Headaches Flashcards
1
Q
What are the main types of primary headache?
A
No underlying cause
- Migraine
- Tension Headache
-
Autonomic cephalgias
- Cluster
- Paroxysmal hemocrania
- SUNCT
- SUNA
2
Q
What are main types of secondary headache?
A
Structural or biochemical cause
- Thunderclap headache
- Postural headaches
- Associated with CNS infection
- Asscoiated with Systemic illness
3
Q
What are features of migranous aura?
A
-
Visual Aura
- Positive - Fortification spectra, scintillations, spots
- Negative - visual field loss
- Sensory Aura - spreading unilateral numness - Fingers to face
- Motor - ataxia, dysarthria, opthalmoplegia, hemiparesis
- Speech - dysphasia/paraphasia
- Migranous Vertigo
- Speech Distrubance
- Neck/limb pain
- Hemiplegic migraine
4
Q
What is the following?
A
Fortification spectra
5
Q
What type of visual field defects are seen in migraines?
A
- Scotoma
- Hemianopia/tunnel vision
6
Q
What are red flag features of a headache?
A
SNOOPY
- Systemic symptoms or illness - fever, vomiting, stiff neck, photophobia, pregnancy, cancer, immunocompromised
- Neurological signs - altered mental state, focal neurological signs, seizures, papilloedema
- Onset recent or sudden
- Other associated symptoms - associated with trauma, wakened during sleep, worsened by Valsalva maneuvers
- Previous headaches that have been different - headaches becoming more frequent or character changing
- You can trigger headache - positional or valsalva
7
Q
What is hemiplegic migraine?
A
This rare autosomal dominant disorder causes a hemiparesis and/or coma and headache, with recovery within 24 hours. Some patients have permanent cerebellar signs as it is allelic with episodic ataxia. It is distinct from commoner forms of migraine.
8
Q
What is the mechanism behind migraine development?
A
- Spreading cortical depression (causing aura) – wave depolarization followed by depressed activity spreading anteriorly across cortex from the occipital region
- Activation of trigeminal pain neurones (causing headache) - Release of CGRP, substance P and other vasoactive peptides by activated trigeminovascular neurones causes painful meningeal inflammation and vasodilation.
- Peripheral and central sensitization of trigeminal neurones and brainstem - makes innocuous sensory stimuli (such as CSF pulsation and head movement) painful and light and sound perceived as uncomfortable.
9
Q
What are partial triggers of migraine?
A
- Chocolate
- Hangovers
- Orgasms
- Cheese/caffeine
- Oral contraceptives
- Lie-ins (sleep disturbance)
- Alcohol
- Travel
- Exercise
Stress, dehydration, hunger
10
Q
What are negative visual aura symptoms?
A
Visual field loss
11
Q
What are the 3 main areas of migraine treatment?
A
- Lifestyle
- Acute treatment
- Preventative treatment
12
Q
What are positive visual aura symptoms?
A
- Fortification spectra
- Scintillations
- Scotoma
- Hemianopia
- Chaotic distortion
13
Q
What are sensory features of migraine aura?
A
Spreading unilateral numbness - over minutes, spreading fingers to face
14
Q
What are motor features of a migraine aura?
A
- Dysarthria + Ataxia
- Opthalmoplegia
- Hemiparesis
- Dysphasia - can be confused with TIA
15
Q
What proportion of migraine sufferers have aura preceding an attack?
A
25%
16
Q
What are features of the prodromal phase of a migraine?
A
- Mood changes
- Fatigue, yawning
- Cognitive changes
- Muscle pain
- Food craving
- Nausea
17
Q
Which sex is migraines more common in?
A
Females - 3:1
18
Q
What are features of a migraine?
A
- Severe unilateral headache
- Nausea
- Vomiting
- Photophobia/Phonophobia/Osmophobia
- Allodynia
- Throbbing pain
19
Q
What are the diagnostic crtieria for diagnosing migraine?
A
>/=5 headaches lasting 4-72 hrs + nausea/vomiting (or photo/phonophobia), plus any two of:
- Pulsating/Throbbing
- Impairs routine activity
20
Q
What changes in routine can cause increased migraines?
A
- Sleep disturbance
- Stress
- Hormonal factors - menstruation, pregnancy, menopause, OCP
- Eating - skipping meals/alcohol
- Sensory stimuli
21
Q
What would be your differential be for a migrainous type headache?
