Headaches Flashcards
describe the history taking for a headache?
no of types of headache? Time? Character? Cause? Response to hdx? health between attacks? anxieties/concerns?
SOCRATES
MEDS
EtOH
Depression
FAM hx
Is there >1 type of headache? Take a separate history for each.
• Time When did the headaches start? New or recently changed
headache calls for especially careful assessment. How often do they happen? Do they have any pattern? (e.g. constant, episodic, daily) How long do they last? Why is the patient coming to the doctor now? A headache diary over >8wk may help if long-standing headaches
- Character Nature/quality, site, and spread of the pain. Associated symptoms, e.g. nausea/vomiting, visual disturbance, photophobia, neurological symptoms
- Cause Predisposing and/or trigger factors; aggravating and/or relieving factors; relationship to menstrual cycle; family history
- Response Details of medication used (type, dose, frequency, timing). What does the patient do, e.g. can the patient continue work?
- Health between attacks Do headaches go completely or is the patient unwell between attacks? Other past/current medical problems
- Anxieties and concerns Of the patient/family
what physical exams should be carried out in a headache patient?
in acute patients?
in all patients?
in young children?
General Vitals Fundoscopy Cranial nerves General neuro Temporal arteries Head and neck muscles
In acute, severe headache, examine for fever and purpuric skin rash.
In all cases check BP, brief neurological examination including fundi, visual acuity, and gait, palpation of the temporal region/sinuses for tenderness, and examination of the neck.
In young children, measure head circumference and plot on a centile chart.
what are the red flags for headaches?
Red flags
• Fever and worsening headache ± purpuric rash/meningism
- new headache, >50yrs
• Thunderclap headache (reaching peak intensity in 1h ± motor weakness)
• Aura for first time and using CHC
DDx for headaches?
Tension headache Secondary headache Migraine Cluster headache Temporal arteritis Space occupying lesion, bleed, CVA Cervical spondylosis Infective
damage to CN III leads to what symptoms?
Damage to the oculomotor nerve (III) can cause
double vision (diplopia) and
inability to coordinate the movements of both eyes (strabismus),
also eyelid drooping (ptosis) and
pupil dilation (mydriasis).
Lesions may also lead to inability to open the eye due to paralysis of the levator palpebrae muscle.
give an overview of migraines?
4-72hrs
Repeated attacks
Quality of life
2+ of: unilateral pain, throbbing, moderate-severe intensity, aggravation by movement
1+ of: nausea/vomiting, photo/phonophobia
Aura- transient- 5-60 mins
Due to irritation of CN V, meninges, or blood vessels (release of substance P, CGRP, vasoactive peptides).
give examples of acute & new headaches causes?
Oxford GP book page 553
meningitis- IV/IM penicillin V and immediate admission
encephalitis- immediate admission sub arachnoid hemhorrhage- immediate admission head injury- consider admission self limiting viral sinusitis dental caries tropical illness
investigations for headaches?
ESR if temporal arteritis is suspected
hospital admission & CT if sub arachnoid hemhorrhage
causes of chronic headaches?
increased BP tension cervical spondylosis increased ICP errors of refration (new glasses)
medication overuse- rebound headaches on stopping analgesics
pagets disease
management of migraines?
Diary
Triggers- food, psychological, environmental, sleep, health (menstrual. HRT)
Meds
Prophylaxis
Abortive therapies (e.g., triptans, NSAIDs) and prophylactic (propranolol, topiramate, calcium channel blockers, amitriptyline).
MOA of triptans (used in migraines)?
eg…
sumatriptan
Their action is attributed to their agonist[2] effects on serotonin 5-HT1B and 5-HT1D receptors in cranial blood vessels (causing their constriction) and subsequent inhibition of pro-inflammatory neuropeptide release. Evidence is accumulating that these drugs are effective because they act on serotonin receptors in nerve endings as well as the blood vessels. This leads to a decrease in the release of several peptides, including CGRP and substance P.
moa of amitryptaline? and what class of drugs is it in?
TCA
Block re-uptake of norepinephrine and 5-HT.
contraindications to taking NSAIDS?
coronary artery disease past history of heart attack angina [chest pain due to narrowed heart arteries] history of a stroke narrowed arteries to the brain kidney disease heart failure uncontrolled hypertension cirrhosis people who take diuretics
people who are at a higher than average risk for these conditions should avoid using COX-2 inhibitors. Of the nonselective NSAIDs, naproxen may be the safest for people with coronary artery disease, but a clinician should be consulted before use of this or any other NSAID.
tension headache overview?
Mild-moderate steady pain Pressing/ tightening Bilateral no photo/phono phobia
analgesics
NSAIDs
acetaminophen
Prophylaxis
overview of cluster headache?
Severe Unilateral Recurrent Orbital/ supra-orbital/ temporal 15m-3h focussed around 1 eye with associated autonomic symptoms on that side (drooping eyelid, constricted pupil, red watery eye, runny or blocked nose, forehead sweat- ing)
0xygen, Triptan (sumatriptan)
