headaches Flashcards
what are primary headaches?
no identified cause
what are secondary headaches?
characteristics attributed to another cause eg infection/ vascular
what are red flags for subarachnoid headache?
sudden onset thunderclap headache reaching max intensity in 5 mins
what are red flags for viral/ bacterial meningitis?
fever with worsening headache, necks stiffness, photophobia, change in mental status
what is red flag for haemorrhagic/ ischaemic stroke/ space occupying lesion?
new onset focal neuro deficit, personality change or cog dysfunction
what is red flags for ICP?
headache worsening on lying down and coughing
what are red flags of angle closure glaucoma?
: severe eye pain/ blurred vision/ red eye/ vomiting
what are general red flags for headaches?
decreased level of consciousness
head trauma within last three months
what are concerns within past medical history?
compromised immunity, malignancy, systemic illness, current pregnancy
what are concerns within drug history for headaches?
previous headache meds, anticoags/ anti-platelets, glucocortoids, methamphetamines, coke, GTN, combined oral contraceptive pill. Allergies
what are features of low risk headaches? - 6 things
- > 30 yrs
- Typical features of primary
- History of similar episodes – no change in usual pattern
- No abnormal neuro findings
- No high risk co-morbidities
- No new, concerning history or physical examination
what is S on headache history?
S: site – bilateral, unilateral, symmetrical
what is O on headache history?
O: onset – speed, aura (migraines – lines, zig zag, not focused vision, smell/ taste change)
what is C on headache history?
C: character: sharp/ dull/ boring/ electrical (nerve), pressure
what is R in headache history?
R: radiation: face (trigeminal neuralgia), eye- glaucoma, neck- meningitis
what is A in headache history?
A: associated symptoms: autonomic (tearing, drooping, swollen eyelid, pain around one eye – cluster), meningitis triad, SOL (neuro deficits, weight loss, visual disturbance)
what is T within headache history?
T: timings: episodic, daily, duration, unremitting
what is E on headache history?
E: exacerbation factors: posture, Valsalva, medication, caffeine
what examinations would you do within headache history?
- Basic obs
- GCS
- Features: photophobia, eyes – redness/ pupils, feel sinuses, neck stiffness – passive as well as active
brudzinki sign
kernigs sign
cranial nerve examinations
what is brudzinkis sign?
passive flexion of neck causing involuntary FLEXION OF KNEE AND HIP
what is kernigs sign?
:pain on passive knee extension with hip fully flexed - lie on back lift leg up and then bend knee
how do you distinguish primary and secondary headaches?
SSNOOP
what is SSNOOP?
to differentiate between 1st and 2nd headaches
- S: systemic symptoms
- S: secondary risk factors eg HIV or immunocompromised
- N: neurological symptoms/ findings
- O: onset – sudden, thunderclap
- O: older age – 50+
- P: progression pattern: change form usual headache
what is 1st investigations of headaches?
headache diary
what is most common age for tension headache?
- Age: 20-50
how would a tension headache be described as?
- Location: bilateral and symmetrical band around head
- Severity: mild-moderate – worsens during day
- Duration: 30mins to 7day
- Character: band like – not pulsatile, more pressure
what are RF for tension headaches?
- Risk factors: mental tension, stress, fatigue, missing meals, dehydration
where would tension headaches pain radiate?
- Pain: sternocleidomastoid, trapezius and temporalis commonly tender
how do you manage a tension headache?
- Simple analgesia – NSAIDS/ paracetamol
- If chronic (7-9 headache days per month) prophylactic low dose amitriptyline.
- Acupuncture
- Relaxation therapy
- Advise: medication overuse
what do you do with amitriptyline in tension headaches?
- If chronic (7-9 headache days per month) prophylactic low dose amitriptyline. Want to attempt to withdraw after 4-6months
what is a medication overuse headache?
Medication overuse headache: analgesia rebound
- Due to regular OVERUSE eg > 3months per year
how often of taking NSAIDS/ paracetamol could trigger medication overuse?
- NSAIDS/ paracetamol if taken >15 days/ mth
- Headache must be present for >15 days a month in a patient with pre-existing headache disorder
what drugs can cause medication overuse?
Aetiology drugs: analgesics, birth control (usually on inactive days eg break days), nitrates, CCB, digoxin, corticosteroids, HRT, alcohol, caffeine
what ages are most common for migraines?
- Age: 10-40
describe the character of a migraine headache?
- Location: usually unilateral – can become bilateral
- Severity: moderate to severe
- Duration: 4hrs to 3days
- Character: throbbing, poundings, pulsating
what are the associated symptoms of a migraine?
- Associated symptoms: prodromal symptoms irritable, cravings, yawning, aura. During headache: N+V, photophobia, allodynia
what is allodynia?
pain that shouldnt be caused by a non painful stimulus
what is atypical migraine?