A
- Cluster/tension headache
- Cervical spondylosis
- Hypertension headache
- Intracranial pathology
- Sinusitis/otitis media
- TIA - hemiplegic, visual and hemisensory signs must be distinguished from (migraine aura)
- Sudden onset may resemble SAH, meningitis
22
Q
What lifestyle advise would you give someone suffering from migraines?
A
- Avoid food triggers
- Sleep
- Hydration
- Regular meals
- Look at meds - overuse headache?
23
Q
What treatment would you prescribe someone with migraines for acute attacks?
A
Stop regular opiates/paracetamol
- 1st line - Combination therapy Oral triptan + NSAID/Paracetamol
-
If monotherapy preferred
- Triptan
- NSAID
- Aspirin - 900 mg every 4–6 hours
- Paracetamol
- Consider anti-emetics
24
Q
What are contraindications of triptan use?
A
Eg Zolmitriptan
- IHD
- Coronary Spasm
- Uncontrolled HTN
- Recent Lithium use
- SSRI use
- Ergot use
25
What would you prescribe for prophylactic management of migraines?
* **1st lines** - Propranolol or topiramate
* **Amitryptiline (TCAs)**
* **Candesartan**
* **Others** - (eg antiepileptics) valproate, pizotifen, pregabalin, ACEi
26
What dose of propranalol would you start someone on for prophylactic management of migraines?
40mg daily for 2 weeks, then increase to 80mg daily
27
What dose of topiramate would you start someone on as prophylactic treatment of migraine?
25mg daily, increase by 25mg every 2 weeks up to 75 mg
28
What dose would you start amitryptyline on for prophylactic treatment of migraine?
10mg nightly, increase by 10 mg weekly up to 75 mg
29
What are women with migraines at risk of if on OCP?
Increased stroke risk
30
What would you give as oral contraception in women with migraines?
1. **POP**
2. **Non-hormonal contraception**
31
What are tension type headaches?
In contrast to migraine, pain is usually mild to moderate severity, bilateral and relatively featureless, with tight band sensations, pressure behind the eyes, and bursting sensations being described.
32
How would you manage tension type headaches?
* **Simple analgesia** - don't encourage overuse
* Eg NSAIDS
* Eg aspirin or paracetmol
* Prophylaxis
* Tri-cyclic antidepressants
33
What are trigeminal autonomic cephalgias?
RARE apart from cluseter
* Cluster
* Paroxysmal hemicranias
* SUNCT (short lasting unilateral headache attack with conjunctival injection and tearing)
* SUNA (short lastin unilateral neuralgiform headache with autonomic symptoms)
Common symptoms include:
* Unilateral head pain
* Very severe/excruciating
Attack frequency and duration differs
Treatment responses differ
*
34
What is a cluster headache?
Recurrent bouts (clusters) of excruciating unilateral retro-orbital pain with parasympathetic autonomic activation in the same eye causing redness or tearing of the eye, nasal congestion or even a transient Horner’s syndrome
35
Describe the following features of SUNCT headaches:
* Duration
* Onset
* Frequency
* **Duration** - 2-250s
* **Onset** - Rapid
* **Frequency** - 1/day - 30/hr
36
Describe the following features of a cluster headache:
* Duration
* Onset
* Frequency
* **Duration** - 15 mins - 3 hrs
* **Onset** - Rapid
* **Frequency** - 1 every other - 8/day
37
What are features of a cluster headache?
Suicide headache
* **Rapid onset excruciating pain around one eye**
* ****Restless patient
* **Prominent ipsilateral autonomic symptoms**
* Conjunctival injection / lacrimation
* Nasal congestion / rhinorrhoea
* Eyelid oedema
* Forehead & facial sweating
* Miosis / ptosis (Horner’s syndrome)
38
In terms of yearly time course, what are the distinct features of cluster headaches?
Clusters last 4-12 weeks, then have headache free periods of months to 1-2 years
39
How would you manage cluster headaches acutely?
Acute
* **Give high flow oxygen** - non re-breath mask
* **Triptan injection**
To cure bout
* Occipital depomedtrom injection
* tapering course of prednisolone
40
How would you manage cluster headaches prophylactically?
* **Verapamil**
* **Topiramate**
Alcohol can trigger attack so avoid
41
What is SUNCT?
