Headaches Flashcards
What parts of the symptoms graph are important to include in the history?
- onset
- peak
- relieving factors
- exacerbating factors
- associated features
What are the headache red flags?
- new onset headache in >55 years old
- known/previous malignancy
- immunosuppressed
- early morning headache
- exacerbation by valsalva - coughing, sneezing
How often do migraines usually occur?
One attack a month
What is the criteria for headache diagnosis without an aura?
At least 5 attacks lasting 4-72 hours
2 of moderate severity, unilateral throbbing, worse on movement
1 with associated autonomic features - phonophobia/photophobia
Describe the pathophysiology of a migraine
Vascular and neural influences as a result of stress triggers leads to serotonin release - blood vessels constrict and dilate - chemicals including substance P irritate nerves and blood vessels causing pain
What is the migraine generating centre?
Dorsal raphe nucleus and locus coeruleus
What causes a migraine with an aura?
Triggers will cause activation of the trigeminal vascular system causing dilatation of cranial blood vessels, cortical spreading of depolarisation and ultimately release of substance P, neurokinin A and CGRP
How long do visual auras last?
20-60 minutes with a headache less than an hour after - can be simultaneous
What is the most common visual symptom?
Monochromatic
Name the triggers of migraines
- sleep deprivation
- dietary
- stress
- hormonal
- physical exertion
What is the acute treatment for a migraine?
Analgesia - aspirin, naproxen, ibuprofen
+/- antiemetic if gastroporesis
Triptans
What are triptans?
5HT agonists that should be taken at the start of a headache
Name two triptans used?
Rizatriptan
Frovatriptan - for sustained relief
When should prophylaxis be given in migraines?
More than 3 attacks a month or very severe attacks - trial for 10-12 weeks aim to titrate drug as tolerated to achieve efficacy at lower dose
Name three drugs that can be used as prophylaxis for migraines
- Amitriptyline
- Propranolol
- Topiramate
State the five types of ‘fancy’ migraine
Acephalgic - aura without a headache Basilar - vertigo Retinal/ophthalmic Hemiplegic - encephalopathic, weakness Abdominal - usually in kids +/- headache
Describe a tension type headache
Episodice, chronic pressing tingling, tends to be mild to moderate bilateral with no associated features
How is a tension headache treated?
Identify cause/triggers and relaxation physiotherapy
Amytriptyline/dothiepin can be used for three months
What is a trigeminal autonomic Cephalgia? Name the three types
Primary headache complexes affecting the trigeminal nerve
- cluster headache
- paroxysmal hemicrania/continua
- SUNCT
What are the signs of trigeminal autonomic cephalgia?
Ptosis, miosis, nasal stuffiness, nausea/vomiting, tearing, eye lid oedema
What is a cluster headache?
Often in young men, circadian rhythm with seasonal variation - severe unilateral headache lasting 20mins -3hours and 1-8 per day. Clusters can last weeks to months
How are cluster headaches treated?
High flow oxygen at home
Sub-cutaneous sumatriptan (reduces severity)
Steroids for 2 weeks
Verampamil prophylaxis
Describe paroxysmal hemicrania/continua
More common in elderly females - severe unilateral headache with unilateral autonomic features - lasts 2 mins to 45 hours and can have up to 40 attacks a day
What does paroxysmal hemicrania respond to?
Inclomethicin
What does SUNCT stand for?
Short lived Unilateral Neuralgiaform headache Conjunctival injections Tearing
How can SUNCT be treated?
Lamotrigine or gabapentin
What investigation is given in all trigeminal cephalgias?
MRI including angiogram to check for aneurysm
How does idiopathic intracranial hypertension present?
Bilateral papilloedema, diurnal variable headache with nausea and vomiting in the morning. Visual loss when standing up often in overweight females.
What will an MRI of idiopathic intracranial hypertension show?
Empty sella and flattened optic disc
What will CSF in idiopathic intracranial hypertension show?
Elevated pressure but normal constituents
How is idiopathic intracranial hypertension treated?
Weight loss, acetazolamide
If persistent visual loss ventricular atrial/lumbar peritoneal shunt may be done
Describe trigeminal neuralgia
Elderly women, severe sharp stabbing many times a day often aggregated by touch. 10-100 a day lasting 1-90 seconds can last weeks/months before remission
What is the most common cause of trigeminal neuraliga?
Aberrant blood vessel irritating the nerve
How is trigeminal neuralgia treated?
Anticonvulsant - carbamazepine, gabapentin, phenytoin, baclofen
Ablation or compression if very severe
