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Pathophysiology > Headaches > Flashcards

Headaches Flashcards

1
Q

Case History 1:

  • Young girl in early 20s
  • Right side throbbing headache (pulsating)
  • Not feeling well with it
  • Can’t stand loud sounds
  • Light is bothering
  • Dark room helps, earmuffs on and lie down to fall asleep helps
  • Before the headaches started she saw some light flashes in her eyes for 15 minutes and then headaches start
  • Family history of headaches - mother and grandmother
A

Migraine with Aura

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2
Q

Case History 2:

  • man, mid 30s
  • Wears expensive clothes
  • Spends all his times in meetings
  • Works for an American law firm
  • No rest
  • Stressed
  • Also suffering from headaches
  • Headaches around the whole head
  • Usually comes second part of the day, after meetings
  • Sits in front of the computer all th estime
    Doesn’t eat well, no home cooked food, on third marriage
  • Happily married in third marriage; previous wives couldn’t cope with his timetable
A

Diagnosis = Tension Headache

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3
Q

Case History 3:

  • Man in 40s, but could be anyone - girl, woman
  • Describes usually a headache on one side
  • Usually involves eye and nose
  • As soon as he feels headache his eye turns red and tears on one side
  • The other eye is fine
  • Nose on the same side becomes blocked
  • When asked how severe, he says so severe he can’t sit still
  • He has to walk up and down
  • Sometimes he feels banging his head on the wall helps him cope with it
  • Comes and lasts 3 hours max, always 30 minutes minimum
  • When about to fall asleep or at night asleep
  • Heachaches come for several days consecutively and then goes away for 3-6 months
  • Pain severity - 10/10
A

Diagnosis = Trigeminal Cluster Headache

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4
Q

Case History 5:

young girl - 18/19 - she notices one sided headache
No symptoms before headache
Throbbing, painful 6-9/10 pain score
Doesn’t last longer than 2-2.5 days
Can sleep it out
Irritated by light and sound
Somehow related to periods, every time she has period she has a headache
Whatever she does aggravates her headache

A

Diagnosis = Menstrual Repeated Migraine

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5
Q

What Headaches Examinations to perform if PT has headaches?

A
  • Case Hx most important diagnositic tool for PT with HA (headache)
  • If HA examinations are positive then refer

Examinations:
- Blood pressure => high blood pressure => headaches; first thing to do; blood pressure of person needs to be treated not anything else (potentially)
- Special senses => CHx (changes) in:
- Vision
- Hearing
- Smell
- Facial movements
- Numbness
- Neuro exam
- Whole body screening including cranial nerves
- Brain is bringing everything to the whole body e.g. stroke
- Temperature
- Infections e.g. meningitis
- Any infection will affect the nervous system
- Rash
- Shingles
- Neck stiffness
- Generalised stiffness (another sign of meningitis)
- Measure fingers under chin
- 4 finger => possible sign of meningitis; especially with fever

Particularly with recent onset of HA:
- Scalp tenderness
- GCA (Giant Cell Arteritis)
- Vascularised disease of temporal artery and what is supplies is inflamed
- If not treated in time can result in permanent - blindness
- Painful to lie head on pillow or comb hair on one side
- Rarely bilateral
- Can be accompanied by jaw claudication (painful eating)
- Refer to GP for blood test + ultrasound or temporal artery and biopsy
- Linked to PMR (polymyalgia rheumatica)
- Fundoscopy in all patients (eye check or to GP

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6
Q

What to ask PT about their HAs?

A
  • Location
  • Bilateral
  • When?
  • How long/progression? Is it getting worse?
  • Severity
  • Time of day
  • Quality of pain - What does it feel like?
  • Aggravations/relieving factors
  • Triggers
  • Sleep patterns
  • Associated symptoms => really important as point in right direction
  • Previous head trauma
  • Age => in younger people think about different conditions to older people
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7
Q

Name the primary types of HAs

A
  • migraine (with/without aura)
  • tension type headaches
  • Trigeminal Autonomic Cephalagia
  • valsava effect headaches
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8
Q

What are the signs and symptoms associated with migraines?

A
  • unilateral location
  • last 4-72 hours
  • pulsating or severe in intensity
  • aggravated by physical activity
  • nausea
  • phonophobia
  • photophobia
  • precipitated or accompanied by premonitory phase
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9
Q

What are the symptoms of tension-type HAs?

A
  • increased pericranial tenderness
  • palpation on frontal, temporal, masseter, pterygoid, SCM, splenius or trapezius may be tender
  • increase in symptoms during HA
  • tenderness/tightness increases with intensity + frequency of HAs
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10
Q

What are the signs and symptoms of Trigeminal Autonomic Cephalagia?

