Headaches Flashcards
1
Q
What is the definition of a migraine?
A
Migraine is a chronic, genetically determined, episodic neurological disorder that usually presents in early-to-mid life.
2
Q
Epidemiology of migraines
A
- Second most common primary headache
- Migraine is a common condition with a global prevalence of 14.7%
- F>M
- In 90% onset is before 40yrs
3
Q
Risk factors for migraines
A
- Family history
- Female gender: migraines are three times more common in women
- Obesity
- Other important triggersinclude tiredness, lack of food, dehydration, menstruation, red wine and bright lights
- Pathophysiology
4
Q
Pneumonic for triggers of Migraines
A
CHOCOLATE
5
Q
CHOCOLATE
A
- Chocolate
- OralContraceptive
- Alcohol
- Anxiety
- Travel
- Exercise
6
Q
Types of migraines
A
- Migraine without aura
- Migraine with aura
- Silent migraine(migraine with aura but without a headache)
- Hemiplegic migraine
7
Q
What are classic migraines preceded by?
A
an aura, however, these only occur in one-third of patients.
8
Q
What is the theory around ‘aura’
A
aura was due to cerebral vasoconstriction, whilst the subsequent headache occurred due to reflex vasodilatation.
9
Q
What are the headaches in migraines due to?
A
- During aura serotonin levels increase causing vasoconstriction
- During the attack serotonin levels decrease lower than normal which triggers vasodilation
10
Q
What is aura thought to occur due to?
A
cortical spreading depression, which is a propagating wave of depolarisation across the cerebral cortex causing the brain to become hypersensitive to certain stimuli
11
Q
5 stages of migraines
A
- Premonitoryorprodromalstage (can begin 3 days before the headache)
- Aura(lasting up to 60 minutes)
- Headachestage (lasts 4-72 hours)
- Resolutionstage (the headache can fade away or be relieved completely by vomiting or sleeping)
- Postdromalorrecoveryphase
12
Q
Clinical manifestations of migraines
A
-
Severe, unilateral, pulsating headache lasting up to 72 hours
- In children, migraines are more commonly bilateral,
- Nausea and vomiting
-
Photophobia and phonophobia
Typical aura: develops over 5 minutes, lasts 5-60 minutes and is fully reversible
Atypical aura: may last more than 60 minutes - Visual symptoms affectingoneeye
- Poor balance (e.g. vestibular migraine)
- Decreased level of consciousness
13
Q
Diagnostic criteria for migraine with aura and without aura
A
Look it up
14
Q
Investigations to rule out pathology of migraines
A
- CT or MRI head: rule out the cause of a secondary headache, such as a subarachnoid haemorrhage
- ESR: exclude giant cell arteritis
15
Q
Differential diagnosis for migraines
A
- Stroke: hemiplegic migraines can mimic strokes
- Primary headaches
- Migraines
- Trigeminal autonomic cephalalgias
- Other primary headache disorders
- Secondary headaches
- Trauma
- Idiopathic intracranial hypertension
- Subarachnoid haemorrhage
- Space occupying lesion
- Giant cell arteritis
- Infection
- Drugs and medications
- Venous sinus thrombosis
- Malignant hypertension
- Temporomandibular disorder
16
Q
first line prophylaxis for migraines ?
