Headaches Flashcards
Headaches : Red flag syptoms
CNS infection symptoms
1. Fever, photophobia or neck stiffness
(meningitis, encephalitis or brain abscess)
IC compression
2. New neurological symptoms (haemorrhage or tumours)
3. History of trauma
4. History of cancer (brain metastasis)
Optic nerve compression
5. Visual disturbance
(giant cell arteritis, glaucoma or tumours)
6 . Sudden-onset occipital headache
(subarachnoid haemorrhage)
Increased IC pressure
7. Worse on coughing or straining
8. Postural, worse on standing, lying or bending over
9. Vomiting
10 .Pregnancy (pre-eclampsia)
Tension headache : Clinical features
Symptoms
1. Bilateral headache
2. Mild ache / Pressure in a band-like pattern around the head.
3. No visual changes
Onset
* They develop and resolve gradually
* Recurrent
Associated with:
* Stress / Depression
* Alcohol/Caffeine
* Skipping meals/ Dehydration
Tension Headache : Mx
- First line
- Reassurance
- Simple analgesia (e.g., ibuprofen or paracetamol)
- Second line
- Recurrent head ache : Amitriptyline
Sinusitis : Definition
inflammation of the paranasal sinuses in the face.
Sx
1. Pain and pressure following a recent viral upper respiratory tract infection.
- Tenderness and swelling on palpation of the affected areas.
Sinusitis : Management
Indic : Sx > 10 days
* Steroid nasal spray/antibiotic
1.Phenoxymethylpenicillin
Medication-overuse headache : Definition
- Headache caused by frequent analgesia use.
- Higher risk with opiod use
Medication-overuse headache : Cause
- Alter brain’s pain modulation pathway
- Sensitises pain pathways
- Brain becomes more sensitive to headache triggers and amplifies pain signals
Medication-overuse headache : Pathophysiology
Highest risk : Hx of Opiod / Triptan use
Symptoms
- Similar non-specific features to a tension headache
- Present for 15 days or more per month
- Developed/ Worsened whilst taking regular symptomatic medication
Medication-overuse headache : Management
- Withdrawal of the analgesia
Temporal arteritis : Definition
- (Giant cell arteritis: GCA) is a vasculitis of unknown cause that affects medium and large-sized vessels arteries.
Temporal arteritis : Clinical features
Overlap between temporal arteritis and polymyalgia rheumatica (PMR
Symptoms
1. headache (found in 85%)
2. jaw claudication (65%)
3. tender, palpable temporal artery
Temporal arteritis : Onset
- Typically patient > 60 years old
- usually rapid onset (e.g. < 1 month)
Temporal arteritis : Complications
1. Visual loss /changes
- Inflammation and occlusion of posterior ciliary artery (branch of ophthalmic artery)
- Ischaemia to Optic nerve } anterior ischemic optic neuropathy
2. Polymyalgia Rheumatic associated symptoms :
- 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
Temporal arteritis : Investigations
- Raised inflammatory markers
- ESR > 50 mm/hr (note ESR < 30 in 10% of patients)
- CRP may also be elevated
- Temporal artery biopsy
- skip lesions may be present
Temporal arteritis : Management
Urgent to prevent permanent visual loss
1. high-dose prednisolone if no visual loss
2. IV methylprednisolone } evolving visual loss
3. Opthalnology review
Trigeminal neuralgia: Definition
Trigeminal neuralgia causes intense facial pain in the distribution of the trigeminal nerve, which has three branches:
* Ophthalmic (V1)
* Maxillary (V2)
* Mandibular (V3)
Trigeminal neuralgia: Clinical features
Symptoms
- Unilateral
- Pain over 1> trigeminal nerve distribution
- Electricity-like, shooting, stabbing or burning pain
- Trigger : light touch, taking, eating
Onset
1. Sudden onset
2. Last seconds to hours.
Trigeminal neuralgia: Disease association
More common in patients with Multiple sclerosis
Trigeminal neuralgia: Mx
First line : Carbamazepine
Cluster headaches : Definition
- Severe and unbearable unilateral headaches, usually centred around the eye.
- Come in clusters of attacks and then disappear for extended periods.
Cluster headaches : Clinical features
1. Symptoms
typically unilateral:
- Red, swollen and watering eye
- Pupil constriction (miosis)
- Eyelid drooping (ptosis)
- Nasal discharge
- Facial sweating
2. Onset
- Occur in clusters of attacks and then disappear for extended periods.
- Attacks last between 15 minutes and 3 hours.
Cluster headaches :Incidence
30-50 year old male smoker.
Cluster headaches :Management
Acute attacks Mx
1. Triptans (e.g., subcutaneous or intranasal sumatriptan)
2. High-flow 100% oxygen (may be kept at home)
Prophylaxis Mx
1. Verapamil is the first line for prophylaxis
Migraine : Types
Migraine can be categorised into four main types:
* Migraine without aura
* Migraine with aura
* Silent migraine (migraine with aura but without a headache)
* Hemiplegic migraine
Migraine : Clinical features
Migraine headaches last between 4 and 72 hours.
Typical features are:
- Aura - progressive symptoms occurring hours before the headache
- Visual aura : Sparks, blurred vision, Scomata (loss of visual field)
- Paresthesia
- Dysphasia
Symptoms
Usually unilateral but can be bilateral
1. Moderate-severe intensity
- Throbbing in nature
-
Aversion to stimuli
* Photophobia / Phonophobia / Osmophobia - Nausea and vomiting
Hemiplegic migraines : Definition
- Migraine with unilateral limb weakness
- Other symptoms may include ;
* ataxia (loss of coordination)
* impaired consciousness.
Hemiplegic migraines can mimic a stroke or TIA. It is essential to exclude a stroke with sudden-onset hemiplegia.
Migraine : Acute Mx
Acute treatment
1. First-line: offer combination therapy with
- an Oral Triptan and an NSAID,
or - an Oral Triptan and paracetamol
Migraine : Prophylaxis Mx
Indicated if ;
Migraine attack have a significant impact on quality of life and daily function or very severe/prolonged.
- First line
1 . Propranolol
2 . Topiramate:- Teratogenic - avoid in women of childbearing age
- it can reduce the effectiveness of hormonal contraceptives
- Second line
1. up to 10 sessions of acupuncture over 5-8 weeks’
Triptans : MOA
MOA : Stimulate serotonin receptors
various mechanisms of action, including:
- Cranial vasoconstriction (avoid in CVS disease + HTN)
- Inhibiting the transmission of pain signals
- Inhibiting the release of inflammatory neuropeptides
