Headaches Flashcards
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
Migraine with Aura
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
Diagnosis = Tension Headache
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
Diagnosis = Trigeminal Cluster Headache
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
Diagnosis = Menstrual Repeated Migraine
What Headaches Examinations to perform if PT has headaches?
- 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
What to ask PT about their HAs?
- 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
Name the primary types of HAs
- migraine (with/without aura)
- tension type headaches
- Trigeminal Autonomic Cephalagia
- valsava effect headaches
What are the signs and symptoms associated with migraines?
- unilateral location
- last 4-72 hours
- pulsating or severe in intensity
- aggravated by physical activity
- nausea
- phonophobia
- photophobia
- precipitated or accompanied by premonitory phase
What are the symptoms of tension-type HAs?
- 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
What are the signs and symptoms of Trigeminal Autonomic Cephalagia?
- lateralised HA
- parasympathetic autonomic ilsilateral to HA e.g. tears from one eye, nose running on one side
What are the signs and symptoms of Valsalva HAs?
- associated with:
- coughing
- sneezing
- exercise
- sex
- cold temperatures
- external pressure change
- sleep
Name the different types of secondary headaches
- 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
What are the symptoms of Migranes?
- 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
What are the symptoms of tension type HAs?
- 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
What are the symptoms of cluster HAs?
- 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
What are the symptoms of Medication over-use HAs
- 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
When do you need to consider referral for investigation for HAs?
- 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
When should you consider further investigations/referral for people who present w/ or w/o migraine HA?
- motor weakness
- double vision
- visual symptoms affecting one eye
- poor balance
- decreased level of consciousness
What are the symptoms of trauma/injury to the head and/or neck?
- 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
What are the aggravating factors for HAs associated with trauma or injury to the head/neck?
- post traumatic sleep disturbances
- mood disturbances
- psychosocial stressors can influence development/perpetuation of HAs
- overuse of abortive HA medications
Name the diseases which are included in HAs attributed to cranial or cervical vascular disorders
- 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
What type of HAs are associated with vascular disorders?
Thunderclap
What are the symptoms of Thunderclap HAs?
- 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)
Which diseases are associated with thunderclap HAs?
- subarachnoid haemorrhage
- cervical arterial dissection
- subdural, extramural or intra cerebral haemorrhage
- pituitary apoplexy
What types of HAs are associated with non-vascular intracranial disorders?
- intracranial hypertension or hydrocephalus (ventricles leak increasing CSF in brain)
- metabolic, toxic or hormonal causes
- inflammatory diseases, such as meningitis
- neoplasm
- epilepsy
Which substances are associated with withdrawal HAs?
- nitric oxide
- carbon monoxide
- alcohol
- cocaine
- histamine
- medication-overuse HAs (rebound HAs)
- caffeine withdrawal
- opioids withdrawal
- oestrogen withdrawal
Which diseases are associated with HAs of infection?
- influenza
- meningitis
- sepsis
What is the most frequently encountered symptom of intracranial infections?
HAs
HAs associated with intracranial infections have which associated symptoms?
- diffuse HA
- focal neurological signs
- altered mental state
- fever
Which HAs are associated with disorders of homeostasis?
- high altitude
- aeroplane travel
- diving
- sleep apnoea
- dialysis
- encephalopathy
- pre-eclampsia or eclampsia
- hypothyrodism
- fasting
- cardiac cephalalgia (exertion HA preceded by CHD)
Which diseases are associated with HA or facial pain?
- degenerative changes (found in > 40yo individuals)
- Spondylosis
- osteochondrosis
- chronic sinusitis
- temporomandibular disorder
- refractive errors of the eyes
Where do HAs associated with facial pain originate from?
- c2-c7
HAs or facial pain can be associated with which areas of the body?
- cranium
- neck
- eyes
- ears
- nose
- sinuses
- teeth
- mouth
- other facial/cervical structures
What disorders can be associated with psychiatric HAs?
- depression
- anxiety
- trauma
- stress
What diseases are associated with painful cranial neuropathies and other facial pain HAs?
- 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
How do you differentially diagnose a cluster headache?
- often around the eyes
- patient may wake up often in the middle of the night
- unilateral
How do you differentially diagnosis tension type HA?
- tension HA may be once/few times a week
- continuous for several days
- bilateral
- around the temples, occipitals, TMJ, SCM, masatter, splenius muscles
How do you differentially diagnose a Migraine HA?
- unilateral
- severe intense throbbing pain
- pulsating in character
What is the recommendation from NICE for management of Acute HAs?
- combination of Tristan (serotonin receptor agonists) + NSAID
- OR Tristan + paracetamol/NSAID
- anti-emetic if nausea symptoms
- NO OPIODS
What is the recommendation from NICE for management of Migraine HAs?
- 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
What is the recommendation from NICE for management of cluster HAs?
- O2
- subcutaneous/nasal Tristan
- NO paracetamol, NSAID, opiods, ergots or oral triptans
- Verapamil (CA2+ channel blocker)
What is the recommendation from NICE for management of TTH?
- aspirin
- paracetamol
- NSAIDs
- NO opiods
- up to 10 sessions of acupuncture over 5-8 weeks
