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3A Neurology > Headaches > Flashcards

Headaches Flashcards

1
Q

What is the definition of a migraine?

A

Migraine is a chronic, genetically determined, episodic neurological disorder that usually presents in early-to-mid life.

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2
Q

Epidemiology of migraines

A
  • Second most common primary headache
  • Migraine is a common condition with a global prevalence of 14.7%
  • F>M
  • In 90% onset is before 40yrs
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3
Q

Risk factors for migraines

A
  • Family history
  • Female gender: migraines are three times more common in women
  • Obesity
  • Other important triggersinclude tiredness, lack of food, dehydration, menstruation, red wine and bright lights
  • Pathophysiology
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4
Q

Pneumonic for triggers of Migraines

A

CHOCOLATE

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5
Q

CHOCOLATE

A
  • Chocolate
  • OralContraceptive
  • Alcohol
  • Anxiety
  • Travel
  • Exercise
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6
Q

Types of migraines

A
  • Migraine without aura
  • Migraine with aura
  • Silent migraine(migraine with aura but without a headache)
  • Hemiplegic migraine
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7
Q

What are classic migraines preceded by?

A

an aura, however, these only occur in one-third of patients.

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8
Q

What is the theory around ‘aura’

A

aura was due to cerebral vasoconstriction, whilst the subsequent headache occurred due to reflex vasodilatation.

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9
Q

What are the headaches in migraines due to?

A

During aura serotonin levels increase causing vasoconstriction
During the attack serotonin levels decrease lower than normal which triggers vasodilation

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10
Q

What is aura thought to occur due to?

A

cortical spreading depression, which is a propagating wave of depolarisation across the cerebral cortex causing the brain to become hypersensitive to certain stimuli

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11
Q

5 stages of migraines

A
  • Premonitoryorprodromalstage (can begin 3 days before the headache)
  • Aura(lasting up to 60 minutes)
  • Headachestage (lasts 4-72 hours)
  • Resolutionstage (the headache can fade away or be relieved completely by vomiting or sleeping)
  • Postdromalorrecoveryphase
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12
Q

Clinical manifestations of migraines

A
  • Severe, unilateral, pulsating headache lasting up to 72 hours
    • In children, migraines are more commonly bilateral,
  • Nausea and vomiting
  • Photophobia and phonophobia
    Typical aura: develops over 5 minutes, lasts 5-60 minutes and is fully reversible
    Atypical aura: may last more than 60 minutes
  • Visual symptoms affectingoneeye
  • Poor balance (e.g. vestibular migraine)
  • Decreased level of consciousness
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13
Q

Investigations to rule out pathology of migraines

A
  • CT or MRI head: rule out the cause of a secondary headache, such as a subarachnoid haemorrhage
  • ESR: exclude giant cell arteritis
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14
Q

Differential diagnosis for migraines

A
  • Stroke: hemiplegic migraines can mimic strokes
  • Primary headaches
    • Migraines
    • Trigeminal autonomic cephalalgias
    • Other primary headache disorders
  • Secondary headaches
    • Trauma
    • Idiopathic intracranial hypertension
    • Subarachnoid haemorrhage
    • Space occupying lesion
    • Giant cell arteritis
    • Infection
    • Drugs and medications
    • Venous sinus thrombosis
    • Malignant hypertension
    • Temporomandibular disorder
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15
Q

first line prophylaxis for migraines ?

A

propranolol

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16
Q

Acute management of migraines

A
  • Analgesia
    • Ibuprofen or aspirin or paracetamol
    • Oral triptan alone+/- paracetamol or an NSAID
      • Oral sumatriptan is the first choice triptan (5-HT receptoragonist - mimic serotonin to cause vasoconstriction)
      • Consider a nasal triptan over an oral triptan in peopleaged 12 to 17 years old
  • Antiemetic:consider metoclopramide or prochlorperazine
  • Avoid opiates: due to the risk of medication-overuse headache, dependence, and worsening nausea
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17
Q