**S**hort-lasting **U**nilateral **N**euralgiform headaches with **C**onjunctival injection and **T**earing
A rare headache disorder that belongs to the trigeminal autonomic cephalalgias (TACs). Symptoms include excruciating burning, stabbing, or electrical headaches mainly near the eye and typically these sensations are only on one side of the body. The headache attacks are typically accompanied by cranial autonomic signs that are unique to SUNCT. Each attack can last from five seconds to six minutes and may occur up to 200 times daily.
42
What are features of SUNCT?
* **Severe unilateral headache** - stabs, sawtooth
* Restless patient
* **Prominent ipsilateral autonomic symptoms******
* Conjunctival injection / lacrimation
* Nasal congestion / rhinorrhoea
* Eyelid oedema
* Forehead & facial sweating
* Miosis / ptosis (Horner’s syndrome)
43
In terms of daily time course, what are features of cluster headaches?
* **Attacks occur at the same time each day**
* **Bouts occur at the same time each year**
44
How would you manage someone with SUNCT?
NO DEFINITIVE TREATMENT
Prophylaxis:
* **Lamotragine**
* **Topiramate**
* **Gabapentin**
45
What can trigger SUNCT?
Cutaneous contact
Eg wind, cold, touching, chewing
46
What percentage of those with SUNCT have chronic SUNCT?
70%
47
Desribe the following features of paroxysmal hemicrania:
* **Duration**
* **Onset**
* **Frequency**
* **Duration** - 2- 45mins
* **Onset** - rapid
* **Frequency -** 1-40/day
48
What are features of paroxysmal hemicrania?
* **Excruciatingly severe headache** - unilateral
* Restless patient
* **Prominent ipsilateral autonomic symptoms**
* ****Conjunctival injection / lacrimation
* Nasal congestion / rhinorrhoea
* Eyelid oedema
* Forehead & facial sweating
* Miosis / ptosis (Horner’s syndrome)
49
How do you distinguish between cluster headaches and paroxysmal hemicrania?
Duration and Frequency - PH is shorter duration (2-30 mins) and higher frequency per day (2-40 per day)
50
What can paroxysmal hemicrania attack be precipitated by?
Bending or rotating head
51
How would you manage someone with paroxysmal hemicrania?
* Indomethicin
52
What are the autonomic cephalgias?
* **Cluster headaches**
* **SUNCT**
* **Paroxysmal hemicrania**
53
What is a cervicogenic headache?
A chronic headache arising from the atlanto-occipital and upper cervical joints and perceived in one or more regions of the head and/or face. These occur due to a neck disorder or lesion and feature the converging of trigeminal and cervical afferents in the trigeminocervical nucleus within the upper cervical spinal cord.
54
What are features of a cervicogenic headache?
* **Unilateral dominant headache** - Exacerbated by neck movement or posture
* **Tenderness of the upper cervical spine joints**
* **Weakness** - deep neck flexors
55
How would you manage cervicogenic headache?
* Amitryptilline
* Physiotherapy
56
What clinical examinations would you perform in someone presenting with headache?
* **General/systemic**
* **Cranial nerve** - mainly eyes
* **Limb Examination** - weakness, coordination, reflexes
57
What CNS infections can present with headache?
* **Meningitis**
* **Viral encephalitis**
58
If someone had chronic headache which was worse on lying flat, and improved on sitting up, what might this indicate?
Riased ICP
59
What are features of raised pressure headaches?
* **Worse on lying flat, improved on sitting / standing up**
* **Worse in the morning**
* **Worse on valsalva**
* **Worse with physical exertion**
* **Vomiting without nausea**
* **Transient visual obscurations with change in posture**
60
If someone had a headache which was worse on lying down, whilst doing any valsalva maneuvre, and was worse in the mornings, what might you expect to find on examination?
* **Optic disc swelling** – papilloedema
* **Restricted visual fields / enlarged blind spot**
* **VIth nerve palsy** - false localising sign
* **Focal neurological signs**
61
What are mass effect causes of raised ICP?
* **Tumour**
* **Infarction with oedema**
* **Subdural/extradural/intracerebral haematoma**
* **Abscess**
62
What venous problems can cause raised ICP?
* **Cerebral venous sinus thrombosis**
* **Obstruction of jugular venous system**
63
What CSF problems can cause raised ICP?
* **Hydrocephalus**
* **Meningitis**
64
What idiopathic processes can cause raised ICP?
Idiopathic intracranial hypertension
65
What are features of low-pressure headaches?