A
  • lateralised HA
  • parasympathetic autonomic ilsilateral to HA e.g. tears from one eye, nose running on one side
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11
Q

What are the signs and symptoms of Valsalva HAs?

A
  • associated with:
  • coughing
  • sneezing
  • exercise
  • sex
  • cold temperatures
  • external pressure change
  • sleep
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12
Q

Name the different types of secondary headaches

A
  • trauma to head/neck
  • cranial or cervical vascular
  • non-vascular intracranial
  • substances or withdrawal of substances
  • infections
  • homeostasis
  • facial pain
  • psychiatric disorders e.g. depression
  • cranial neuropathies/facial pains
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13
Q

What are the symptoms of Migranes?

A
  • Aura = can be with/without aura
  • Duration = 4-72 hours
  • Frequency = episodic, variable
  • Location = unilateral
  • Character = pulsating
  • Pain = moderate/severe pain
  • Aggr. = movement, need to be still
  • Eased by movement = no
  • Nausea/Vomiting = Yes
  • Photo/phonophobia = Yes
  • Red, watery eye = No
  • watery or blocked nose = No
  • speech disturbance
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14
Q

What are the symptoms of tension type HAs?

A
  • Aura = No
  • Duration = 30 minutes to 7 days
  • Frequency = 1-15 days per month/variable
  • Location = Bilateral
  • Character = Pressing/tightening
  • Pain = Mild/Moderate
  • Aggr. By movement = no
  • Eased by movement = no
  • Nausea/Vomiting = no
  • Photo/phonophobia = no
  • Red, watery eye = no
  • watery or blocked nose = No
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15
Q

What are the symptoms of cluster HAs?

A
  • Aura = no
  • Duration = 15-180 minutes
  • Frequency = 1 on alternative days to 8 per day, often for 7 days to 1 year when episodic
  • Location = unilateral
  • Character = knife-like, severe, excruciating
  • Pain = severe/very severe
  • Aggr. = No
  • Eased by movement = Yes - tendency to be restless
  • Nausea/Vomiting = No
  • Photo/phonophobia = No
  • Red, watery eye = Yes
  • watery or blocked nose = Yes
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16
Q

What are the symptoms of Medication over-use HAs

A
  • Aura = no
  • Duration = some or all of the day
  • Frequency = Daily > 15 days/month for > 3 months
  • Location = unilateral/bilateral
  • Character = pressing/tightening/pulsating
  • Pain = mild/moderate/severe
  • Aggr. By movement = no
  • Eased by movement = no
  • Nausea/Vomiting = no
  • Photo/phonophobia = no
  • Red, watery eye = no
  • watery or blocked nose = No
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17
Q

When do you need to consider referral for investigation for HAs?

A
  • worsening headache
  • sudden onset of HA reaching max w/i 5 mins
  • new on-set neurological deficit
  • new on-set cognitive dysfunction
  • change in personality
  • impaired level of consciousness
  • recent (w/i 3 months) head trauma
  • HA triggered by cough, valsalva or sneeze
  • HA triggered by exercise
  • orthostatic HA (HA changes with posture)
  • symptoms suggestive of giant cell arteritis (visual disturbance + jaw claudication)
  • symptoms/signs of acute narrow angle glaucoma (painful red eye, misty vision, nausea, semi-dilated pupil)
  • substantial change in character of HA
18
Q

When should you consider further investigations/referral for people who present w/ or w/o migraine HA?

A
  • motor weakness
  • double vision
  • visual symptoms affecting one eye
  • poor balance
  • decreased level of consciousness
19
Q

What are the symptoms of trauma/injury to the head and/or neck?

A
  • these symptoms can be isolated or together
  • dizziness
  • fatigue
  • reduced ability to concentrate
  • psychomotor slowing
  • mild memory problems
  • insomnia
  • anxiety
  • personality changes
  • irritability
  • these can comprise a post-concussion syndrome
20
Q

What are the aggravating factors for HAs associated with trauma or injury to the head/neck?

A
  • post traumatic sleep disturbances
  • mood disturbances
  • psychosocial stressors can influence development/perpetuation of HAs
  • overuse of abortive HA medications
21
Q

Name the diseases which are included in HAs attributed to cranial or cervical vascular disorders

A
  • stroke
  • TIA
  • Haemorrhage
  • Aneurysm or AVM (arteriovenous malformations - blood vessels form incorrectly
  • Arteritis
  • Cervical arterial dissection - tear the wall of a blood vessel in your neck
  • Pituitary apoplexy - explodes
22
Q

What type of HAs are associated with vascular disorders?

