Headaches Flashcards
Red flags for headaches
New onset >55 years Early morning/Wakes you up Hx of malignancy Immunosupressed Exacerbation by Valsalva manouvre
If headache that is worse in the morning (wakes them up) and vomiting then what is it that we are worried about?
Tumour
If there is a headache that is increased with coughing/leaning forward that what are we worried about?
Congenital problem ass with cerebellum
If headache with flashing lights and one sided what is the most likely diagnosis?
Migraine
Headache with tiptoeing, ataxia and vomiting in children. What is the likely differential?
Posterior fossa tumour
on average how many attacks will someone with migraines have?
1 a month
Who is the classic migraine patient?
Young female
Triggers for migraines
Stress Skipping meals Binge eating Mensuration/ovulation OCP Bright sunshine Sleep Physical exertion
What criteria do you need to meet in order to be classified as a migraine without aura?
5+ attacks with duration of 4-72h with the following features
Phono/Photophobia
+ 2 of….
Binge eating, Mensturation, Throbbing headache, worse on movement and N&V
How do migraines with aura look different in children?
Short lasting
May be bilateral
more prominent gastrointestinal disturbance
Pathophysiology of migraine without aura
- Stress triggers changes in the brain, these changes cause serotonin to be released
- Blood vessels constrict and dilate
- Chemicals inc Substance P irritate nerves and blood vessels causing pain
What is an aura?
A visible sign of migraine
occur before 20% of migraines
usually last 20-60m
Headaches follow<1h later but can occur simultaneously
Why is the COCP contraindicated in migraines with aura?
As migraines with aura increase chance of ischaemic stroke significantly
What is the pathophysiology of migraine with aura?
Cortical spreading depolarisation
Activation trigeminal vascular system-dilation cranial blood vessels
Release of substance P, Neurokinin A, CGRP
Acute treatment for migraines
Lie in a dark room
Oral triptan and/or NSAID + consider anti-emetic
What are 3 CI to triptans?
Coronary vasospasm
IHD
Previous cerebrovascular incidents
When would you use prophylaxis for migraines?
If >3 attacks per month OR if severe
What 3 drugs can be used as prophylaxis for migraines?
Propanolol
Topiramate
Amitriptyline
What lifestyle modifications can be made in order to reduce the likelihood of migraines?
Diet Hydration Stress Avoidance of triggers Non-pharmacological methods
What is the name when migraines last more than 3 days?
Status migrainosus
Classic description of tension type headaches?
Band like pressure around the head radiating to the neck
TRUE/FALSE
In tension-type headaches there is absence of N&V and phono/ohotophobia
TRUE
Tension-type headaches have a strong association with
Depression and anxiety
Most patients who have tension-type headaches self-manage. If it is a chronic refractory type headache then what drug can be used?
Amitriptyline
Define TAC
A group of headache disorders categories by common features of unilateral pain (often severe) in the distribution of the trigeminal nerve.
What are the symptoms of TAC?
Symptoms on the ipsilateral side
- ptosis
- miosis
- nasal stuffiness
- N/V
- Tearing
- Eyelid oedema
What are cluster headaches affectionately known as?
Suicide headaches
When do cluster headaches occur?
Last 10m-3h
occur in bouts (1-8x a day)
for a certain period of the year (few weeks-months)
before ceasing for a long period of time
Occur when going to bed or in the early hours of the morning
What is the age of onset and sex distribution of cluster headaches?
M>F
Age 20-55
What are the 3 characteristic features of cluster headaches?
- Severe unilateral pain
- Ipsilateral autonomic features
- Circadian rhythm of onset
What investigation is undertaken in all cluster headache patients?
MRI and MR angiogram
Treatment of Cluster headaches
High flow O2 and SC sumitriptan
What is the prophylaxis of cluster headaches?
Verapamil
How are paroxysmal hemicranial different to cluster headaches?
They are slightly shorter (10-30m), more often (1-40 times a day), more common in females and have an older age of onset (50-60)
What is the Rx for paroxysmal hemicranial?
Indomethicin (has complete resolution)
What does SUNCT stand for?
S-short lived (15-120s) U-unilateral N-Neuralgiaform headache C-Conjunctival infections T-Tearing
Treatment of SUNCT
Lamotrigine or Gabapentin
Compression of CNV by the superior cerebellar artery at the dorsal root entry zone leads to
Trigeminal Neuralgia
What is another cause of trigeminal neuralgia aside from compression of the nerve?
Demyelinating disorder
TRUE/FALSE
Trigeminal neuralgia symtpoms tend to be bilateral
FALSE
Symptoms tend to be unilateral
How would you describe trigeminal neuralgia?
Electric shock like pain, usually around nose-mouth
<90s
10-100 a day
Can last weeks-months
Incidence of trigemenial neuralgia increases with age TRUE/FALSE
TRUE
What is trigeminal neuralgia exacerbated by?
Touching the area
cold wind
shaving or brushing teeth
talking, eating and drinking
Why is MRI an important investigation for trigeminal neuralgia?
Use dot exclude compression of the dorsal root entry zone
Treatment for trigeminal neuralgia
1st line- Carbamazepine
2nd line- Neurosurgical debulking or radio frequency ablation
What is the most common cause of secondary headache?
Medication overuse syndrome
If you have a primary cough headache what might be two underlying causes?
Chiari malformation
Aneursym
Primary exertion headache is bilateral and pulsating TRUE/FALSE
TRUE
What are the two subclassifications of primary sexual headache?
Early coital cephalgia
Post coital cephalgia
What is an early coital cephalgia headache like?
Dull, aching, pain in the occipital region
When is the most severe headache in post coital cephalgia?
During an orgasm
What headache is the acute thunderclap headache?
Subarachnoid headache
What are the two most likely causes for a carotid dissection?
1- Spontaneous
2- Due to hyperextension injury of the neck
TRUE/FALSE
Giant cell arteritis can present as scalp pain aswell as ischaemic pain in the muscles of mastication
TRUE
What are the classic RF for IIH
Female, Fat, Fertile
What is IIH?
Idiopathic intracranial hypertension
An idiopathic process, chronically raised CSF pressures within the brain without any discernible SOL to raise ICP
What are the symptoms of IIH?
Headache
Moderate/gross bilateral papiloedema
N&V
CN VI palsy
Is the headache caused by IIH relieved on standing?
TRUE
What is the treatment for IIH?
Wt loss
Acetazolamide
Lumboperitoneal shunt
