Headaches Flashcards
Investigations are required to differentiate between different types of headaches. True or false?
False
- investigations are carried out to rule out more sinister conditions
Acute onset - think
Haemorrhage
Sub-avute onset - think
Migraine
Associated features to ask about
N+V Photophobia Blurred vision Ptosis Nasal stuffiness
Red flag - new onset headache at which age
55 and ABOVE
Early morning headache is a red flag. True or false
True
A headache that is exacerbated by coughing/sneezing (valsalva) is not a red flag. True or false?
False
- it is a red flag
Migraine - most common in young males. True or false?
False
- young females
Migraine - triggers
Stress Hormonal - menstrual related Sleep Environment After exercise Dietary: red wine, cheese
Migraine - Trigger factor causes changes in the brain which results in the release of _____
Serotonin
Migraine - release of serotonin causes activation of which system, resulting in what?
Activation of trigeminal vascular system
Causes cranial blood vessels to constrict and dilate
Give examples of chemicals which irritate nerves and blood vessels to cause pain
Substance P
Neurokinin A
CGRP
Which part of the brain is the migraine generating centre found?
Brainstem
Migraine with aura - what is aura
Fully reversible
Visual, sensory, motor or language symptom which occurs before you get the headache
Migraine with aura - list some common visual symptoms
Central fortification spectra
Central scotoma
Hemianopic loss
Migraine with aura - how long does it typically last?
20-60 mins
If people have migraine with aura, which medication must they NOT receive
Combined OCP
Migraine without aura - criteria needed to diagnose - at least ___ attacks with duration ____ each time
at least 5 attacks with a duration between 4-72 hours each time
Migraine without aura - additional criteria needed to diagnose: at least 2 of the following
Moderate/severe headache
Unilateral
Throbbing pain
Worst with movement
Migraine without aura - additional criteria needed to diagnose: 1 of the following
N+V
Photophobia
Basilar migraine - clinical features
Vertigo
N+V
Dizziness
Who are most likely to get abdominal headaches ?
Children
Migraine - how often do people get them
Average is 1 attack per month
Migraine - clinical features
Moderate/severe pain Unilateral Throbbing/pounding sensation N+V Photophobia Phonophobia
When patients have a migraine where do they often want to rest?
Lie down in a dark room
Migraine - acute pharmacological management
NSAIDS
- aspirin 900mg
- naproxen 250mg
- ibuprofen 400mg
+/- anti-emetics
Triptans
Migraine - acute pharmacological management - triptans - examples
5-HT agonist
Examples
- rizatriptan
- frovatriptan
Migraine - acute pharmacological management - these medications should be taken as early as possible. true or false?
True
Acute management of an uncomplicated migraine
Over the counter medication is first line
Migraine - non pharmacological management
Avoid triggers
Relaxation/stress management
When would you consider prophylaxis management
When the patient has more than 3 attacks per month
When the patient has very severe migraines
Migraine - prophylaxis management - must trial a drug for how long before giving up
4 months
Migraine - examples of drugs used for prophylactic management
Propranolol Atopiramate Amitryptiline Gabapentin Sodium Valproate
Migraine - drugs used for prophylactic management - side effects of propranolol
Avoid in asthmatics
Heart failure
Tension headache is always stress related. True or false?
True
Tension headache is more debilitating than a migraine. True or false?
False
- less debilitating
Tension headache is unilateral. True or false?
False
- bilateral
Tension headache - clinical features
Bilateral headache
Tingling sensation
Tension headache - what are they NOT associated with
No N+V
No photophobia
No phonophobia
Tension headache - management
Relaxation physiotherapy
Anti-depressant (amitryptiline)
Trigeminal autonomic cephalgia (TAC) - definition
Group of primary headache disorders that affect the trigeminal vascular system
TAC - general clinical features
Unilateral trigeminal (CNV) distribution of pain + Prominent ipsilateral cranial autonomic features - ptosis - miosis - nasal stuffiness - N+V - tearing - eye lid oedema
TAC - what are the 4 types
Cluster headache
Paroxysmal hemicrania
Hemicrania continua
SUNCT
Patient with new onset unilateral cranial autonomic features require which type of investigation?
Imaging
TAC - cluster headache - more common in men/women?
Men
TAC - cluster headache - average age range
30-40
TAC - cluster headaches - triggers
Sleep
Seasonal variation
TAC - cluster headaches - unilatera/bilateral
Unilateral
TAC - cluster headaches - clinical features
Severe unilateral headache
Patient wants to walk about
Patient can’t sit still
TAC -cluster headache - the pain is worse than a migraine. True or false?
True
TAC - cluster headache - duration
Short
- 30 mins -> 2 hrs
TAC - cluster headache - how often do they occur
Around 1-8 per day
TAC - cluster headache - acute management
High flow oxygen for 20 mins
Subcutaneous sumitriptan 6mg
TAC - cluster headache - management to treat a cluster bout
Steroids for 2 weeks
TAC - cluster headache - prophylaxis mangement
Verapamil
TAC - paroxysmal hemicrania - who gets it
Elderly (50-60s)
TAC - paroxysmal hemicrania is more common in males/females?
Females
TAC - paroxysmal hemicrania - - clinical features
Severe unilateral headache
Unilateral autonomic features
Pain comes and goes
TAC - paroxysmal hemicrania - duration
Short duration
10-30 mins
TAC - paroxysmal hemicrania - how often do they occur
1-40 per day
TAC - paroxysmal hemicranias are SHORTER/LONGER duration and MORE/LESS frequent than cluster headaches
Shorter duration
More frequent
TAC - paroxysmal hemicrania - management
Indomethacin
TAC - paroxysmal hemicrania - if the headache doesn’t respond to indomethacin then what happens?
You have made the wrong diagnosis
TAC - SUNCT - clinical features
Short lived (15-120 secs) Unilateral Neuralgiform headache Conjunctibal injections Tearing
TAC - SUNCT - management
Lamotrigine
Gabapentin
Idiopathic intracranial hypertension - more common in males/females?
Females
Idiopathic intracranial hypertension - more common in skinny/obese people?
Obese
Idiopathic intracranial hypertension - clinical features
Headache Papilloedema Diurnal vriation Morning N+V Visual loss
Idiopathic intracranial hypertension - investigations
MRI scan
- should be normal
Lumbar puncture
Idiopathic intracranial hypertension - why is an MRI scan necessary?
If there is headache + papilloedema it may be a brain tumour so it is necessary to do imaging investigations to check
Idiopathic intracranial hypertension - what are the rules about lumbar puncture here
Only perform lumbar puncture once you are sure that MRI scan is normal
Idiopathic intracranial hypertension - management
Weight loss can resolve the issue
Acetazolamide
Trigeminal neuralgia - pathogenesis
Due to blood vessel touching CNV
Trigeminal neuralgia - who gets it?
Elderly patients
Trigeminal neuralgia - more common in men/women ?
Women
Trigeminal neuralgia - clinical features
Severe, stabbing pain
Unilateral
Very short duration (1-90 secs)
Bouts of pain which may last weeks/months before remission
Trigeminal neuralgia - investigations
MRI brain
Trigeminal neuralgia - management (pharmacological)
Carbamazepine
Gabapentin
Phenytoin
Baclofen
Trigeminal neuralgia management (surgical)
Ablation of CN V nerve root
Decompression if blood vessel is touching CN V
What is the first line pharmacological management for trigeminal neuralgia?
Carbamazepine