Chronic management of migraines

A
  • Headache diary:document headache frequency to illicit triggers
  • Avoid triggers
  • Prophylaxis (pharmacological):
    • Propranololis considered first-line
    • Topiramate: contraindicated in pregnancyas it isteratogenicand reduces oral contraceptive efficacy
    • Amitriptyline:low-dose may be considered
    • Frovatriptanorzolmitriptan: for predictable menstrual migraines
  • Prophylaxis (non-pharmacological):
    • Mindfulness:alternatives include meditation and CBT
    • Acupuncture: if bothpropranololandtopiramateare ineffective or unsuitable
    • Riboflavin (vitamin B2): **may be effective in some people, but avoid in pregnancy
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18
Q

Complications of migraines

A
  • Depression
  • Status migrainosus: a severe, debilitating migraine lasting for more than 72 hours that may warrant admission
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19
Q

Prognosis of migraines

A

NAME?

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20
Q

What is the tension headache definition?

A

Tension-type headaches is a common primary headache disorder and can be either episodic or chronic.

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21
Q

Epidemiology of tension headaches

A
  • Very common: most common primary headache
  • Onset tends to be in a patients’ 20’s
  • Most common between ages of 20-39
  • Gradually becomes less common with advancing age
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22
Q

characteristis features of tension headaches

A

often described as a ‘tight band’ around the head or a pressure sensation. Symptoms tend to be bilateral, where as migraine is typically unilateral
tends to be of a lower intensity than migraine
not associated with aura, nausea/vomiting or aggravated by routine physical activity
may be related to stress
may co-exist with migrain

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23
Q

RFs for tension headaches

A
  • Stress
  • Bad posture
  • Sleep deprivation
  • Eye strain
  • Depression
  • Alcohol
  • Skipping meals
  • Dehydration
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24
Q

Pathophysiology of Tension headaches

A

May be due to muscle ache in the frontalis, temporalis and occipitalis muscles.

prolonged stimulation of nocireceptors

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25
Q

Clinical manifestations of tension headaches

A
  • Bilateral with a pressing/tight sensation of mild-moderate intensity
    • Frequency varies depending on type of headache: chronic or episodic

Rubber band, tight around head, bilateral pain, feel it in trapezius too

26
Q

What is the clinical diagnosis criteria for frequent episodic tension-type headache

A

Frequency:At least 10 episodes of headache occurring on 1-14 days/month on average for >3 months (≥12 and <180 days/year)

Time:30 minutes to 7 days

Characteristics:At least two of the following:

  1. Bilateral location
  2. Pressing or tightening (non-pulsating) quality
  3. Mild or moderate intensity
  4. Not aggravated by routine physical activity such as walking or climbing stairs

Both of:

  1. No nausea or vomiting
  2. No more than one ofphotophobia or phonophobia
27
Q

Diagnostic crtiera for chronic tension-type headache

A

Frequency:Headache occurring on ≥15 days/month on average for >3 months (≥180 days/year)

Time:Hours to days, may be unremitting

Characteristics:At least two of the following:

  1. Bilateral location
  2. Pressing or tightening (non-pulsating) quality
  3. Mild or moderate intensity
  4. Not aggravated by routine physical activity such as walking or climbing stairs

Both of:

  1. No more than one of photophobia, phonophobia or nausea
  2. Neither moderate or severe nausea or vomiting
28
Q

first line management of tension headaches

A

aspirin, paracetamol, NSAID

29
Q

Investigations to rule out pathology

A
  • CT or MRI head: rule out the cause of a secondary headache, such as a subarachnoid haemorrhage
  • ESR: exclude giant cell arteritis
30
Q

Differential diagnosis for tension headaches

A

Primary headaches

  • Migraines
  • Trigeminal autonomic cephalalgias
  • Other primary headache disorders

Secondary headaches

  • Trauma
  • Idiopathic intracranial hypertension
  • Subarachnoid haemorrhage
  • Space occupying lesion
  • Giant cell arteritis
  • Infection
  • Drugs and medications
  • Venous sinus thrombosis
  • Malignant hypertension
  • Temporomandibular disorder
31
Q

What are cluster headaches classified as?

A

trigeminal autonomic cephalgia (TAC) and are thought to occur due to hypersensitivity of the trigeminal-autonomic reflex arc, resulting in vascular dilation and trigeminal nerve stimulation.

