Headaches Flashcards by Philip Meakin

How might patients describe a tension headache?

Tight band across the head
Head being in a vice
No GI or visual symptoms associated with the headache
May have coexisting anxiety or depression

How well did you know this?

Not at all

Perfectly

What conditions may often coexist with tension type headaches?

Anxiety and depression

How well did you know this?

Not at all

Perfectly

What might be used to treat tension type headaches?

Detox from caffeine, NSAIDs
Reassure the patient that there is not serious pathology
TCAs such as amitriptyline may be used

MRI not indicated but maybe done for reassurance

How well did you know this?

Not at all

Perfectly

What is the most common type of headache?

Tension type

How well did you know this?

Not at all

Perfectly

What are the features of a migraine headache?

Episodic headaches that typically last for several hours
Patients will want to go and lie down in a dark quiet room
Unilateral (but may move to a different side of the head)
Preceding aura
Pain felt behind the eye
Associated nausea, vomiting, photophobia and phonophobia
Sleep helps to relieve the headache

How well did you know this?

Not at all

Perfectly

What are the features of a migraine headache?

Unilateral (but may shift sides)
Pain felt behind the eye
Associated nausea, vomiting, photophobia and phonophobia
Typically lasts several hours to a couple of days

How well did you know this?

Not at all

Perfectly

What do patients often say they want to do when they have a migraine headache?

Lie down and go to sleep
(This would make headache much worse if due to raised ICP)

Migraine headaches are associated with photophobia, photophobia and nausea and vomiting. Pain is unilateral and often felt behind the eye.

How well did you know this?

Not at all

Perfectly

Who is migraine more common in?

Young people

Women

How well did you know this?

Not at all

Perfectly

What is the management for migraine?

Avoid trigger if known but there often isn’t one
Treat acute attacks with aspirin (high dose 900mg) and paracetamol
Antiemetics (some agents combined simple analgesia with antiemetic)
Triptans (5-HT agonists) commonly used- SC, Nasal Spray or PO.

How well did you know this?

Not at all

Perfectly

What preventative options are there for the management of migraine?

Propranolol
Amitriptyline
Topiramate 
Pizotifen- 5HT 2 Agonist
SSRI/SNRI

How well did you know this?

Not at all

Perfectly

What causes a medication overuse headache?

Taking analgesia (especially containing codeine) almost on a daily basis. May have been done to manage migraine or tension headaches.

Headache is transiently relieved by analgesic.

How well did you know this?

Not at all

Perfectly

How should medication overuse headaches be managed?

Try to reduce use of medication

Headache prevention- Amitriptyline

How well did you know this?

Not at all

Perfectly

What is a cluster headache?

This is the most common type of trigeminal autonomic cephalalgia

How well did you know this?

Not at all

Perfectly

Describe the features of a cluster headache

Headaches come in clusters- e.g. 1-2 per day for 4-8 weeks happening once or twice a year
Strictly side locked
Severe headache that lasts from 30 minutes to an hour to 2 hours
Often at night- tend to occur at the same time during the cluster
Associated autonomic activation- watering of the eye, redness of the eye, nasal blockage, Horner’s

How well did you know this?

Not at all

Perfectly

What is interesting about the timings of cluster headaches?

They tend to occur at the same time during clusters
Typically at nightime

Clusters are headaches happen for around 4-8 weeks with one to two a day and this happens 1-2 times per year

How well did you know this?

Not at all

Perfectly

Describe the pain felt in cluster headaches?

Strictly side locked
Severe pain
Behind the eye

How well did you know this?

Not at all

Perfectly

What autonomic features might be seen in cluster headaches?

Watering of the eye
Redness of the eye
Constriction of the pupil
Nasal discharge/blockage

How well did you know this?

Not at all

Perfectly

What is the management for cluster headaches?

Rescue treatment- Fact acting triptan e.g. sumatriptan, zolmitriptan and high flow oxygen
Break the cluster- Oral Prednisolone, topiramate, verapamil, pizotifen

How well did you know this?

Not at all

Perfectly

What should verapamil never be combined with?

Beta blockers

How well did you know this?

Not at all

Perfectly

How do triptans work?

5HT1 agonist- used for headache relief if severe

How well did you know this?

Not at all

Perfectly

Describe the headaches felt in trigeminal neuralgia?

Hypersensitivity in the trigeminal distribution with electric shock sensations on touching the face
Shaving, washing and brushing teeth very painful

How well did you know this?

Not at all

Perfectly

What branch of the trigeminal nerve is most often affected in trigeminal neuralgia?

Maxillary or mandibular

How well did you know this?

Not at all

Perfectly

What is the treatment for trigeminal neuralgia?

Carbamazepine is 1st line
Phenytoin, lamotrigine and gabapentin are also used.
Surgical treatments- glycerol injections and microvascular decompression

What two things may be a cause of trigeminal neuralgia?

