Headaches Flashcards
What are the 4 different onsets of headaches?
Acute, recurrent acute, subacute, chronic
What are some differentials of acute onset headaches?
meningitis, subarachnoid haemorrhage, encephalitis, acute glaucoma, sinusitis, head injury, gtn spray
What are some differentials of recurrent acute?
Migraine, cluster headache, coital headache, tension headache, medication-induced headache
What is a type of subacute headache?
Giant cell ateritis
What are some differentials of chronic headaches?
raised ICP due to hydrocephalus, space occupying lesion or benign raised intracranial pressure
What are the common triggers of Migraines
Chocolate Hormones Oral contraceptive Caffeine Obesity Lights Alcohol Travel Exercise Others - cheese, pregnancy, common around puberty, menstruation, menopause
What are the aura features of a migraine with aura?
Aura fully reversible
Visual, sensory, motor or language symptom (aura)
Aura duration 20-60mins
Headache follows <1hour
What are the general symptoms of a migraine?
throbbing sensation photophobia unilateral pain begins locally then spreads vomiting sensitivity to pain and stimuli no neurological signs
What are the symptoms of a basilar migraine?
tongue tingling, vertigo, diplopia, visual disturbance, dysarthria, ataxia
What is the feature of a facioplegic migraine?
Unilateral face weakness
What are the other less common types of migraines?
Acephalgic, retinal, opthalmic, hemiplegic, abdominal
What is the diagnostic criteria of a migraine with aura?
headaches lasting 4/72 hours with aura
What are the diagnostic criteria of a migraine without aura?
at least 5 attacks
duration 4-72 hours
2 of: moderate/severe, unilateral, throbbing pain, worse movement
1 of: autonomic features, photophobia/phonophobia
What investigations could you consider in those presenting with migraine symptoms?
ESR
LP
CSF culture
CT head
What is the non-pharmacological management of migraines?
set realistic goals education headache diary relaxation/stress management diet, hydration, regular exercise
What is the acute pharmacological of migraines?
offer combination therapy with a oral triptan (sumatriptain) and an NSAID (aspirin), or an oral triptan AND paracetamol
What is the prophylactic management of migraines?
1st line - topiramate or propranolol
Others - amitriptyline
What is the underlying pathophysiology of tension headaches?
increased tension in scalp muscles and neurovascular irritation, raised cortisol levels?
triggers of tension heads
stress, noise, concentrated visual effort, funes
clinical symptoms of tension headaches
bilateral, tight band sensation, radiate to neck, pressure behind the eyes, throbbing sensation, not sensitive to head movement, no nausea, absense of photo/phonophobia
management of tension headaches
reassurance, avoiding triggers, stress relief, massage, analgesia
What are the ipsilateral cranial autonomic features?
Ptosis miosis nasal stuffiness nausea/vomiting tearing chemosis
What are the 4 TAC headaches?
cluster
paroxysmal hemicrania
hemicrania continua
SUNCT
What investigations should be done on those with TACSs?
MRI and MR angiogram
pathophysiology of TACs
increased CGRP
increased VIP
simultaneous activation of trigeminal nerve and parasympathetic components of facial nerve
hypothalamus and endogenous clock
Cluster headaches affect which group?
young (20-55)
Men>Women
duration of cluster headaches
20mins - 3 hours
frequency of cluster headaches
1 to 8
acute management of cluster headaches
sumatriptan
high flow oxygen
prophylactic management of cluster headaches
verapamil
steroids?
paroxysmal hemicrania affects which group?
elderly
women
duration of paraoxysmal hemicrania headaches?
2-45 minutes
frequency of paraoxysmal hemicrania headaches?
1 to 40 a day
management of paraoxysmal hemicrania?
Indomethicin
Differences between paraoxysmal hemicrania and cluster headaches?
shorter duration, more frequent, affects elderly women (not younger men)
what does SUNCT stand for?
short lived (15-120 secs, frequency 3-200 per day)
unilateral (temporal, retro-orbital, supraorbital)
neuralgiaform headache (sawtooth)
conjunctival injections
tearing
management of SUNCT
lamotrigine, gabapentin
trigeminal neuralgia effects which group?
elderly (>60)
women>men
which divisions of the trigeminal nerve most commonly affected?
maxillary and mandibular
underlying pathophysiology of trigeminal neuralgia
microanatomical small and large fibre damage in the nerve, essentially at its root entry zone, leads to ephaptic transmission, in which action potentials jump form one fibre to another
lack of inhibitory inputs
re-entry mechansim
What are the risk factors of trigeminal neuralgia
increased age
MS
female
hypertension
causes of trigeminal neuralgia
focal compression by aberrant vascular loop (superior cerebellar artery) demyelinating disease (demyelinating plaque)
What are common triggers of trigeminal neuralgia?
touch, cold wind, shaving, brushing teeth, talking, eating and drinking
clinical features of trigeminal neuralgia
severe unilateral pain (electric shock like)
duration: 1 to 90 secs (sometimes longer)
Frequency: 10 to 100 a day
Bouts can lasts months before remission
no weakness
What are the different classifications of trigeminal neuralgia?
IDIOPATHIC TRIGEMINAL NEURALGIA TYPE I (TNI) ‘CLASSIC TRIGEMINAL NEURALGIA’ (CTN)
IDIOPATHIC TRIGEMINAL NEURALGIA TYPE II (TNII) ‘ATYPICAL TN’
TRIGEMINAL NEUROPATHIC PAIN
TRIGEMINAL DEAFFERENTATION PAIN ‘ANAESTHESIA DOLOROSA
SYMPTOMATIC TN
POST-HERPETIC TN
ATYPICAL FACE PAIN
management of trigmenial neuralgia
Pain - carbamazepine (then gabapentin + amitriptyline)
Microvascular decompression, ablation
Definition of medication overuse headaches
headache lasting 15 days, which started or got worse while patient was on regular medication use and improves within 2 months of discontinuing overused medications
Features of primary cough headaches
occurs on coughing
sharp bilateral pain lasting short duration
most have underlying cause (chiari, anuerysm)
features of primary exertion headache
occurs with exercise
pulsating headache, bilateral
features of primary sexual headache
early coital cephalgia - dull, aching pain in occipital region that increases in severity as sexual excitement increases
Late coital cephalgia - severe and maximal during an organism
features of carotid dissection
can be spontaneous or due to extreme hyper extension of neck, presents in head/neck with pain, symptoms of ischaemia distal to dissection with horners syndrom
features of giant cell arteritis
scalp tenderness, jaw claudication
