Headache Syndromes Flashcards
What are the red flags in a headache history?
- New onset headache >55 years old
- Known/previous malignancy
- Immuno-suppressed
- Early morning headache
- Exacerbation by coughing/sneezing (increased ICP)
A patient who has a headache which is worse upon lying down is likely to have what condition?
Intracranial hypertension
Autonomic symptoms (photo/phonophobia) usually occur with what type of headache?
Primary headaches - e.g. Migraine
What type of headache should be considered if the patient who is presenting is immunosuppressed?
intracranial infection
What visual sign is often present previous to a migraine?
“aura”
- disturbance of vision
- may also cause speech/word-finding difficulty
Social and lifestyle problems can aggravate chronic headaches. TRUE/FALSE?
TRUE
What gender is more likely to get migraines, and how often are attacks per month on average?
Females>males
usually around 1 attack per month
Most migraine sufferers experience an aura prior to their migraine. TRUE/FALSE?
FALSE
80% - no aura
What features are needed to be diagnostic of migraine?
At least 5 attacks (lasting between 4-72 hours)
2 of : Moderate/ severe, unilateral, throbbing pain, worse during movement.
1 of : Autonomic features, photophobia/ phonophobia
In females, migraines can be hormonally driven. At what ages do you think the incidence of migraine in females peaks?
early teenage years (due to puberty)
Menopausal age
Describe the pathological events that lead to the pain felt during a migraine.
- Stress triggers in the brain cause serotonin to be released
- Blood vessels constrict and dilate
- Chemicals including substance P are released causing sensation of pain
What structures are found in the migraine centre of the brain?
Dorsal Raphe Nucleus
Locus Coeruleus
How long does a pre-migraine aura usually last for?
around 20-60 minutes
What visual symptoms can be present during an aura?
Central scotomata
Central fortification
Hemianopic loss
What are the potential triggers of a migraine?
Sleep Dietary Stress Hormonal Physical exertion
What can help to identify specific migraine triggers?
Headache diary
What pharmacological therapies can be given acutely in migraine?
NSAID => Aspirin 900mg/Naproxen/Ibuprofen
+/- anti-emetic
Triptan (serotonin agonist)
- Rizatriptan, sumatriptan
What different formulations of triptans are made?
Oral tablets
sub-lingual wafers (no water required)
subcutaneous - consider in those with N+V
When is migraine prophylaxis considered?
If > 3 attacks per month OR very SEVERE
What non-pharmacological methods are used for migraine prophylaxis?
acupuncture
relaxation exercises
What pharmacological treatments can be given for migraine prophylaxis?
Amitriptyline => 10 - 25mg (max 75mg)
Propranolol => 80-240mg daily
Topiramate => 25mg-100mg daily
Sometimes: gabapentin, pizotifen, Sodium valproate, Botulinum toxin
What are the adverse effects of amitriptyline?
Dry mouth
Postural hypotension
sedation
Who should NOT be given a beta-blocker?
asthma
Peripheral vascular disease
What are the adverse effects of Topiramate?
- weight loss
- paraesthesia
- impaired concentration
How should migraine patients modify their diet?
- Keep hydration up (drink 2litres /day)
- Avoid triggers e.g. chocolate and cheese
What are the different classifications of migraine?
Acephalgic - no headache, but aura + N+V
Basilar - in brainstem => vertigo
Retinal migraine - flashes at back of eye
Hemiplegic - stroke-like symptoms
What symptoms indicate a tension type headache?
- tingling
- mild to moderate pain
- bilateral
- absence of N and V
- absence of autonomic symptoms
How are tension type headaches treated?
- relaxation physiotherapy
- amitriptyline if required
What are trigeminal autonomic cephalgias (TACs)?
- primary headache disorders
- unilateral trigeminal distribution pain
- ipsilateral cranial autonomic features.
What cranial autonomic features present with a TAC?
- Ptosis
- Miosis
- Nasal Stuffiness
- Nausea/ vomiting
- Tearing
- Eye lid oedema
What are the four main types of TAC?
Cluster headache
Paroxsymal hemicrania
Hemicrania continua
SUNCT
Who usually gets a cluster headache?
Young (30s-40s)
Men> women
How long do cluster headaches normally last?
Individual headache duration = 45- 90mins
Patients can have between 1 to 8 day, which continues for a few weeks -> months.
How are cluster headaches treated?
- High flow O2 => 100% for 20 mins
- S/C sumatriptan 6mg
- Steroids- reducing course over 2 weeks
- Verapamil for prophylaxis
Who usually develops a paroxysmal hemicrania?
Elderly (50s-60s)
women> men
How long does a a paroxysmal hemicrania usually last for?
Duration: 10- 30mins
Frequency: 1 to 40 day
How is a paroxysmal hemicrania treated?
indomethicin
What is a SUNCT headache?
S= Short lived (15-120 secs) U=unilateral N= neuralgiaform headache C= conjunctival injections T= Tearing
What is used to treat SUNCT headaches?
Lamotrigine
Gabapentin
Patients with new onset cranial autonomic features require what investigations?
MRI brain
MR angiogram
What patient group usually get idiopathic intracranial hypertension?
F > M
obese
What symptoms are usually present in idiopathic intracranial hypertension?
- headache worse in the morning
- morning N + V
- enlarged blind spot
- visual loss on standing
Why is an MRI completed to investigate idiopathic intracranial hypertension?
To rule out tumour or hydrocephalus
How is idiopathic intracranial hypertension treated?
- weight loss
- acetazolamide
- shunt (only if no weight loss OR acetazolamide untolerated and worried vision will be compromised)
- monitor visual fields
Who usually gets trigeminal neuralgia?
Elderly (>60)
women>men
How is trigeminal neuralgia usually triggered?
Triggered by touch, usually V2/3
How long do trigeminal neuralgia attacks last?
Duration: 1 sec to 90 secs
Frequency: 10 to 100 day
Lasts few weeks to months before remission
How can trigeminal neuralgia be investigated?
MRI brain
How is trigeminal neuralgia treated?
Carbamazepine
Gabapentin
phenytoin
baclofen
Surgical decompression if CN V squished