Irritation by a blood vessel

Multiple sclerosis in younger patients

What is a post-traumatic headache?

Headache experienced following head injury

How soon after a head injury does a post traumatic headache happen?

Around 2 weeks

What symptoms are experienced in concussion?

Confusion Poor memory Lack of concentration Dizziness

What is used as a treatment for post traumatic headache?

Amitriptyline

What are the presenting features of giant cell arteritis?

Scalp tenderness Pain on brushing hair Jaw claudication Loss of vision due to anterior ischaemic optic neuropathy Large, boggy, tender, non-pulsatile temporal artery

What is the investigation for GCA?

Temporal artery biopsy Also ESR is typically raised Treat with high dose prednisolone before biopsy to reduce risk of loss of vision

What kind of patient typically has idiopathic intracranial hypertension?

Obese young women

What features are seen with headaches due to raised ICP?

``` Worse with coughing, straining Papilloedema Reduced peripheral vision Nausea and vomiting Morning headache or waking from sleep due to headache ``` Other red flags include: Focal neurological signs Visual disturbance Papilloedema

What should be done for all patients with papilloedema?

Brain MRI to rule out intracranial mass CSF pressure measuring MRV or CTV- Exclude central venous sinus thrombosis

What is the management for idiopathic intracranial hypertension?

Weight loss Monitoring of visual fields Diuretics such as acetazolamide Deteriorating vision is an indication for surgery to reduce intracranial pressure

What do NICE recommend is the acute management for migraine?

Acute- Oral triptan NSAID/ Paracetamol (Nasal in young if issues with oral) + Antiemetic metoclopramide, prochlorperazine

What do NICE recommend for prophylaxis of migraines?

1st- Topiramate (anti-epileptic) or Propranolol 2nd Acupuncture or Gabapentin (anti-epileptic) Advise that riboflavin may help

What should be used for prophylaxis of migraines in women of childbearing age?

Propranolol as topiramate may be teratogenic and reduces the effectiveness of the OCP

When should prophylaxis be offered for migraines?

2 or more attacks per month

What might be done for women with menstruation related headache?

Triptains as a preventative treatment

What is a helpful mnemonic for remembering some red flags for headaches?

SNOOP ``` Systemic features Neurological Signs Onset sudden Other associated features Pattern- is it getting worse, staying constant, changes with posture and coughing? ```

What should you immediately think about if someone describes the worst headache of their life that has come on very suddenly?

Subarachnoid haemorrhage

What symptoms might a carotid or vertebral artery dissection cause?

Sudden onset headache after trauma Radiates down one side of the neck Horner syndrome Pulsatile tinnitus May lead to stroke

What symptoms should raise concern of meningitis?

``` Acute headache Photophobia Neck Stiffness Fever Altered mental status ```

what symptoms could a cerebral abscess cause?

Headache Focal neurological signs Signs of raised ICP- papilledema, nausea, vomiting, worse on lying down and coughing

What are the features of acute angle closure glaucoma?

Acute onset very painful red eye Unilateral headache More commonly occurs at night and in long sighted/hypermetropia

What features might indicate a brain tumour?

``` Focal neurological signs Seizures Papilledema Heachache with N+V, worse at night when lying down and with coughing/straining Headache worsened since initial onset ```

What is the most common type of pituitary tumour?

Prolactinoma- therefore develop bitemporal hemianopia as about galactorrhoea or gynaecomastia, decreased libido, erectile dysfunction

What procedure can be done if the vision is becoming threatened in idiopathic intracranial hypertension?

Optic nerve sheath fenestrations

What features might you see with sinusitis if suspecting this could be a cause of headache?

Headache Tenderness over the affected sinuses Worse on leaning forward

How can you divide the causes of headache?

Primary- Tension type, Migraine, Cluster Secondary- Tumour, GCA, Carotid dissection, IIHT, Sinusitis, AACG

What might be described in a migraine aura?

``` Seeing bright lights Seeing zig zag lines Hallucinations Tinnitus Aphasia Confusion ``` Less commonly temporary paralysis of 1 side of the body- hemiplegic migraine

When are triptans contraindicated?

Coronary artery disease Cerebrovascular disease Pregnancy Triptans are used for the acute management of migraine

What drug is contraindicated in women with migraine with aura?

Oestrogen Contraceptive Pill -Increased risk of stroke in this population

What is the management of an acute cluster headache?

High flow oxygen Triptans High dose NSAIDs

What is used in the prophylaxis of cluster headaches?

Verapamil first Steroids Topiramate

What is the first line treatment for trigeminal neuralgia?

Carbamazepine, Others- Phenytoin, Gabapentin, Baclofen Surgical treatments to manage the irritant vessel or glycerol injections too.