A
propranolol
17
Q
Acute management of migraines
A
-
Analgesia
- Ibuprofen or aspirin or paracetamol
-
Oral triptan alone+/- paracetamol or an NSAID
- Oral sumatriptan is the first choice triptan (5-HT receptoragonist - mimic serotonin to cause vasoconstriction)
- Consider a nasal triptan over an oral triptan in peopleaged 12 to 17 years old
- Antiemetic:consider metoclopramide or prochlorperazine
- Avoid opiates: due to the risk of medication-overuse headache, dependence, and worsening nausea
18
Q
Chronic management of migraines
A
- Headache diary:document headache frequency to illicit triggers
- Avoid triggers
-
Prophylaxis (pharmacological):
- Propranololis considered first-line
- Topiramate: contraindicated in pregnancyas it isteratogenicand reduces oral contraceptive efficacy
- Amitriptyline:low-dose may be considered
- Frovatriptanorzolmitriptan: for predictable menstrual migraines
-
Prophylaxis (non-pharmacological):
- Mindfulness:alternatives include meditation and CBT
- Acupuncture: if bothpropranololandtopiramateare ineffective or unsuitable
- Riboflavin (vitamin B2): **may be effective in some people, but avoid in pregnancy
19
Q
Complications of migraines
A
- Depression
- Status migrainosus: a severe, debilitating migraine lasting for more than 72 hours that may warrant admission
20
Q
Prognosis of migraines
A
- The prognosis associated with episodic migraine is generally good with treatment, whilst the frequency of headaches is thought to decrease with age.
21
Q
What is the tension headache definition?
A
Tension-type headaches is a common primary headache disorder and can be either episodic or chronic.
22
Q
Epidemiology of tension headaches
A
- Very common: most common primary headache
- Onset tends to be in a patients’ 20’s
- Most common between ages of 20-39
- Gradually becomes less common with advancing age
23
Q
characteristis features of tension headaches
A
often described as a ‘tight band’ around the head or a pressure sensation. Symptoms tend to be bilateral, where as migraine is typically unilateral
tends to be of a lower intensity than migraine
not associated with aura, nausea/vomiting or aggravated by routine physical activity
may be related to stress
may co-exist with migrain
24
Q
RFs for tension headaches
A
- Stress
- Bad posture
- Sleep deprivation
- Eye strain
- Depression
- Alcohol
- Skipping meals
- Dehydration
25
Pathophysiology of Tension headaches
May be due to muscle ache in the frontalis, temporalis and occipitalis muscles.
prolonged stimulation of nocireceptors
26
Clinical manifestations of tension headaches
- **Bilateral with a pressing/tight sensation of mild-moderate intensity**
- Frequency varies depending on type of headache: chronic or episodic
Rubber band, tight around head, bilateral pain, feel it in trapezius too
27
What is the clinical diagnosis criteria for frequent episodic tension-type headache
**Frequency:** At least 10 episodes of headache occurring on 1-14 days/month on average for >3 months (≥12 and <180 days/year)
**Time:** 30 minutes to 7 days
**Characteristics:** At least two of the following:
1. Bilateral location
2. Pressing or tightening (non-pulsating) quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity such as walking or climbing stairs
**Both of:**
1. No nausea or vomiting
2. No more than one of photophobia or phonophobia
28
Diagnostic crtiera for chronic tension-type headache
**Frequency:** Headache occurring on ≥15 days/month on average for >3 months (≥180 days/year)
**Time:** Hours to days, may be unremitting
**Characteristics:** At least two of the following:
1. Bilateral location
2. Pressing or tightening (non-pulsating) quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity such as walking or climbing stairs
**Both of:**
1. No more than one of photophobia, phonophobia or nausea
2. Neither moderate or severe nausea or vomiting
29
first line management of tension headaches
aspirin, paracetamol, NSAID
30
Investigations to rule out pathology
- **CT or MRI head**: rule out the cause of a secondary headache, such as a subarachnoid haemorrhage
- **ESR:** exclude giant cell arteritis
31
Differential diagnosis for tension headaches
Primary headaches
- **Migraines**
- **Trigeminal autonomic cephalalgias**
- **Other primary headache disorders**
Secondary headaches
- **Trauma**
- **Idiopathic intracranial hypertension**
- **Subarachnoid haemorrhage**
- **Space occupying lesion**
- **Giant cell arteritis**
- **Infection**
- **Drugs and medications**
- **Venous sinus thrombosis**
- **Malignant hypertension**
- **Temporomandibular disorder**
32
What are cluster headaches classified as?
trigeminal autonomic cephalgia (TAC) and are thought to occur due to hypersensitivity of the trigeminal-autonomic reflex arc, resulting in vascular dilation and trigeminal nerve stimulation.