Orthostatic headaches - Headache worse on sitting / standing up and relieved by lying down
66
What are causes of low-pressure headaches?
* **Post LP**
* **Spontaneous intracranial hypotension** - following dural tear
67
What investigations would you consider in someone with features of raise ICP?
* **CT head**
* **CT/MR Venogram** - rule out venous sinus thrombosis
* **Consider LP** - after imaging!!!! risk of coning
68
If someone had features of a SOL, and they're imaging showed no features of mass lesion, venous sinus thrombosis or hydrocephalus, what would you consider as the diagnosis?
Idiopathic intracranial hypertension
69
If someone presented with a headache and a red, painful eye +/- reduced vision, what diagnosis would you want to rule out?
Acute angle glaucoma
70
If someone presented with a temporal headache and jaw claudication, what diagnosis would you want to rule out?
Giant cell arteritis
71
If someone presented with a headache which felt like a tight band around their head, what might you suspect to be the cause?
Tension headache
72
What are causes of medication overuse headaches?
* **Mixed analgesia** - Paracetamol + opiates
* **Ergotamines**
* **Triptans**
* **Caffeine**
For medications, more at risk if using analgesia for \> 10 days
73
In terms of management of migraines, what medications should you avoid using when they are of childbearing age?
**Anti-epileptics** - valproate
74
What are migraneurs more at risk of if they are pregnant?
Pre-eclampsia/eclampsia
75
What is idiopathic intracranial hypertension?
Increased intracranial pressure caused by reduced CSF resorption
76
Who does Idiopathic Intracranial Hypertension occur most commonly in?
Younger overweight female patients, many of whom have polycystic ovaries
77
How does Idiopathic intracranial hypertension present?
Raised ICP headache features
* **Positional Headaches** - worse on lying, bending over
* **Transient visual obscurations** - florid papilloedema
* **VIth nerve palsy** - false localizing sign
78
What investigations might you do in someone with suspected intracranial hypertension?
* **Imaging** - Exclude SOL
* **Consider LP** - Opening pressure
* If Safe to do so
79
How would you try to minimise medication overuse headache in someone using simple analgesia for tension type headache?
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
80
What is medication overuse headache?
Headache present on ≥15 days / month which has developed or worsened whilst taking regular symptomatic medication
81
Which of the Autonomic cephalgias are there no abortive treatments for?
* **SUNCT**
* **Paroxysmal Hemicrania**
82
How would you manage low-pressure headaches?
Significant number resolve spontaneously
* **Bed rest**
* **Fluids**
* **Analgesia**
* **Oral/IV caffeine**
* **Epidural blood patch**
83
How would you manage someone with Idiopathic intracranial hypertension?
Usually self-limiting
* **Regular monitoring of visual fields with perimetry**
* **Reduce CSF**
* Repeated LP
* Acetazolamide
* Thiazide diuretics
* **Consider surgery**
* Ventriculoperitoneal shunt
* Optic nerve sheath fenestration
84
What are secondary causes of intracranial hypertension?
* **Drugs (tetracycline, Vit A)**
* **Sleep apnea**
* **Chronic renal failure**
* **Addisons disease,**
* **Cushings disease,**
* **Hypoparathyroidism**
85
Name the cranial autonomic symtpoms
Conjunctival infection/lacrimation
Nasal congesion/rhinorrhoea
Eyelid oedema
Forehead/facial swelling
Miosis/ptosis (horner's)
86
What is trigeminal neuralgia?
TN results from a neuropathic disorder of the Vth cranial nerve (trigeminal nerve).
87
Presentation trigmenial neuralgia
Unilateral pain
Maxillary and madnibular division
Stabbing (esp around eye), sudden, severe
Autonomic symtpoms rare
88
Investigations
MRI (lesion/vascular loop)
89
Management trigeminal neuralgia
Carbamezapine
Surgical ablation of trigeminal nerve
Surgical decompression of vascular loop
90
Presentation GCA
Headache - severe, throbbing
Scap tenderness
Jaw claudication
Visual symptoms -amaeurosis fugax or sudden blindness), tpically one eye
Typically in those \>50
91
Investigations GCA
Raised ESR, rasied CRP and platelets
Temporal artery biopsy is definitive dianosis
92
Management of GCA
Prednisolone - if suspected GCA take ESR and start prednisolone high dose straight away (to prevent risk of irreversible bilateral visual loss)
Associated with PMR in 50%
