Headaches Flashcards
Name some examples of primary and secondary headaches
Primary - Migraines and trigeminal autonomic cephalgia.
Secondary - Thunderclap headache, Raised ICP headaches, low ICP headaches and neuralgia
What are the important history questions when taking a headache history?
- Any personal/family history?
- How many headache types have they had and then for each type ask:
- Age of onset, is it chronic/episodic, any premonitory symptoms (low mood/nausea), progression, location, character, intensity, precipitating factors, exacerbating or relieving factors, associated symptoms
What are the examinations of the headache patient?
- Blood pressure is important, urine drip, pregnancy test, temp and weight.
- GCS,
- Palpation of skill, TMJ, nuchal rigidity,
- Fundoscopy (papilloedema), presence of cranial nerve palsy and test facial sensation.
- Any autonomic features,
- Skin exam, lymphadenopathy
What are the investigations for a headache patient?
- Blood pressure is important,
- ECG incase you put patient on meds,
- Urinalysis,
- Bloods (UEs, LFT, CRP, ESR, thyroid function)
- LP (measure opening pressure)
- CT angiogram/MR angiogram
- CT venogram/MR venogram (VST)
What headache patients should you image?
SSSNOOPPP
- Systemic symptoms,
- Secondary risk factors,
- Seziures,
- Neurological symptoms,
- Older onset (over age 50)
- Progression (change in type or intensity of headache),
- Papilloedema
- Precipitated by cough/exertion/valsalva
What headache patients should get an LP?
CSF
- Change in nature of headache,
- Systemic signs and features,
- Focal neurological deficit
What is the diagnostic criteria for tension type headaches?
A. At least 10 episodes occurring on 1 day of the month.
B. Two of following: Bilateral, pressing/tightening quality, mild-mod and not aggravated by physical activity.
C. Both of following: No nausea/vomiting and no photophonophobia
What is the pathophysiology of a migraine?
- Interaction between multiple parts of the brain. Link with Calcitonin gene related peptide.
What is the diagnostic criteria for a migraine?
A. At least 5 attacks of:
B. Lasting 4-72h
C. Two of the following: Unilateral, pulsating quality, mod-severe pain and its aggravated by physical activity like walking.
D. One of the following: Nausea/vomiting or photophobia or phonophobia
What are the phases of a migrane?
Prodrome - Yawning, polyuria, depression, poor sleep/concentration. This can last hours to days.
Aura - Can be visual, sensory, language or motor. 5-60mins
Headache - Throbbing headache, nausea/vomiting, photophonophia worse with activity.
Postdrome - Depression, euphoria, poor concentration (24-48 hours)
What are the key elements of aura?
- It evolves over 5-60mins with positive and negative elements but is fully reversible.
- Most common is visual, then sensory then language and finally motor
What is the treatment of an acute mingrane?
- Avoid opiates.
- Single dose of 900mg aspirin or
- Triptans such as sumatriptan.
- If persistent vomiting then give metoclopramide.
What are the prophylactic therapies for migranes?
- Lifestyle advice - avoid triggers,
- Give pharmacological prophylaxis if >4 headaches a month. 1st line is propranolol, others include topiramate or amitriptyline. Switch if no benefit at 3 months
- Headache diaries
What prophylaxis meds can be used for migraines if all others have failed?
- Onabotulinimtoxin A (botox)
- CGRP inhibitors (Erenumab)
What is the diagnostic criteria for cluster headaches
A. At least 5 attacks
B. Severe or very severe orbital/supraorbital pain lasting 15-180mins
C. One or both of following: autonomic features ipsilateral to headache or a sense of agitation/restless ness
D. Frequency of one every other day to 8 per day.