33
Management for episodic tension type headache
- **Analgesia:** Simple painkillers e.g. paracetamol or NSAIDs to be taken when headache occurs.
- Limit the use of analgesia to no more than 6 days a month to reduce
chance of medication-overuse headache
- **Hot towels to local area**
- **Lifestyle:** Evaluate and offer help with possible precipitants. Consider sources of stress, depression/anxiety, sleep disorder and chronic illnesses. Some patients find regular exercise helps.
34
Management for chronic tension-type headache
- **Acupuncture/ massage**
- **Prophylaxis: consider low dose amitriptyline**
- **Lifestyle:** Evaluate and offer help with possible precipitants. Consider sources of stress, depression/anxiety, sleep disorder and chronic illnesses. Some patients find regular exercise helps.
- **Referral:** If there is no improvement or diagnostic uncertainty refer to neurology.
35
What is the definition of cluster headaches?
Cluster headaches are intensely painful, unilateral, periorbital headaches with associated autonomic dysfunction.
Around the eye
36
Epidemiology of cluster headaches
- The estimated annual incidence of cluster headaches is 53 per 100,000 in the Western population
- Peak onset of 20 to 40 years old
- M>F
37
RFs for cluster headaches
- **Male**: 3 times more common in males
- **Family history**
- Autosomal dominant gene has a role
- **Smoking**
- **Alcohol excess**
38
2 other important types of TAC
- *Paroxysmal hemicranial*
- *Short-lived unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT)*
39
What is involved in cluster headaches
- histamine release
- increase in mast cells
- Activation of autonomic nervous system
40
What are the common precipitants of cluster headaches
- alcohol
- volatile smells
- warm temperatures
- sleep
41
What can cluster headaches be?
Can be episodic (clusters followed by remission periods) or chronic (no substantial remission period)
42
Clinical manifestations of cluster headaches
**Headaches occur in clusters:**
- Clusters usually last 2 weeks to 3 months, separated by remission periods lasting at least 3 month
- Patients experience 1 to 8 attacks per day
- Clusters typically occur 1 to 2 times per year
43
Symptoms of cluster headaches
- **Unilateral, periorbital or temporal headaches** lasting 15 minutes to 3 hours
- Ipsilateral **autonomic** symptoms:
- **Lacrimation** (teary eye)
- **Conjunctival injection** (red eye due to enlargement of conjunctival vessels)
- **Nasal congestion**
- **Rhinorrhoea** (nasal discharge)
- **Ptosis** (eyelid drooping)
- **Miosis** (excessive constriction of the pupil of the eye)
- **Facial sweating**
- **Nausea and vomiting**
- **Photophobia, with agitation and restlessness**
44
Diagnosis for cluster headaches
- Diagnosis is predominantly based on **clinical presentation**
- At least 5 headache attacks fulfilling the symptomatic criteria
45
Investigations to rule out other pathology for cluster headaches
- **CT or MRI Brain:** to rule out an underlying cause such as a space-occupying lesion or pituitary adenoma
- **ESR:** to exclude giant cell arteritis
46
Differential Diagnosis for Cluster headaches
Primary headaches
- **Migraines**
- **Trigeminal autonomic cephalalgias**
- **Other primary headache disorders**
Secondary headaches
- **Trauma**
- **Idiopathic intracranial hypertension**
- **Subarachnoid haemorrhage**
- **Space occupying lesion**
- **Giant cell arteritis**
- **Infection**
- **Drugs and medications**
- **Venous sinus thrombosis**
- **Malignant hypertension**
- **Temporomandibular disorder**
47
Acute management of cluster headaches
- **Triptans**: triptans are 5HT 1B/D agonists. Subcutaneous or intranasal sumatriptan provides symptomatic relief within 15 minutes in 75% of patients.