Atypical: no aura – can be known as common migraine can diagnose after 5 attacks
what are the 4 phases of migraine?
- prodrome
- aura
- headache
- postdrome
what is prodrome?
Prodrome (preheadache): problems concentrating, difficulty speaking, trouble sleeping, nausea, fatigue, sensitivity to light, increased urination, muscle stiffness
what is aura?
- Aura: seeing bright flashing lights, blind spots in vision, speech changes, ringing in ears, temporary vision loss, funny feeling, changes in taste/ smell
- Reversible stage
what is scintillating scotoma?
(shimmering oddly shaped area of visual deficit) - seen in aura
how long can aura last?
can last 5 mins to 1hr before migraine onset
how long can a migraine headache last?
Headache: can last 4-72hrs
what is postdrome?
Postdrome (hungover like) : unable to concentrate, feeling depressed, not being to be able to understand things, euphoria
how can you manage headaches via lifestyle modifications?
- Lifestyle: headache diary – find triggers, stress management, hydration, regular meals, exercise, healthy BMI
how do you manage an acute attack of migraine?
- Acute attack: NSAID/ paracetamol + triptan, anti-emetics, AVOID OPIOIDS
- These meds should be taken early to avoid progression and triptans should be taken at start of headache not aura
what medication is contra-indicated within migraine?
combined oral contraceptive pill
what prevention medication can be taken if severely impacted?
- Meds: propranolol, amitriptyline, topiramate (contra-indicated in pregnancy need contraception
what non pharmacological preventative therapies can be used in migraines?
- Non pharma: relaxation therapy/ CBT, acupuncture, riboflavin (vit B2)
what can hemiplegic stroke mimic?
stroke
what are symptoms of a hemiplegic migraine?
: typical migraine, sudden/ gradual onset, hemiplegia (unilateral weakness of the limbs), ataxia, changes in consciousness
- Tingling/ numbness across different parts of body
what does a hemiplegic migraine respond to?
indomegthacin - NSAID
what is usual age for cluster headache?
- Age: 20-40
what is character of cluster headache?
- Character: sharp, pulsating, boring, burning
- Associated symptoms: ipsilateral cranial autonomic symptoms conjunctival injection, lacrimation, eyelid oedema Location: unilateral, peri-orbital
- Severity: severe
when do cluster headaches usually occur?
- Duration: 15 to 180 mins
- Timimgs: predictable – same time night/ day typically 1-2hrs after falling asleep
what are RF in cluster headaches?
RF: More common in men, head trauma, smoking
what are triggers in cluster headaches?
- Triggers: alcohol, histamine, exercise, sleep, volatile smells (petrol/ perfume)
what are chronic cluster headaches?
- Chronic: attacks occur more than one a year without remission – lasting 1mth
what are episodic cluster headaches?
- Episodic: occur in periods typically between 2weeks and 3months separated by pain-free periods for at least one month
how do you manage cluster headache?
- First pres: urgent referral
- Acute: subcut triptan, nasal triptan, oxygen – 15L non rebreather
what preventative therapies can be used for cluster headaches?
- Preventative: verapamil (CCB), ECG monitoring , pred in short periods
what should not be used to manage cluster headaches?
- DO NOT USE: paracetamol/ NSAIDS/ opioids
what is trigeminal neuralgia like?
- Chronic, debilitating, intense and extreme electric shock like
- Lasts seconds to minutes can have hundreds attacks per day
what can trigger trigeminal neuralgia?
Triggers: light touch, eating, cold wind, vibrations, brushing teeth
what imaging is needed in trigeminal neuralgia?
MRI - rule out other pathology
how do you manage trigeminal neuralgia?
- 1st line: carbamazepenine – withdraw after 1 month
- Gabapentin, botox
- Surgery: sever trigeminal nerve root, microvascular decompression
what are sinus headaches?
Sinus headaches: headaches due to inflammation of mucosal lining of nasal cavity and paranasal sinuses
- Tender to palpation over sinuses
what is the aetiology of sinus headaches?
Aetiology: viral/ bacterial usually 2 to URTI but if lasting more than 10 days bacterial
how do you manage sinus headaches?
- NSAIDS/ paracetamol/ codeine, nasal corticosteroids
- Bacterial: symptomatic treatment, watchful waiting – up to 10days , AB depending on bacteria (phenoxymethylpenicillin) or co-amox if worsening
what causes subarachnoid haemorrhages?
aneurysms - no trauma
where is the bleeding within subarachnoid haematoma?
bloods vessels - usually within circle of willis
what condition is linked to aneurysm at circle of willis?
polycystic kidney disease
what is sentinel headaches?
- 30% have sentinel headache (progressive worsening headache leading up – 2wks prior) before subarachnoid headache
what is the clear sign of subarachnoid headache?
thunderclap sudden onset headache
what are RF for aneurysms?
