Headaches Flashcards
What is giant cell arteritis (GCA)
Inflammation of large and medium sized arteries
What artery is primarily affected in GCA
Branches of the external carotid artery
What is the typical patient profile for Giant Cell Arteritis (GCA), and what condition is commonly associated with it?
- White female over 60
- commonly occurs in patients with polymyalgia rheumatica
Give 5 common symptoms of GCA
- New constant, throbbing headache
- Scalp pain or tenderness
- Aching and stiffness - neck, shoulders, hips
- Jaw claudication
- Systemic: fever, weight loss, malaise, fatigue
What are 3 signs of GCA
- anterior ischemic optic neuropathy: fundoscopy will show swollen pale disc and blurred margins
- Absent temporal artery pulse
- Reduced visual acuity (+ diplopia/ change to colour vision)
How is GCA investigated
- Vascular ultrasonography of temporal and axillary artery
- GS: Temporal artery biopsy
- ESR/CRP - high
- FBC - may have normocytic normochromic anaemia
- Fundoscopy - optic disc pallor/ oedema
Give 3 positive finding of GCA on a temporal artery biopsy
- Multinucleated giant cells
- Granulomatous inflammation (skip lesions)
- Intimal thickening and narrow lumen
Why are negative biopsies possible in patients with GCA (2)
Less helpful in extracranial GCA
* presence of skip lesions along the artery
* Involvement of arteries besides superficial temporal artery
What may a positive vascular ultrasonography for GCA show (2)
- Wall thickening (non-compressible halo sign)
- Stenosis or occlusion
How is GCA managed
- high dose glucocorticoids as soon as a diagnosis is suspected:
- no visual loss: oral high-dose prednisolone
- evolving visual loss: IV methylprednisolone then high-dose prednisolone
- urgent ophthalmology review
- low dose aspirin
- Specialist Tx - SC tocilizumab or Oral methotrexate once weekly
- bone protection with bisphosphonates
Give 3 complications of GCA
- Glucocorticoid toxicity - osteoporosis, diabetes, HTN
- Aortic aneurysm
- Vision loss
What is a migraine
Chronic, episodic, primary headache typically presenting in early-mid life (<40)
Give 4 RF of migraines
- Female
- Family Hx
- Obesity
- Sleeping disorders
Give 6 Triggers of a migraine
Chocolate
Oral contraception
Alcohol
Bright lights
Exercise
Menstruation
What is aura in relation to migraines
Unilateral fully reversible visual, sensory or other CNS Sx that develop gradually and are usually followed by a headache
Describe the 5 stages of a migraine
- Prodromal - 3 days before headache
- Aura - lasts up to 60mins
- Headache - lasts 4-72h
- Resolution - headache relieved
- Recovery
What is a hemiplegic migraine
Migraine with aura including motor weakness
Give 5 ways migraines present
- Severe, unilateral, throbbing headache lasting 4-72h
- Nausea
- Photophobia
- Worse with activity
- Aura: flashing lights, zigzag lines, Paraesthesia, blind spot
How is a migraine diagnosed
Clinical
* A) At least 5 attacks fulfilling criteria B-D
* B) Headache attacks lasting 4-72 hours
* C) Headache has at least two of the following characteristics:
1. unilateral location, 2. pulsating quality, 3. moderate or severe pain intensity, 4. aggravation by or causing avoidance of routine physical activity
* D) During headache at least one of the following:
1. nausea +/- vomiting, 2. photophobia and phonophobia
* E) Not attributed to another disorder - ruled out by history or appropriate investigations
Management of acute migraine
- First line: oral triptan + NSAID or triptan + paracetamol
- nasal triptan if <17y
- metoclopramide or prochlorperazine
- Triptans: should be taken at start of headache not aura - oral sumatriptan
Give 4 pharmacological therapies used to prevent migraines
- Propranolol
- Topiramate
- Amitriptyline (25-75mg at night)
- Riboflavin (B2) 400mg - avoid in pregnancy
What preventative tx for migraines is teratogenic
Topiramate
Give 2 non-pharmacological therapies that can be offered to prevent migraines
- Relaxation techniques - mindfulness/ meditation
- Acupuncture - if both propranolol and topiramate are ineffective