32
Q

Management for episodic tension type headache

A
  • Analgesia:Simple painkillers e.g. paracetamol or NSAIDs to be taken when headache occurs.
    • Limit the use of analgesia to no more than 6 days a month to reduce
      chance of medication-overuse headache
  • Hot towels to local area
  • Lifestyle:Evaluate and offer help with possible precipitants. Consider sources of stress, depression/anxiety, sleep disorder and chronic illnesses. Some patients find regular exercise helps.
33
Q

Management for chronic tension-type headache

A
  • Acupuncture/ massage
  • Prophylaxis:consider low dose amitriptyline
  • Lifestyle:Evaluate and offer help with possible precipitants. Consider sources of stress, depression/anxiety, sleep disorder and chronic illnesses.Some patients find regular exercise helps.
  • Referral:If there is no improvement or diagnostic uncertaintyrefer to neurology.
34
Q

What is the definition of cluster headaches?

A

Cluster headaches are intensely painful, unilateral, periorbital headaches with associated autonomic dysfunction.

Around the eye

35
Q

Epidemiology of cluster headaches

A
  • The estimated annual incidence of cluster headaches is 53 per 100,000 in the Western population
  • Peak onset of 20 to 40 years old
  • M>F
36
Q

RFs for cluster headaches

A
  • Male: 3 times more common in males
  • Family history
    • Autosomal dominant gene has a role
  • Smoking
  • Alcohol excess
37
Q

2 other important types of TAC

A
  • Paroxysmal hemicranial
  • Short-lived unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT)
38
Q

What is involved in cluster headaches

A
  • histamine release
  • increase in mast cells
  • Activation of autonomic nervous system
39
Q

What are the common precipitants of cluster headaches

A
  • alcohol
  • volatile smells
  • warm temperatures
  • sleep
40
Q

What can cluster headaches be?

A

Can be episodic (clusters followed by remission periods) or chronic (no substantial remission period)

41
Q

Clinical manifestations of cluster headaches

A

Headaches occur in clusters:

  • Clusters usually last2 weeks to 3 months, separated byremissionperiods lasting at least3 month
  • Patients experience1 to 8 attacks per day
  • Clusters typically occur1 to 2 times per year
42
Q

Symptoms of cluster headaches

A
  • Unilateral, periorbital or temporal headaches lasting 15 minutes to 3 hours
  • Ipsilateralautonomicsymptoms:
    • Lacrimation (teary eye)
    • Conjunctival injection (red eye due to enlargement of conjunctival vessels)
    • Nasal congestion
    • Rhinorrhoea (nasal discharge)
    • Ptosis (eyelid drooping)
    • Miosis (excessive constriction of the pupil of the eye)
    • Facial sweating
  • Nausea and vomiting
  • Photophobia, with agitation and restlessness
43
Q

Diagnosis for cluster headaches

A
  • Diagnosis is predominantly based on clinical presentation
    • At least 5 headache attacks fulfilling the symptomatic criteria
44
Q

Investigations to rule out other pathology for cluster headaches

A
  • CT or MRI Brain: to rule out an underlying cause such as a space-occupying lesion or pituitary adenoma
  • ESR: to exclude giant cell arteritis
45
Q

Differential Diagnosis for Cluster headaches

A

Primary headaches

  • Migraines
  • Trigeminal autonomic cephalalgias
  • Other primary headache disorders

Secondary headaches

  • Trauma
  • Idiopathic intracranial hypertension
  • Subarachnoid haemorrhage
  • Space occupying lesion
  • Giant cell arteritis
  • Infection
  • Drugs and medications
  • Venous sinus thrombosis
  • Malignant hypertension
  • Temporomandibular disorder
46
Q

Acute management of cluster headaches

A
  • Triptans: triptans are 5HT 1B/D agonists. Subcutaneous or intranasal sumatriptan provides symptomatic relief within 15 minutes in 75% of patients.
  • High flow oxygen- first line I believe: 100% oxygen at 12-15L/minute via a non-rebreather mask for 15-20 minutes; provides symptomatic relief within 15 minutes in 70% of patients
  • Avoid triggers
  • The following drugs should beavoided: paracetamol, NSAIDs, opioids, ergots, and oral triptans
47
Q

