Headaches Flashcards
What are the two types of headaches, which is more likely to be dangerous? Give examples of both
- primary headache disorder e.g. tension headache, migraine, cluster headache (one side, often around eyes, with nasal congestion/ watery eyes)
Non- life or sight threatening
Many chronic
Secondary due to another condition
E.g. extradural haemorrhage, space occupying brain lesion, stroke, intracranial haemorrhage (subarachnoid haemorrhage), intracranial infections (abscess, meningitis), hydrocephalus💀,
medication related (overuse painkillers for headaches, CCB), acute sinusitis, hypertension, pre-eclampsia,
temporal (giant cell arteritis 👁 ), acute glaucoma 👁
Some are life or sight threatening
Many acute
Red flags for headaches
SNOOp
Systemic signs and disorders (meningitis - fever, neck stiffness. HIV, cancer, pregnant)
Neurological symptoms (SOL, ICH, glaucoma)
Onset new or changed and patient >50yrs (malignancy, GCA)
Onset in thunderclap presentation (vascular haemorrhage)
Papilledema, pulsatile tinnitus, positional provocation, precipitated by exercise (raised ICP)
Clinical examination of headaches
Vital signs - BP, PR, temp
Neurological examination (cranial and peripheral nerves)
Guided by history
What are the 4 most common types of headache in order
Commonest: tension type headaches
Migraine
Medication over use
Cluster headache
Tension headaches
Risk factors
Pathophysiology
History
Female
Young (teens/ young adults 20-39)
Tension in muscles of head and neck
Front/ back/ band/ tight
Generalised predilection for frontal and occipital
Mild - moderate
Worse at end of day
Recurrent (30m-1hr)
Stress/ poor posture/ lack of sleep - triggers
Responds simple analgesia
Migraine
Risk factors
Pathophysiology
History
Females
15% population
Presents early to mid life (most by 30)
Unclear - vasodilation of meningeal Bvs
Unilateral, temporal/ frontal
Throbbing, pulsating
Moderate- severe
4-72 hrs
Triggers: certain food, menstrual cycle, stress, lack sleep, FH
Can respond simple analgesics (May need triptans)
Nausea, vomiting, dislike light/ sound - photophobia/ funnel-phobia, neurological features (aura- sensory, hallucinations- can have without headache), sweating
Clinical exam: neurological deficit
Medication over-use headache
Risk factors
Treatment
Painkillers for headaches over used (primary-> secondary)
Females
Often at least 15days/ month (constant)
Pre-existing headache disorder
Using regular analgesics (10+days/ month) worst cocodamol
Co- exists with depression and sleep disturbance
✅discontinue mediation (worse first, resolves by 2months)
- shouldn’t take more than 2 days a week normally
Cluster headache
Risk factors
History
Treatment
Males
1/1000 rare
Usually begins 30-40yrs
One of worst pains - intents
Autonomic features (nasal congestion, watery eyes, ptosis)
Pain around/ behind eye
Unilateral
Sharp/ stabbing
15m-3 hrs (occurs in clusters, periods of remission 3m-3yrs)
Triggers: alcohol, lack sleep, smoking, volatile smells, hot
✅high flow O2 and triptans used
Clinical exam: may autonomic features if during attack
Most common 4 secondary headaches
Meds over- use
Raised ICP
Trigeminal neuralgia
Temporal (giant cell) arteritis
Space- occupying lesion SOL
History
Clinical exam
Treatment
Headache rarely occurs in absence of other suspicious findings
- gradual progressive
Dull, character varies
Mild,
worse in mornings
Worsened with posture (leaning forwards, cough, valsalva manoeuvre)
Nausea, vomiting, focal neuralgia, visual (behavioural/ personality changes, seizures)
✅simple analgesics initially -> imaging
Clinical exam: focal (unilateral) neurological signs, papilloedema
Trigeminal neuralgia
Risk factors
Pathophysiology
History
Females
Rare
50-60yrs
Most compression CN5 due to loop of BV
5% due tumours/ skull base abnormalities or AV malformations
Unilateral
Pain felt 1+ CN 5 Divisions
Sharp, stabbing, electric shock, burning
Severe lasts few secs- 2 mins
Sudden onset
Triggers: light touch face/ scalp, easing, cold wind, combing hair
Preceding symptoms: tingling, numbness, pain radiate areas within CN5 divisions
✅difficult
Temporal arteritis
History
Risk factors
Females
Vasculitis involving small/ medium arteries head
>50yrs
Abrupt onset headache + visual disturbance or jaw claudication
Risk of irreversible loss of vision due to ischaemia of CN1
Temporal artery often involved
Symptoms of giant cell arteritis
Involvement of cranial vessels: headache, jaw claudication, scalp tenderness, loss vision, abnormal, abnormalities of temporal artery (pain, modules, absent pulse)
Involvement of great vessels (aorta and branches of aorta): claudication of extremities (esp arm)
Systemic inflammation: fever, night sweats, weight loss
Polymyalgia rheumatica: mainly proximal myalgia, stiffness in neck/ shoulder/ pelvic girdles
