Headaches Flashcards
what are the common types of headache (benign)
migraine
muscular tension
analgesia overuse
systemic illness
cervicogenic
what are some serious types of headache
subarachnoid haemorrhage
raised intercranial pressure
infection-meningitis
temporal arteritis
cerebral venus sinus thrombosis
low intercranial pressure
what questions should you ask in a headache history
-how long?
-position?
-character- pressure, sharp, ache dislike of light/noise?
-frequency?
-diurnal variation?
-change in character? progression
-nausea/vomiting?
-postural- worse lying down?
-other neurological symptoms- aura? double vision?
-previous medical history, fam history?
-medicine- how often?
what is IBS linked to (headache wise)
venous sinus thrombosis
what history of symptoms do you get with a tension headache
-lasts week, months, years
-tightness, pressure round the head
-constant- worse in evening (stress build throughout day)
-frequently used analgesia
-rarely present with nausea
what is treatment for a tension headache
-reassurance about severity and duration
-won’t go away overnight
-relaxation exercises
-reduce analgesia- to stop analgesia induced headache
LOW DOSE AMITRIPTYLINE (10-20mg)
what are some symptoms of a migraine
-classically on one side
-most headache with nausea will be migraine
-unilateral or bilateral, usually hours-days
-photophobia, phonophobia, gut symptoms
(IBS may be a form of gut migraine- responds to amitriptyline)
-pulsating, sharp
-women more common, especially mid-cycle, menopause (oestrogen)
- can have an AURA
discuss auras that might be found in migraines
visual problems – such as seeing flashing lights, zig-zag patterns or blind spots.
can be visual, weakness, sensory and spread over minutes
can look similar to hemiplegia from stroke
BLACK AND WHITE SCOTOMA
what does a coloured scotoma indicate
it is a danger sign as is associated with epilepsy
what is a scotoma
blind spot or partial loss of vision in what is otherwise a perfectly normal visual field
what are some causes of migraine
-vascular (reduce blood flow-increase toxicity) and neural (overstimulated neurons) mechanisms together
look for triggers- FOOD, ALCOHOL, BEGINNING OR END OF WORKING WEEK
might be exacerbated by physical activity, bang on the head
family history
keep a DIARY
what treatments do you use for acute migraines
aspirin, paracetamol
anti-nausea
TRIPTANS
what are some anti-nausea drugs
prochlorperazine
metoclopramide
what treatments do you use if migraines occur more than twice a month
-prophylactics
beta blockers- propranolol
low dose amitriptyline
pizotifin
topiramate
sodium valproate
candesartan
flunarazine
lisinopril
methysergide
botulinum toxin injection every 90 days
anti-cgrp monoclonal antibodies - ERENUMAB
acupuncture
what is the issue with methysergide
ergot derivative
therefore:
retroperitoneal fibrosis
hallucinations
when can you use erenumab to treat migraines
if have more than 4 migraines a month
must have tried at least 3 other prophylactics
can women use OCP if have migraine and aura
no
due to a stroke risk
describe symptoms of trigeminal autonomic cephalagia (TAC)
rare
commonest cause is CLUSTER HEADACHE
-unilateral, often around eye
-circadian rhythm, same time of day
-clustering in period usually a few weeks, then goes comes back- SUICIDE HEADACHES
recurrent pain in trigeminal distribution
autonomic features- eye watering, nasal congestion, redness eye
MORE COMMON IN MEN
other causes-
PAROXYSMAL HEMICRANIA
more common in WOMEN
shorter, more frequent attacks
respond to INDOMETHACIN
how do analgesic abuse headaches present
worse with analgesia
present for over 15days/month- bad headaches
common if taking common analgesia more than 15 days a month
or
more than 10 days for other acute- triptans
what is a thunderclap headache
instant or rapidly appearing within 60 seconds
very severe
must consider SUB-ARACHNOID HEAM
therefore urgent investigation
-CT
-lumbar puncture after 12 hours (look for blood/bilirubin and oxyhaemaglobin in CSF)
what is coital cephalgia
type of migraine from vasospasm
quickly reversible
comes back - which is reassuring
occurs during sex
what is coital cephalgia
type of migraine from vasospasm
quickly reversible
comes back - which is reassuring
occurs during sex
exertional
what can cause early morning headaches
- CERVICOGENIC
-poor posture in bed pillow bending neck
-anatomical position in bed
-over exertion
-spinal degeneration- spondylosis
-usually muscular if not presenting with neurological compromise (reflex loss, weakness)
break pain/spas, cycle
- sleep apnoea with co2 retention
build up of biproducts of cellular respiration
-obesity
-history snoring- common with alcohol
-tested by monitoring chest movements
-treated with positive pressure oxygen
how does raised intracranial pressure present as
mild headache
diurnal variation- worse in MORNING, gone by lunchtime
mild nausea
NILATERAL PAPILLOEDEMA
-could be from tumours, abscess or CSF blockage (spina bifida)
how does meningitis present
fever
photophobia
neck stiffness
altered consciousness (encephalitis)
petechial rash from meningococcal meningitis
how does temporal arteritis present
relatively rare
never occur below 50
jaw claudication
polymyalgia (tired, stiff in morning) then temporal headache
can cause blindness through embolism into eye
(clots from inflammation break off into eye)
how do you test for temporal arteritis
-palpate temporal arteries for tenderness
(if there are pulsations, and not tender= unlikely to be be this)
-check for raised erythrocyte sedimentation rate (ESR>50)
- US, or temporal artery biopsy for inflammation
what is management for temporal arteritis
high dose steroids early
problems if getting them- cause osteoporosis, hypertension, muscle wasting, truncal obesity
how does cerebral venous sinus thrombosis present
-often female on OCP-> pro antithrombotic effect of oestrogen
-headache, often severe
-raised ICP
-papilloedema and seizures (pressure of motor cortex- neurons break down)
-maybe MR bilateral heam
-empty delta sign (empty sinus)
therefore build up pressure
-refer to neurosurgical centre
what is low icp due to , treatment, presentation
happens after lumbar puncture
-due to CSF leakage through hole left in dura
-tear covering of spinal cord
-reduced by using atraumatic needles or angle of needle bevel
present
headaches on standing, eased with lying
can develop into fits as brain is supported less
can cause death
LOW CSF IN SYSTEM- IF CORRECT SITS RIGHT, BRAIN SETTLES DOWN WHEN STANDING, COMES THROUGH FORAMA
treatment
blood patch for post-LP headache– stops leaking
TAKE SAMPLE OF BLOOD AND REINJECT SAME SITE, SQUIRT BLOO OVER DURA NEEDLE WENT IN–BLOOD CLOTS- PATCH ON MEMBRANE
CSF PRODUCED NORMALLY AND BACK TO NORMAL AND BRAIN FLOATS