- **High flow oxygen- first line I believe**: 100% oxygen at 12-15L/minute via a non-rebreather mask for 15-20 minutes; provides symptomatic relief within 15 minutes in 70% of patients
- **Avoid triggers**
- The following drugs should be **avoided**: paracetamol, NSAIDs, opioids, ergots, and oral triptans
48
Prophylaxis treatment for cluster headaches
- **Verapamil**: first-line preventative management
- **Lithium**
- **Prednisolone:** a short course for 2-3 weeks to break the cycle during clusters
49
Complicatins of cluster headaches
- **Mental illness:** depression, anxiety, self-harm and suicide
- **Auto-enucleation:** individuals attempting to remove the affected eye due to a belief that the pain will subside
50
What is the definition of trigeminal neuralgia
Trigeminal neuralgia is a pain syndrome which describes severe unilateral pain in the distribution of one or more trigeminal branches.
51
Epidemiology of trigeminal neuralgia
- The estimated prevalence of trigeminal neuralgia ranges from 0.03% to 0.3%
- Rare in people younger than 40 years of age. Peak incidence between 50-60yrs
- F>M
52
Rfs for trigeminal neuralgia
- **Advancing age**: rare in people younger than 40 years of age
- **Female gender:** more common in women
- **Demyelinating disease**: trigeminal neuralgia is 20 times more common in patients with multiple sclerosis
53
What is the most likely cause of trigeminal neuralgia?
90% of patients with trigeminal neuralgia have compression of the nerve by a vascular loop near the nerve’s root entry zone, typically by the superior cerebellar artery.
54
What are the other caues of trigeminal neuralgia?
- **Demyelinating disease**
- **Posterior fossa masses**
- **Brainstem infarcts.**
55
What does the pathophysiology of the trigeminal nerve involve
The pathophysiology involves **aberrant conduction along the trigeminal nerve resulting in neuropathic pain.**
Specific triggers include light touch, such as washing, shaving, and talking, and brushing the teeth as well as cold weather, spicy food, caffeine and citrus fruits.
56
S + S of trigeminal neuralgia
Pain may be provoked by touch on examination
- **Facial pain:** comes on spontaneously and last anywhere between a few seconds to hours.
- **Trigeminal distribution**
- **Severe**
- **Unilateral** (but minority of cases are bilateral)
- **Electric shock-like sensation**
- **Episodic**
- **Provoked, e.g. touch or cold**
- Some patients experience autonomic symptoms e.g.
- **Lacrimation**
- **Facial swelling**
- **Rhinorrhoea**
- **Ptosis**
57
Red flag features of trigeminal headaches that may suggest a serious underlying cause
- **Age of onset before 40 years**
- **Pain only in the ophthalmic division (eye socket, forehead, and nose), or bilaterally**
- **Sensory changes**
- **Deafness or other ear problems**
- **History of skin or oral lesions that could spread perineurally**
- **Optic neuritis**
- **Family history of multiple sclerosis**
58
Investigations and diagnosis of trigeminal neuralgia
- Trigeminal neuralgia is a **clinical diagnosis**
- Investigations to rule out other pathology
- **MRI brain:** imaging may be used if a sinister cause is suspected, such as a space-occupying lesion or demyelination, or if the patient is refractory to medical treatment and surgical intervention is being considered
59
1st line management for trigeminal neuralgia
- **Medical: carbamazepine** is first-line. The dose is titrated upwards every two weeks until the pain is relieved.
- Other medication may be used but only under specialist guidance
- **Refer to neurology**: ****if there is severe pain or pain that significantly affects daily function, as well as patients refractory to treatment or with atypical symptoms (e.g. age < 50 years)
60
2nd line management of trigeminal neuralgia
Surgery: microvascular decompression or ablative surgery may be considered in refractory patients
61
Complications of trigeminal neuralgia
Depression and anxiety
62
Prognosis of trigeminal neualgia
Trigeminal neuralgia is a chronic pain condition, meaning that patients often have a relapsing and remitting course throughout their life.
Medical and ablative procedures are associated with partial relief of symptoms in the majority of patients.
However, over time, patients often become less responsive to conventional treatments and relapse.
