Headaches - 1 Flashcards
What is a primary headache?
No underlying medical cause
Tension type headache, migraine and cluster headache
What is a secondary headache?
Has identifiable structural or biochemical cause
Tumour, meningitis, vascular disorders, systemic infection, head injury and drug-induced
Describe the pathophysiology of a primary headache
Sensitisation of normal pain pathways
Involves brainstem, cortical structures and trigemino-vascular system
Calcitonin gene related peptide a key transmitter
What is used for management for primary headache?
Modifiable lifestyle triggers - sleep, dehydration, stress
Abortive treatment
Transitional treatment
Preventative treatment
What is the aim of preventative treatment?
Adjust threshold for developing headache - reduce sensitivity
What is the identifiable structural or biochemical cause of secondary headache?
Headache occurring for first time in close temporal relation to another disorder known to cause headache
Pre-existing primary headache becoming significantly worse in close temporal relationship another disorder known to cause
What are the specific headache features that give clues to diagnosis of secondary headache?
Thunderclap in SAH
Postural headache in low pressure headache
Biology is mainly migraine and migrainous features
What is the investigations for headaches?
Primary - look for underlying cause, usually need no investigation but can have MRI or CT
Secondary - CT and CT angiogram, MRI
Describe a tension type headache
Most frequent primary headache
Not disabling
Is mild, bilateral headache with pressing or tightening quality
Aggravated by routine exercise
What is the treatment for tension type headache?
Acute - paracetamol or NSAIDs
Preventative - Tricyclic antidepressants (Amitriptyline)
Describe a migraine
Most disabling primary headache
A chronic disorder with episodic attacks and complex changes in brain
What are the symptoms of a migraine?
During - headache, nausea, vomiting, phonophobia, photophobia and functional disability
In between attacks - anticipatory anxiety
Describe the course of a migraine
Premonitory - mood changes, fatigue, cognitive changes, muscle pain and food craving
Aura
Early headache - dull, muscle pain and nasal congestion
Advanced headache - unilateral, throbbing, nausea
Postdrome - fatigue and cognitive changes
Describe aura in migraines
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve sensory, visual, motor or speech systems
Is a slow evolution of symptoms
Duration - 15 to 60 mins
Can be confused with transient ischaemic attack
Describe chronic migraine
Headache more than 15 days a month of which more than 8 days are migraine, for more than 3 months
Transformation can occur with or without escalation of medication use
What is a transformed migraine?
History of episodic migraine, increasing frequency of headache over weeks/months, migraine symptoms become less frequent and severe
Describe medication overuse headache
Headache present more than 15 days a month which have developed or worsened whilst taking regular symptomatic medication
Can occur in primary headache
What can medication overuse headache be caused from?
Use of triptans, ergots, opioids and combination analgesics more than 10 days a month
Use of simple analgesics more than 15 days a month
Caffeine overuse
What are some modifiable lifestyle triggers for a migraine?
Dehydration, diet, environmental stimuli, changes in oestrogen in women, stress, hunger and sleep disturbance
What is used for acute treatment of migraines?
Aspirin and NSAIDs
Triptans
Limit to 10 days per month
What is used for prophylactic treatment for migraines?
Propranolol, Candesartan
Anti-epileptics - topiramate and valproate
Tricyclic antidepressants
Flunarizine
Botox
CGRP monoclonal antibodies
What is the treatment for medication overuse headache?
Prevention - limit treatment to 2 days a week
Abrupt withdrawal of medication
Best strategy is not clear
What are specific headache issues in women?
Migraine without aura is better in pregnancy and with doesn’t change
First migraine can occur in pregnancy
Combined OCP is contraindicated if migraine with aura
Avoid anti-epileptics in women of child bearing age
What is the treatment of migraine is women is pregnant?
Acute attack - paracetamol, triptans and NSAID
Preventative - propranolol and amitriptyline
Describe new daily persistent headache
Distinct and clearly remembered onset, with pain becoming continuous and unremitting within 24hrs
Medication overuse is common
Diagnosis and exclusion of secondary cause
What are the clinical features of primary new daily persistent headache?
2 subtypes
Self-limiting - usually resolves within months even without therapy
Refractory - resistant to aggressive treatment
Headache can resemble chronic migraine or chronic tension type headache