Which preventative drug should be prescribed for menstrual related migraines
- Frovatriptan or zolmitriptan (2.5mg twice daily)
State 3 characteristics of a tension headache
- Generalised, bilateral
- Non-pulsatile dull pain
- Constricting - tight band around head
What regions are typically affected by tension headaches
- Frontal
- Occipital
Give 2 characteristics that would favour a diagnosis of a tension headache over a migraine
- Mild/ moderate intensity
- Not aggravated by routine physical activity
What is the most common type of primary headache
Tension headache
What age range has the peak prevalence of tension headaches
20-39 years
Give 3 RFs/ aggravating factors of tension headaches
- Stress
- Missing meals
- Fatigue
How are tension headaches investigated
- Clinical diagnosis - typical headache without associate Sx (N+V) and normal neuro exam
- CT sinus/ MRI brain - normal
How is an acute tension headache managed
Simple analgesia ASAP after onset
* Aspirin
* Paracetamol
* Ibuprofen
Prophylaxis for tension headaches
- up to 10 sessions of acupuncture
- low dose Oral Amitriptyline
What is a cluster headache
severe headache occuring in clusters and lasting several weeks
5 RFs of cluster headaches
- Male
- FHx
- Head injury
- Smoking
- Heavy drinking
5 characteristics of cluster headaches
- Unilateral pain
- Excruciating pain - sharp, piercing, pulsating
- Duration: lasts 15 mins - 3h
- Agitation and restlessness - pacing, rock back and forth
- Autonomic Sx
Give 5 autonomic features that may present in cluster headaches
- lacrimation
- conjunctival infection
- nasal congestion
- rhinorrhoea
- Partial Horner syndrome (ptosis/ miosis)
Describe the frequency of attacks in cluster headaches
- pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
- clusters typically last 4-12 weeks
What differentiates episodic and chronic cluster headaches
- Episodic: Cluster periods separated by pain-free remission periods lasting at least 3 months
- Chronic - attacks occur for over a year without remission or remission is <3 months
How are cluster headaches diagnosed
- Clinical: 5 or more headaches that fulfil Sx criteria
- ESR - Exclude GCA
- Brain/ pituitary MRI with gadolinium contrast - exclude secondary causes
How are acute cluster headaches managed
- SC Sumatriptan 6mg , may repeat 1h after initial dose (max 12mg/day)
- High flow 100% oxygen - flow rate of 12-15L/min via non-rebreather mask for 15-20 mins
What is the prophylactic management for cluster headaches
- verapamil
- tapering dose of prednisolone
When are triptans containdicated
- moderate or severe hypertension
- CAD
- PVD
What is trigeminal neuralgia
Facial pain syndrome in the distribution of the trigeminal nerve
Is the pain in trigeminal neuralgia typically unilateral or bilateral
Unilateral
What are the three branches of the trigeminal nerve
- V1 - ophthalmic
- V2 - Maxillary
- V3 - Mandibular
Give 4 RFs for trigeminal neuralgia
- HTN
- Multiple sclerosis
- Female
- Over 50
Give 5 triggers of trigeminal neuralgia
- Shaving
- Brushing teeth
- Talking
- Cold weather
- Citrus fruits
Describe the facial pain in trigeminal neuralgia
- electric shock sensation - sharp, stabbing
- 90% unilateral
- Lasts seconds - minutes
- Triggered by facial/oral mechanical stimulation
How is trigeminal neuralgia diagnosed
- Usually clinical
- MRI brain - rule out other pathology
How is trigeminal neuralgia treated
- 1st line: Carbamazepine
- 2nd line: lamotrigine or pregabalin
- failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology
Give some red flag symptoms of a headache
- Sudden onset thunderclap headache reaching maximum intensity within 5 minutes
- new-onset cognitive dysfunction
- impaired level of consciousness
- personality change
- vomiting >1 without obvious cause
- triggered by cough, valsalva, sneeze or exercise
- orthostatic headache (changes with posture)
What could a headache accompanied by visual disturbances indicate (2)
- Glaucoma
- Temporal arteritis
What could a headache that is worse laying down indicate
Space occupying lesion
What could a headache lined to Valsalva manoeuvres
raised ICP
