Headaches - 2 Flashcards
Describe cranial neuralgias
An intense burning or stabbing pain - is usually brief and severe
Pain extends length of affected nerve
Caused by irritation or damage to nerve - trigeminal mainly
Describe trigeminal neuralgia
Unilateral maxillary or mandibular division pain more than ophthalmic
Triggered and spontaneous stabbing pain - 5-20sec duration
Triggers - cold, chewing, touch
Refractory period
What are the causes of trigeminal neuralgia?
Vascular compression of the trigeminal nerve
Multiple sclerosis, intracranial arteriovenous malformation, tumour and brainstem lesions
What is the treatment of trigeminal neuralgia?
Medical - Carbamazepine, Oxcarbazepine, Lamotrigine, Pregabalin, Phenytoin
Surgical - glycerol ganglion injection, stereotactic radiosurgery and microvascular decompression (best)
What are the 4 types of trigeminal autonomic cephalalgias?
Cluster headache, paroxysmal hemicrania, SUNCT/ SUNA and hemicrania continua
Describe trigeminal autonomic cephalalgias
Strictly unilateral head pain - V1
Very severe and excruciating pain
Cranial autonomic symptoms - lacrimation, eyelid oedema, forehead sweating, nasal congestion
Restless
Attack frequency and duration differs
Describe cluster headache - the attack
Pain is mainly orbital and temporal
Unilateral and rapid onset
15mins to 3 hrs
Rapid cessation of pain
Excruciating and restless
Prominent ipsilateral autonomic symptoms
Migraine symptoms often present
Describe the bout of cluster headache
Attacks in cluster into bouts lasting 1-3 months with periods of remission at least 1 month
1-8 a day
Striking circadian rhythm
Some have chronic cluster
What is the treatment for cluster headache?
Abortive
Transitional - abort cluster bout and allow time for preventative treatment to work
Preventative
What are some abortive treatments for cluster headache?
Triptans - Sumatriptan is treatment of choice, used 2 x daily, nasal zolmitriptan, oral is not effective
Oxygen - 10-15ltrs for 15-20 mins which may delay rather than abort attack
What is some transitional treatment for cluster headaches?
Oral prednisolone taper - introduce preventative at same time
Greater occipital nerve block - depomedrone and lidocaine
What is preventative treatment used in cluser headaches?
Verapamil
Lithium - chronic cluster headache
Topiramate - 2nd line
Gabapentin
Pregabalin
Sodium Valproate
Levetiracetam
Melatonin
Describe paroxysmal hemicrania
Pain is mainly orbital and temporal
Unilateral and rapid onset
2-30 mins and rapid cessation
Very severe pain
Can be restless
Prominent autonomic symptoms and migraine symptoms
Absolute response to indomethacin
Describe hemicrania continua
Strictly unilateral
Episodic or chronic
Moderate serve continuous background headache
Superimposed exacerbations of more severe pain lasting 20 mins
Mainly orbital and temporal
Describe SUNCT/ SUNA
Unilateral, supraorbital or temporal pain
Stabbing or pulsating pain
10-240 seconds
Triggers - cold, touch, chewing
Attack frequency is 3-200 a day and no refractory period
Conjunctival injection and lacrimation
What is the treatment for SUNCT/SUNA?
Medial - Lamotrigine, topiramate, oxcarbazepine, carbamazepine, duloxetine and pregabalin
Transitional - GON block
Surgical - occipital nerve and deep brain stimulation
What are the main disorder presenting to A+E with headache?
Not just secondary headache - lots of range of disorders in secondary
Disabling primary headache
SAH and brain tumour
Sinister headache is infrequent
What presentations are more likely to predict sinister headache?
Head injury, first or worst, sudden onset, new daily persistent headache, change in headache pattern and returning patient
What features should make us consider secondary headache?
New onset headache, new or change in headache, change in frequency or characteristics, focal or non focal neuro symptoms, neck stiffness, high pressure, low pressure and GCA
Describe a thunderclap headache
High intensity headache reaching max intensity in less than 1 min
Majority peak is instantaneous and is whole head
Must exclude subarachnoid haemorrhage
Describe subarachnoid haemorrhage
Aneurysmal rupture and bleeding into subarachnoid space
There is a risk of re-bleeding and rupture
CT head as soon as possible and CT angiogram is SAH is confirmed
What are some complications of subarachnoid haemorrhage?
Vasospasm, hydrocephalus, seizure, infection and re-bleeding
What is the treatment for SAH?
Early treatment of aneurysm - coiling and clipping
Nimodipine - Ca channel blocker for vasospasm
Treat complications
HHH therapy - hydration, hyperoxia and hypertension
Describe meningism and encephalitis
CNS infection
Presents with headache and fever
Meningism - nausea and vomiting, photophobia, phonophobia and stiff neck
Encephalitis - altered mental state, focal symptoms and seizures
Look for rash
What can cause high pressure?
Intracranial pressure - change in volume of CSF and blood
Space occupying lesion
Brain swelling
Raised CSF pressure - hydrocephalus and intracranial hypertension
What are the symptoms of a high pressure headache?
Headache wakens patient up, cough or other Valsalva headache, visual obscuration, seizures, progressive focal symptoms, cognitive change and LOC
What should be considered if patient has headache and loss of consciousness?
3rd ventricle colloid cyst
What are the signs of high pressure headache?
Papilledema
New abnormal neurological examination
Describe intracranial hypertension
Elevated CSF opening pressure
Presentation - episodic or persistent headache, visual obscuration and papilledema
What is the differential diagnosis of intracranial hypertension?
Idiopathic intracranial hypertension, drug induced, pregnancy, cerebral venous sinus thrombosis, meningitis and after SAH
Describe intracranial hypotension
Spontaneous or post lumbar puncture
Postural headache so worst upright due to brain sink
MRI brain and spine show venous enlargement and subdural hygromas
What is the treatment of intracranial hypotension?
Bed rest, fluids, analgesia and caffeine - IV
Epidural blood patch
Describe giant cell areritis
Inflammation of large arteries
Headache is non specific
Scalp tenderness, jaw claudication and visual disturbance
Prominent, beaded and large temporal arteries present
What investigations are used for giant cells arteritis?
ESR elevated
Raised CRP and platelet count
What is the treatment for giant cell arteritis?
High dose prednisolone
If GCA is considered prednisolone should be started immediately and temporal artery biopsy arranged
