Headaches Flashcards
5 red flags of headaches:
- nausea/vomiting
- fever/systemically unwell, confusion
- sudden onset
- low conscious levels, change in character
- neuro sx eg. weakness, speech disturbance, seizures
- pressure dependent factors e.g. worse lying down/on coughing/straining (raised ICP concern)
- age 65yrs+
- meningism, non blanching rash
- unilateral
Suggest 5 important direct qs to ask in headache history?
- is it purely unilateral, always same side?
- any neck stiffness?
- nausea/vomiting?
- photophobia/phonophobia/osmophobia (smells)
- any redness of eye/face
- ptosis or facial palsy, facial droop
- any sensory/visual changes
- any eye or nose watering
- changes in pupil? Increased sweating on one side?
Migraine headache features:
- starts on 1 side or frontal or back
- builds up over ~30mins
- throbbing and pressing in nature
- recurring disabling attacks last 4-72hrs
- +/- aura
- associated w nausea and photophobia/phonophobia
Suggest 3 possible triggers for migraines?
- diet (not eating regularly/BMs dropping too low)
- physical exertion
- hormonal changes (more common in women)
- head trauma
- stress and anxiety
- sleep deprivation or excess
- environmental factors (e.g. altitude, pollution)
Migraine rx goals:
- pre-empt rx:
- acute rx:
- chronic prophylaxis goal:
- pre-empt rx: manage triggers e.g. sleep/hydration/diet
- acute rx: pain management
- chronic prophylaxis goal: decrease #migraine days/severity
What is the medication class chosen to treat migraines? If can’t take this, what alternative is poss?
- Triptans e.g. sumatriptan 50mg oral or nasal
- Aspirin 800mg or ibruprofen 600-800mg
Cluster headache features:
-last 15-30min, 1-8x a day, always on same side during that cluster
- severe unilateral headache, around eye + autonomic fts
- eye watering/red/swelling
- facial sweating/redness/swelling
- nasal dripping
- smaller pupil of affected eye
- usually at night/post couple hrs sleeping
- pt restless, unable to sit or sleep, agitated, feels like banging his head
Cluster headache treatment in A&E?
- mainstay is giving ___ ___ and subcut ___
- what masks the pain for a short period?
- what may a specialist service do to help?
- for cluster attacks>2weeks what should be considered? What do you need to do first?
- High flow O2 works v well
- Subcut 6mg Sumatriptan per episode
- steroids mask the pain
- greater occipital nerve block by specialist service (injection behind ear, 70% clusters stopped by this)
- consider verapamil (post ECG, for prophylaxis)
What does SUNA headaches stand for? They are a rare headache disorder in the family of clusters known as Tri__ A___ C____.
-fts include: v ___ duration, >___attacks/day, multiple ___ ___ can trigger it
- Short lasting Uniform Neuralgic headache Attacks
- in family: Trigeminal Autonomic Cephalagia
- V short duration
- > 100attacks/day
- multiple cutaneous stimuli can trigger it
-Short lasting Uniform Neuralgic headache Attacks (SUNA) headaches, v short duration, >100x/day.. what is the diagnostic test? (clue: involves therapy)
- indomethacin trial (an NSAID) , GI side effects common
- should discontinue the pain well
3 Characteristics of a thunderclap headache:
-v severe pain in head
-instantaneous reaching max intensity within <5 minutes
-lasts >5mins
-usually pt is sick by time they are in front of you-vomiting reduced consciousness, neck stiffness
NB: consciousness levels may fluctuate, +/-neck stiffness
Give 5 ddx of a thunderclap headache:
- SAH
- carotid artery dissection
- cerebral venous sinus thrombosis
- reversible vasoconstriction syndrome
- acute hypertensive crisis
- pituitary apoplexy
- spontaneous intracranial hypotension
Management pathway of thunderclap headache-always SAH first thought:
- CT head –> if normal and hx concerning, lumbar puncture
- CT head if SAH refer to neurosurgery
- If LP shows raised ICP -> consider venous sinus thrombosis
- If LP shows xanthochromia=diagnostic of SAH -> refer
Idiopathic Intracranial HT features:
- raised ICP of unknown cause
- typically young, obese females
- new onset headache
- papilloedema
- +/-visual disturbances
- +/-sx of raised pressure e.g. double vision, tinnitus
Idiopathic Intracranial HT diagnosis:
- must have what to exclude what?
- then diagnose with what?
- MUST have MRI and MRV to exclude venous sinus thrombosis
- then LP diagnosis with an opening pressure >25cmCSF and normal constituents
Idiopathic Intracranial HT treatment?
- conservatively ___ helps
- what medication reduces CSF production but SEs unfavourable
- weight loss, and keep it off tends to reverse disease
- acetazolamide 250mg BD -tingling SE but decreases appetite is helpful
- if vision threatened consider VP shunt or optic nerve fenestration
- bariatric surgery shows promis
- chronic headache often develops and is managed as migraines
Cerebral Venous sinus Thrombosis features: 1% of stroke 85% make a full recovery 51% pts have acute onset headache presentation?
- subacute w headache, vomiting, visual sx, seizures and focal neuro deficits
- presentation is due to raised ICP due to obstruction, venous infarction and venous haemorrhage
- may just have papilloedema and headache
Give 5 RFs for Cerebral Venous sinus Thrombosis features:
- infective: bacterial and fungal
- inherited or acquired thrombophilia (SLE pregnancy, puerperium)
- dehydration
- inflammation - Behcet’s, Wegenener’s, SLE
- Haematology: sickle cell, PRV, thrombocytopenia, PNH
- head injury, neurosurgery, LP
- Malignancy
- combined OCP esp. if migraine aura