Prophylaxis treatment for cluster headaches

A
  • Verapamil: first-line preventative management
  • Lithium
  • Prednisolone: a short course for 2-3 weeks to break the cycle during clusters
48
Q

Complicatins of cluster headaches

A
  • Mental illness: depression, anxiety, self-harm and suicide
  • Auto-enucleation: individuals attempting to remove the affected eye due to a belief that the pain will subside
49
Q

What is the definition of trigeminal neuralgia

A

Trigeminal neuralgia is a pain syndrome which describes severe unilateral pain in the distribution of one or more trigeminal branches.

50
Q

Epidemiology of trigeminal neuralgia

A
  • The estimated prevalence of trigeminal neuralgia ranges from 0.03% to 0.3%
  • Rare in people younger than 40 years of age. Peak incidence between 50-60yrs
  • F>M
51
Q

Rfs for trigeminal neuralgia

A
  • Advancing age: rare in people younger than 40 years of age
  • Female gender:more common in women
  • Demyelinating disease: trigeminal neuralgia is 20 times more common in patients with multiple sclerosis
52
Q

What is the most likely cause of trigeminal neuralgia?

A

90% of patients with trigeminal neuralgia have compression of the nerve by a vascular loop near the nerve’s root entry zone, typically by the superior cerebellar artery.

53
Q

What are the other caues of trigeminal neuralgia?

A
  • Demyelinating disease
  • Posterior fossa masses
  • Brainstem infarcts.
54
Q

What does the pathophysiology of the trigeminal nerve involve

A

The pathophysiology involves aberrant conduction along the trigeminal nerve resulting in neuropathic pain.

Specific triggers include light touch, such as washing, shaving, and talking, and brushing the teeth as well as cold weather, spicy food, caffeine and citrus fruits.

55
Q

S + S of trigeminal neuralgia

A

Pain may be provoked by touch on examination
- Facial pain: comes on spontaneously and last anywhere between a few seconds to hours.
- Trigeminal distribution
- Severe
- Unilateral (but minority of cases are bilateral)
- Electric shock-like sensation
- Episodic
- Provoked, e.g. touch or cold
- Some patients experience autonomic symptoms e.g.
- Lacrimation
- Facial swelling
- Rhinorrhoea
- Ptosis

56
Q

Red flag features of trigeminal headaches that may suggest a serious underlying cause

A
  • Age of onsetbefore 40 years
  • Pain only in theophthalmic division(eye socket, forehead, and nose), orbilaterally
  • Sensorychanges
  • Deafnessor other ear problems
  • History ofskin or oral lesionsthat could spread perineurally
  • Optic neuritis
  • Family history of multiple sclerosis
57
Q

Investigations and diagnosis of trigeminal neuralgia

A
  • Trigeminal neuralgia is a clinical diagnosis
  • Investigations to rule out other pathology
    • MRI brain: imaging may be used if a sinister cause is suspected, such as a space-occupying lesion or demyelination, or if the patient is refractory to medical treatment and surgical intervention is being considered
58
Q

1st line management for trigeminal neuralgia

A
  • Medical: carbamazepineis first-line. The dose is titrated upwards every two weeks until the pain is relieved.
    • Other medication may be used butonlyunder specialist guidance
  • Refer to neurology:**if there issevere painor pain that significantly affectsdaily function, as well as patientsrefractory to treatmentor withatypical symptoms(e.g. age < 50 years)
59
Q

2nd line management of trigeminal neuralgia

A

Surgery: microvascular decompression or ablative surgery may be considered in refractory patients

60
Q

Complications of trigeminal neuralgia

A

Depression and anxiety

61
Q

Prognosis of trigeminal neualgia

A

Trigeminal neuralgia is a chronic pain condition, meaning that patients often have a relapsing and remitting course throughout their life.

Medical and ablative procedures are associated with partial relief of symptoms in the majority of patients.

However, over time, patients often become less responsive to conventional treatments and relapse.

3A Neurology (24 decks)

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