Headaches Flashcards
What is meant by a secondary headache?
- Headache occurs because of another condition
What are the acute causes of headache?
- Vascular
- Infective/inflammatory
- Ophthalmic
- Situational
What are the vascular causes of headache?
- Haemorrhage (subarachnoid, subdural, extradural)
- Thrombosis (venous sinus thrombosis)
What are the infective/inflammatory causes of headache?
- Meningitis, encephalitis, abscess, temporal arteritis
What are the ophthalmic causes of headache?
- Glaucoma
What are the situational causes of headache?
- Cough
- Exertion
- Colitis
What are the causes of chronic headaches?
- Migraine
- Cluster headaches
- Drug side effects
- Tension headaches
- Trigeminal neuralgia
- Raised ICP
- Temporal/giant cell arteritis
- Systemic
Which drugs can lead to headaches as a side effect?
- Analgesics
- Caffeine
- Vasodilators
What are the systemic causes of headaches?
- Hypertension
- Pre-eclampsia
- Phaeochromocytoma
What history do we need to take from a patient with a headache?
- Full history of presenting complaint using SQITARS
- What might be causing/triggering the headache?
- PMH of headache
What drug history do we need to take from a patient with a headache?
-Analgesics
- Side effects causing headache e.g. vasodilators
What family history do we need to take from a patient with a headache?
- E.g. migraine with aura has some heritability
What social history do we need to take from a patient with a headache?
- Stress
- Diet (some foods can trigger migraine)
- Hydration
What should we look for when examining a patient with a headache?
- Vital signs/ obs
- E.g. raised ICP can cause bradycardia/hypotension
- Hypertension itself can cause headache
- Neurological examination - full peripheral and cranial nerve
- Other relevant systems as guided by history
What are the red flag features of headache?
- Systemic signs and disorders e.g. of meningitis or hypertension
- Neurological symptoms
- Onset is new or changed and patient is >50 yo (suggestive of malignancy)
- Onset in thunderclap presentation (suggests vascular cause)
- Papilledema
Outline the characteristics of a headache caused by a space occupying lesion such as a tumour?
- Gradual onset
- Progressive
- Associated neurological features e.g. visual disturbance or focal signs
- Early morning headache
- Nausea and vomiting
- Worse on coughing and bending
What is the epidemiology of migraine?
- 2% of general population
- Twice as many females as males
- Most have had first attack when young
- Severity decreases as age increases
What is the site of a migraine?
- Unilateral, often frontal
What is the quality of migraine?
- Onset can be sudden or gradual
- Throbbing/pulsating
What is the intensity of migraine like?
- Moderate
What is the timing of migraine like?
- Lasts between 4 and 72 hours, possibly with cyclical character
What are the aggravating factors of migraine?
- Photophobia/phonophobia (dislike of loud noise)
What are the relieving factors of migraine?
- Sleep helps
- A number of medications are available (e.g. triptans)
What are the secondary symptoms of migraine?
- May have aura
- Nausea and vomiting
What are the triggers of migraines?
- Certain foods
- Cheese
- Chocolate
What is the pathophysiology of migraine?
- Unclear
- Often clear family history
What is the epidemiology of tension headaches?
- Most common type of headache
- Females > men
- Young > old
- First onset in over 50s is unusual
What is the site of tension headaches?
- Bilateral frontal
- Can radiate to neck
What is the quality of tension headaches?
- Squeezing/band-like constriction
- Non-pulsatile
What is the intensity of tension headaches like?
- Mild-moderate
What is the timing of tension headaches like?
- Worse at end of day (as stress builds up)
- Chronic if > 15 times per month
- Episodic if <15 times per month
What are the aggravating factors of tension headaches?
- Stress
- Poor posture
- Lack of sleep
What are the relieving factors of tension headaches?
- Simple analgesics can help
What are the secondary symptoms of tension headaches?
- Mild nausea
What is the pathophysiology of tension headaches?
- May be tension in muscles of head and neck (e.g. occipito-frontalisis)
- Usually no family history
What is the epidemiology of medication overuse headaches?
- 3rd most common type of headache
- 1-2% of UK population
- 20% of headaches due to medication overuse
- 30-40 years old
- Females > males
What are the clinical features of medication overuse headaches?
- Present on at least 15 days per month
- No improvement after OTC medication
- Patient is using analgesics on at least 10 days per month
- This headache only seems to come about in people who are taking analgesia for headache in the first place
- Can get a variety of symptoms
- Often co-exists with depression and sleep disturbance
How are medication overuse headaches treated?
- Discontinuation of medication (will get worse before it gets better)
What is the pathophysiology of medication overuse headaches?
- Related to upregulation of pain receptors in meninges
What is the epidemiology of cluster headaches?
- 1/1000 people
- Males > females
- Usual onset 20-40 years old
What is the site of of cluster headaches?
- Around/behind one eye
- No radiation
What is the quality of cluster headaches?
- Sharp and penetrating
What is the intensity of cluster headaches like?
- Very severe
- Constant intensity
What is the timing of cluster headaches like?
- Rapid onset
- Attacks last 15 mins - 3 hours and occur 1-2 times per day
- Usually at night
- Clusters of attacks last 2-12 weeks
- Remissions between clusters can last 3 months to 3 years
What are the aggravating factors of cluster headaches?
- Head injury
- Alcohol
- Smoking
What are the relieving factors of cluster headaches?
- Simple analgesics can help
What are the secondary symptoms of cluster headaches?
- Features associated with decreased sympathetic activity
- Red, watery eye
- Nasal congestion
- Ptosis
What are the triggers of cluster headaches?
- Alcohol
- Histamine
- GTN
- Heat
- Exercise
- Solvent inhalation
- Lack of sleep
What is the epidemiology of trigeminal neuralgia?
- Peak incidence 50-60, increasing with age
- 25/100 000 UK population
- Females > males
What is the site of trigeminal neuralgia?
- Unilateral, often over one eye
- Radiates to eyes, lips, nose and scalp (think distribution of CN V)
What is the quality of trigeminal neuralgia?
- Sharp and stabbing
- Electric shock feeling
What is the intensity of trigeminal neuralgia?
- Severe
What is the timing of trigeminal neuralgia like?
- Sudden onset
- Lasts a few seconds to 2 minutes
What are the aggravating factors of trigeminal neuralgia?
- Light touch to face
- Eating
- Cold wind
- Vibrations
What are the relieving factors of trigeminal neuralgia?
- Can be difficult to alleviate
What are the secondary symptoms of trigeminal neuralgia?
- Can have numbness and tingling preceding an attack
What is the pathophysiology of trigeminal neuralgia?
- Mostly caused by compression of trigeminal nerve by a vascular malformation
- Few cases are caused by tumours, MS, or skull base anomalies
- More common in those with a history of chronic pain
What are the investigations for headaches?
- Clearly dependent on cause
- Headache diary can be useful for chronic headaches
- Imaging may be indicated if red flags
How are headaches treated?
- Dependent on underlying cause
- Simple analgesia
- Triptans for migraine
- Cluster headaches may respond to high flow oxygen
When do headaches need to be referred?
- Suspicion of a tumour
- Suspicion of raised ICP
- Recent onset seizures
- Previous cancer
- Unexplained focal deficit
- Unexplained cognitive/personality changes