- RF: hypetension, smoking, headache, genetic conditions (PKD, ehlers danlos, sickle cell, marfan) coke, black ethnicity, female, aged 45-70n
- Antiplatelets/ anticoags increase severity of bleed
how would you diagnose subarachnoid haemorrhage?
Diagnosis: FBC, U&E, clotting, CT head- hyperdence white following shape of skull – crescent
what would be seen on a lumbar puncture after subarachnoid haemorrhage?
- LP: 12hrs after symptom onset : if bleeding not seen on CT but still highly suspicious – look for xanthochromia (faint, yellow tinge)
what medications can be used to manage subarachnoid haematoma?
Medical: nimodipine – prevent cerebral ischaemia due to vasospasm, analgesia, antiemetics, anticonvulsants
what neurosurgery may be used to manage subarachnoid haematoma?
Surgical: occlude aneurysm if risk of bleeding, coiling – endovascular titanium coils inserted into aneurysm, clipping_ direct neurosurgery
what is hydrocephalus and link to SAH?
There is a risk of hydrocephalus following SAH disruption of CSF driange and treated with LP or shunt
what is normal Intracranial pressure?
: should be between 7 and 15mmHg
what is the aetiology of raised ICP?
mass effect (tumour/ haemorrhage, oedema, abscess), brian swelling, venous sinus thrombosis, obstruction of CSF flow/ absorption, increased CSF production, idiopathic
what are signs of raised ICP?
Signs: headache – postural changes worse on lying down. Valsalva/ coughing/ sneezing makes it worse
- Vomiting with/without nausea
- Ocular palsies
- LOC
- Back pain
- Papilledema
what can cause space occupying lesions?
tumours, haematomas, abscess
what are signs of SOL?
Signs: new onset headache, progressive or persistent headache, postural changes
- New onset personality changes/ cognitions
what is the pathophys of idiopathic intercranial hypertension?
Idiopathic intercranial hypertension
- Due to reduced CSF absorption
who is most at risk of idiopathic intercranial hypertension?
obese women of childbearing age
what are signs of idiopathic intercranial hypertension?
Signs: headache, neck/ back pain, visual palsy – visual field loss (enlargement of blind spott, dislopia (double vision) due to optic nerve atrophy, papilloedema
how is idiopathic intercranial hypertension diagnosed?
Diagnosis: based on exclusion, MRI venography with contrast and CT, LP would indicate >25mmHg
what drugs can manage IIH?
- Drug: tetracycline, cyclosporine, lithium, OCP, tamoxifen removal
acetazolamide - visual symptoms
what lifestyle options can be used to manage IIH?
- Lifestyle: low sodium, weight reduction
what is accelerated hypertension?
rapid and sudden increased bP – can cause end organ dam
what can cause hypertensive emergencies?
- Hypertensive emergency – maliganant hypetension
- Hypertensive encephalopathy neuro symptoms
Patients with BP of 180/120 + retinal haemorrhages, papilloedema + life threatening symptoms – new onset confusion, chest pain, AKI, signs of HF
how do you manage hypertensive emergencies?
need to lowe BP slowly over 24hrs to prevent cerebral infarction (watershed areas) labetalol ?hydrazaline hydrochloride
what is temporal giant cell arteritis?
Temporal (giant cell) arteritis
- Form of vasculitis caused by inflamedmtempral arteries
who does temporal giant cell arteritis mainly affect?
- Mainly affecting women, +50yrs
what condition is linked to tempral giant cell arteritis?
polymyalgia rheumatica
what are signs of temporal giant cell arteritis?
- Frequent severe bilateral headaches
- Temporal/ occipital pain/ tenderness
- Scalp enderness
- Jaw claudication
- Visual disturbances – diplopia, loss of vision
- Fatigue. Myalgia
- Large palpable, non pulsatile arteries of head and face USS temporal artery
how do you manage temporal giant cell arteritis?
Management: high dose steroids, may need PPI and bone protection if long term
what causes pre-ecalmpsia headaches?
raised BP
what are cerebral venous sinus thrombosis?
- Blood clot in dural venous sinuses
- Prevents venous return
- Causing headache and neurosymptoms, treat with anticoags
along with high BP, what else is seen in pre-eclampsia?
protein in urine
what are RF of pre-eclampsia?
RF: previous episodes, hypertension, AI conditions, CKD, diabetes
what are symptoms of pre-eclampsia?
Symptoms: headache, visual changes, RUQ/ epigastric pain (liver swelling), reduced urine output, N+V, oedema (especially face)
how do you manage pre-eclampsia?
Management: prophylaxis – aspirin from 12wks if high risk, labetalol, mg sulphate during/ after labour to prevent seizures, birth is only cure
