Headaches Flashcards
Describe the common components of a history of a patient with tension headache
- can last weeks/months/years
- characterised by a tightness or pressure around the head
- constant or worse towards the evening
- overused analgesia
- rarely prevents with nausea
How would you treat a tension headache
- relaxation exercises
- reduce analgesia
- low dose amitriptyline (10-20mg)
Describe the symptoms of a migraine
- one side at a time with nausea
- unilatera/bilateral for hours/days
- photophobia, phonophobia, gut symptoms
pulsating, sharp character - more common in women mid-cyle/newly menopausal (linked to oestrogen)
- can be with an aura (visual, weakness or sensory deficit that spreads over minutes)
Describe the relevance of a scotoma
Flashing light around visual field
- grey-scale represents migraine
- coloured is associated with epilepsy
How can you try and figure out the cause of a patient’s headache?
- look for triggers (eg. food/alcohol/beginning or end of working week)
- is it exacerbated by physical activity or bang to the head
- family history?
- suggest diary to note patterns and help decide treatments
What is the treatments of acute migraines?
Low frequency migraines
- aspirin, paracetamol
- anti-nausea meds (prochlorperazine, metoclopramide)
- triptans (5-HT receptor agonists)
How would you treat frequent migraines?
Prophylactic treatment:
- B-blockers
- low dose amitriptyline
- pizotifen (5-HT antagonist, antihistamine, anticholinergic)
- topiramate
- sodium valporate
- candesartan
- flunarazine
- lisinopril
- methysergide
What are the non-pharma treatments of migraines?
- botulinum toxin injection every 90 days
- anti-CGRP monoclonal antibodies (erenumab) for patients getting over 4 migraines a month and tried other prophylactics
- acupuncture
What is trigeminal autonomic cephalagia and its presentation?
Cluster headache - unilateral usually around the eye occuring at the same time everyday. Occurs for a few weeks then goes and then returns after a period.
Presentation:
- recurrent pain in trigeminal distribution
- autonomic features (eye watering, nasal congestion, eye redness)
- more common in males
What is paroxysmal hemicrania?
- similar condition to TAC
- more common in women
- shorter, more frequent attacks
How can you differentiate between TAC and paroxysmal hemicrania?
paroxysmal hemicrania responds to indomethacin and TAC does not
How would you treat TACs?
- triptans
- high dose O2
- high dose verapamil (Ca2+ channel blocker)
What are the signs of a medication overuse headache?
- occurs for over half the month and is worse with analgesic use
- common if patient is using analgesia for the majority of days in a month
Describe thunderclap headaches
- rapidly appearing, very severe pain
- consider SAH
- urgent investigation needed (CT looking for blood in the brain and 12 hr CSF)
- can be due to exertion due to vasospasm
What characterises early morning headaches?
- cervicogenic due to poor posture in bed, over exertion, spinal degeneration etc.
- sleep apneoa with CO2 retention due to obesity and snoring, can be associated with alcohol
Describe the presentation and treatment of raised ICP
- mild headache
- diurnal variation (worse in morning before getting better)
- mild nausea
- neuro features - bilaterall papilloedema (sign of abscess or CSF blockage)
Treatment: scan and urgent referral
What characterises temporal arteritis, and how would you test and treat it?
- jaw claudication (pain on chewing)
- features of polymyalgia (tired and stiff in morning)
- onset of temporal headache
- can cause blindness through embolism in eye
Test:
- palpate temporal arteries for tenderness
- check for raised erythrocyte sedimentation rate (sign of inflammation)
- use ultrasound or temporal body biopsy to look for inflammation
Treated with high dose steroids
What is the presentation of cerebral venous sinus thrombosis?
- common in females on OCP
- severe headache
- raised ICP
- papillodema and seizures
- MR shows bilateral haem (diagnostic of CVST)
- empty delta sign on imaging also associated with it
What is the presentation of low ICP headache?
- headache when standing, eased when lying down
- can develop into fits (due to decreased support to brain)
- untreated can cause death
How is low ICP headaches treated?
- blood patch
* patient’s own blood used to clot the hole to stop the leak of CSF
