Headaches Flashcards
Primary vs secondary headache
Primary - migraine, tension, cluster
Secondary - precipitated by another condition/disorder local or systemic. Serious causes uncommon.
Long lasting primary headache
Migraine, tension-type headache, medication overuse headache
Short lasting primary headache
Trigeminal autonomic cephalalgia -> cluster headache
Threshold for long lasting headache (how many hours)
Over 4
Differentiating between primary and secondary after history and examination
No red flag -> primary
Red flag -> secondary -> diagnostic tests
History is key for differentiation
4 key red flags suggesting secondary headache
Age - New onset or different headaches in a person >50yrs
Onset - Sudden, abrupt onset of a severe headache (thunderclap headache)
Systemic symptoms - Fever, neck stiffness, rash, weight loss
Neurological signs - Confusion, impaired consciousness, focal neurology, swollen optic discs
Migraine pathophysiology
Abnormal cortical hyperexcitability
(Ca++, Glu, ¯Mg++)
Abnormal brain stem function
Excitation of brain stem, PAG (periaqueductal gray), etc.
Cortical Spreading Depression - aura
Activation of TGVS (trigeminovascular system) - headache pain
CGRP from activation - Vasodilation, Neurogenic Inflammation (pain perpetuation)
Activation causes central sensitisation
Migraine characteristics
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by routine physical activity
Last hours and sometimes days!
Usually one or more of:
Nausea and/or Vomiting
Photophobia and/or Phonophobia
+/- auras
What is migraine aura
Complex array of symptoms reflecting focal cortical or brainstem dysfunction
Gradual evolution: 5-30minutes (<60minutes)
Usually before headache
Types of migraine aura
Expanding C’s
Elemental visual disturbance
Migraine phases
Premonitory: yawning, polyuria, mood change, irritable, light sensitive, neck pain, concentration difficulty
Aura: Visual, sensory (numbness/paraesthesia), weakness, speech arrest
Headache: Head and body pain, nausea, photophobia
Resolution: rest and sleep
Recovery: mood disturbed, food intolerance, feeling hungover
Can take up to 48 hours
Aspects of migraine management
Lifestyle
Pharmacological therapy
Acute/abortive
Long term preventative
Migraine lifestyle management
avoid triggers, diet, sleep, exercise, mindfulness
Migraine acute management
Hard and fast! Paracetamol, NSAIDs (high dose soluble), Prokinetics, Triptans (5-HT1B/1D/1F receptor agonists)
Migraine long term management
Long term preventative: >5 days/month
“low and slow” with doses until at optimal dose
Tension-type headache characteristics
Patients usually say its feels like:
Tight muscles around head and neck, as though head is in a vice.
Lasts 30mins (but can be hours long):
Bilateral
Mild or moderate
Not aggravated by movement
No added features typically
No nausea or vomiting
No photophobia or phonophobia
Tension-type headache treatment
Reassurance may suffice in the majority of patients.
Individual attacks can be treated with simple analgesics such as Aspirin or Paracetamol.
Preventative medications rarely required
Cluster headache characteristics
Severe unilateral pain
Last 15-180 minutes if untreated.
At least one of the following, ipsilaterally:
Conjunctival redness and/or lacrimation
Nasal congestion and/or rhinorrhoea
Eyelid oedema
Forehead and facial sweating
Miosis and/or ptosis
A sense of restlessness or agitation
Not associated with a brain lesion on MRI
Cluster headache acute treatment
Triptan. Nasal or subcutaneous route
High flow oxygen. Oxygen inhibits neuronal activation in the trigeminocervical complex
Cluster headache preventative treatment
Verapamil (Calcium channel inhibitor)
Get an ECG first!
Greater occipital nerve block
Cluster headache frequency
1-3 per day (up to 8).
Usually occurs daily for 2-3 months at a time