A

Thunderclap

23
Q

What are the symptoms of Thunderclap HAs?

A
  • Worst HA ever
  • can last 5 minutes to a few days
  • non-specific location
  • photophobia
  • nausea
  • vomiting
  • neck pain
  • focal neurological symptoms
  • altered level of consciousness (LOC)
24
Q

Which diseases are associated with thunderclap HAs?

A
  • subarachnoid haemorrhage
  • cervical arterial dissection
  • subdural, extramural or intra cerebral haemorrhage
  • pituitary apoplexy
25
Q

What types of HAs are associated with non-vascular intracranial disorders?

A
  • intracranial hypertension or hydrocephalus (ventricles leak increasing CSF in brain)
  • metabolic, toxic or hormonal causes
  • inflammatory diseases, such as meningitis
  • neoplasm
  • epilepsy
26
Q

Which substances are associated with withdrawal HAs?

A
  • nitric oxide
  • carbon monoxide
  • alcohol
  • cocaine
  • histamine
  • medication-overuse HAs (rebound HAs)
  • caffeine withdrawal
  • opioids withdrawal
  • oestrogen withdrawal
27
Q

Which diseases are associated with HAs of infection?

A
  • influenza
  • meningitis
  • sepsis
28
Q

What is the most frequently encountered symptom of intracranial infections?

A

HAs

29
Q

HAs associated with intracranial infections have which associated symptoms?

A
  • diffuse HA
  • focal neurological signs
  • altered mental state
  • fever
30
Q

Which HAs are associated with disorders of homeostasis?

A
  • high altitude
  • aeroplane travel
  • diving
  • sleep apnoea
  • dialysis
  • encephalopathy
  • pre-eclampsia or eclampsia
  • hypothyrodism
  • fasting
  • cardiac cephalalgia (exertion HA preceded by CHD)
31
Q

Which diseases are associated with HA or facial pain?

A
  • degenerative changes (found in > 40yo individuals)
  • Spondylosis
  • osteochondrosis
  • chronic sinusitis
  • temporomandibular disorder
  • refractive errors of the eyes
32
Q

Where do HAs associated with facial pain originate from?

A
  • c2-c7
33
Q

HAs or facial pain can be associated with which areas of the body?

A
  • cranium
  • neck
  • eyes
  • ears
  • nose
  • sinuses
  • teeth
  • mouth
  • other facial/cervical structures
34
Q

What disorders can be associated with psychiatric HAs?

A
  • depression
  • anxiety
  • trauma
  • stress
35
Q

What diseases are associated with painful cranial neuropathies and other facial pain HAs?

A
  • trigeminal neuralgia
  • glossopharyngeal neuralgia
  • facial nerve neuralgia (nervous intermedium’s)
  • occipital neuralgia
  • optic neuritis
  • burning mouth syndrome
  • central neuropathic pain (MS)
  • central post-stroke pain
36
Q

How do you differentially diagnose a cluster headache?

A
  • often around the eyes
  • patient may wake up often in the middle of the night
  • unilateral
37
Q

How do you differentially diagnosis tension type HA?

A
  • tension HA may be once/few times a week
  • continuous for several days
  • bilateral
  • around the temples, occipitals, TMJ, SCM, masatter, splenius muscles
38
Q

How do you differentially diagnose a Migraine HA?

A
  • unilateral
  • severe intense throbbing pain
  • pulsating in character
39
Q

What is the recommendation from NICE for management of Acute HAs?

A
  • combination of Tristan (serotonin receptor agonists) + NSAID
  • OR Tristan + paracetamol/NSAID
  • anti-emetic if nausea symptoms
  • NO OPIODS
40
Q

What is the recommendation from NICE for management of Migraine HAs?

A
  • prophylactic (prevent disease)
  • topiramate (anti-convulsant)
  • propranolol (beta-blocker)
  • Botox injections
  • triptans for girls/women with menstrual migraines
  • riboflavin (400mg x 1 a day) may be effective in reducing migraine frequency + intensity
41
Q

What is the recommendation from NICE for management of cluster HAs?

A
  • O2
  • subcutaneous/nasal Tristan
  • NO paracetamol, NSAID, opiods, ergots or oral triptans
  • Verapamil (CA2+ channel blocker)
42
Q

What is the recommendation from NICE for management of TTH?

A
  • aspirin
  • paracetamol
  • NSAIDs
  • NO opiods
  • up to 10 sessions of acupuncture over 5-8 weeks

Pathophysiology (12 decks)

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