation - POP or implant/injection (not OCP as oestrogen content may trigger migraine)
Why are there so many different medications for chronic migraines?
Depends on biochemistry of patient - some have issues with sodium channels, others with potassium, others with calcium etc,
What is Erenumab?
How does it work?
A new migraine treatment - injectable drug erenumab (Aimovig) given monthly
Cut number of days people had migraines from an average of 8 a month to between 4 and 5 a month, and reduces severity so worth trying for sufferers of episodic migraine, chronic migraine, or cluster headache
Monoclonal antibody
disables calcitonin gene-related peptide or its receptor (CGRP mAbs)
What is a tension type headache?
Tight muscles around the head and neck bilaterally, as though head is in a vice
Soreness on head and neck
How can tension type headaches be treated?
When prone to tension headaches, what treatments may be given?
NSAID’s preferred - ibuprofen, naproxen, diclofenac
Paracetamol
Tricyclic antidepressants:- Amitriptyline 50-75mg daily 30-60% derive some symptomatic relief SSRI’s probably less effective Biofeedback and relaxation although unproven
What are cluster headaches?
What are they classified as?
Which CN is affected?
Severe unilateral pain lasting around 15-180 mins untreated
Classified as a trigeminal autonomic cephalgia - pain mainly in CN V1
Phantom of the opera mask pain
At least one of the following, ipsilaterally:
Conjunctival redness and/or lacrimation
Nasal congestion and/or rhinorrhoea (runny nose)
Eyelid oedema
Forehead and facial sweating
Miosis and/or ptosis (constriction / dilation of pupil), drooping of eyelid
A sense of restlessness or agitation
Frequency between one on alternate days to 8 per day.
Not associated with a brain lesion on MRI
What is the treatment for acute cluster headaches?
Advise patients to attend A&E for inhaled oxygen. If it works, GP can prescribe oxygen cylinder for use at home
Oxygen inhibits neuronal activation in the trigeminocervical complex
S/C (subcutaneous injection) or Nasal Sumatriptan
What is the treatment to limit / prevent further cluster headaches?
Verapamil Prednisolone Lithium Valproate Gabapentin Topiramate Pizotifen
What are the differences between migraines and cluster headaches in terms of:
Distribution Duration Frequency Remission Nausea Pain Symptoms Activity
Migraine VS Cluster
Distribution: 33% M, 67% F || 90% M, 10% F
Duration: 3-12 hours || 45-180 mins
Frequency: 1-8 attacks monthly || 1-3 attacks daily (often at night)
Remission: Long remissions unusual || Long remissions common
Nausea: nausea and vomiting frequent || Nausea rare
Pain: pulsating and hemicranial pain || steady, exceptionally severe, well localised pain, unilateral in each cluster
Symptoms: visual or sensory auras seen || eyes watery, nose blocked, ptosis etc.
Activity: patient lies in the dark || patients pace about
