Headaches Flashcards
define migraines
a common primary headache disorder that is characterised by attacks of moderate/severe headaches with associated photophobia, phonophobia, nausea + vomiting
classifications of migraines
episodic or chronic, depending on attack frequency
causes of migraines
exacts are unknown but precipitated by disturbed sleep, irregular meal patterns, excessive caffeine intake
risk factors of migraines
high frequency of episodic migraines
obesity
excessive caffeine intake
overuse of acute migraine medication
clinical features of migraine without aura
headache lasting 4-72hrs with at least 2 of
- unilateral location
- pulsating quality
- moderate/severe pain
- aggravated by/avoidance of routine daily activities
associated symptoms of migraine (without aura)
nausea and/or vomiting
phonophobia
photophobia
clinical features of migraine with aura
typical migraine presentation WITH typical fully reversible aura 60mins prior to headache that can involve:
- zigzag lines/scotoma
- unilateral pins + needles or numbness
- dysarthria
symptoms of atypical auras
motor weakness double vision unilateral visual symptoms poor balance decreased consciousness
differentials of migraines
tension-type headache
trigeminal autonomic cephalgias
sinusitis
investigations for migraines
assess BP, HR, RR, temperature and O2 sats
assess extracranial structures (e.g. TMJ, sinuses and temporal arteries)
carry out fundoscopy
conservative management of migraines
recommend keeping diary to track triggers and monitor treatment effectiveness
treat any co-morbidities
restrict acute medication use to max 2 days per week
ensure women not using combined contraception
acupuncture
acute medical management of migraines
oral or intranasal sumatriptan with analgesia (e.g. paracetamol or NSAID)
when are anti-emetics used in migraines?
used if patient experiences vomiting during attacks OR if >2 triptans used and failed
when is prophylaxis treatment considered in migraine patients?
if attacks significantly impact QoL and daily function
acute treatments contraindicated or failed
patient at risk of MOH
what medications are utilised in prophylactic treatment of migraines?
propanolol
topiramate
amitriptyline
what are contraindications of prophylactic treatment in migraines
propanolol not used if patient has asthma
topiramate not used in pregnant women
common complications of migraines
reduced QoL
medical overuse headaches (MOH)
status migrainosus
increased risk of ischaemic stroke and mood disorders
medications used in women with menstrual-related migraines that does not respond to usual treatment
frovatripan
zolmitriptan
define hemiplegic migraine
sudden onset migraines that present with typical migraine symptoms plus hemiplegia, ataxia and changes in consciousness
- mimic stroke so require fast action to exclude stroke
define tension-type headaches (TTH)
a common primary headache disorder that causes generalised headaches
- described as pressure/tight band around head that spreads/arises from neck
classification of TTH
episodic and chronic
- episodic infrequent - <1 per month
- episodic frequent - <10 for 1-14 days over month for >3mnths
- chronic - >15 days affected per month for 3 mnths
risk factors of TTH
female sex middle age stress and anxiety dehydration brightly lit/noisy environments large amount of screen time
clinical features of TTH
bilateral and generalised pain described as tight/pressure band around head and neck
no aggravation of pain
no nausea
EITHER photophobia or phonophobia
pericranial tenderness on manual palpation
requirements for further investigation in TTH
headache develop progressive nature
develop/have associated symptoms (e.g. nausea + vomiting, neck stiffness or neurological changes)
differentials of TTH
migraine MOH temporal arteritis trigeminal autonomic cephalgias idiopathic cranial hypertension
management of episodic TTH
offer simple analgesia and advise to take dose ASAP after
identify co-morbidities that may be associated and manage those
management of chronic TTH
offer course of <10 acupuncture sessions for 5-8 weeks
provide low-dose amitriptyline as prophylaxis
common complications of TTH
overuse of NSAIDs can lead to peptic ulcer disease
overuse of analgesics may cause MOH
definition of cluster headaches
a rare and severe primary headache disorder characterised by unilateral periorbital pain attacks with ipsilateral autonomic symptoms for <3hrs
characteristics of cluster headaches
attacks occur in series followed by remission periods and are either
- episodic - attacks occur in periods of 7 days-year followed but 1 month remission
- chronic - attacks occur over 1 year with no remission or remission <1mnth
risk factors of cluster headaches
male sex age 20-50 smoking alcohol use familial history of CH
suggested causes of cluster headaches
aetiology is unknown but linked to
HCRTR2 gene inheritance
low melatonin levels
hypothalamic dysfunction and vascular changes
clinical features of cluster headaches
unilateral peri-orbital pain
- lasts 15-180 mins
- sharp and pulsating in nature
ipsilateral autonomic symptoms
- nasal congestion, eyelid oedema, ptosis/miosis an and conjunctival lacrimation
restlessness/agitation
differentials of cluster headaches
migraine idiopathic intracranial hypertension head/neck trauma neoplasms raised ICP
investigations of cluster headaches
based on history and neurological examination
requirements of cluster headache diagnosis
> 5 attacks of characteristic symptoms WITH headaches
occurrence of attacks every other day or 8 per day
requirements for further investigations in cluster headaches
change in headache pattern new headache in >50s onset of seizures associated symptoms of raised ICP acute onset of 'worst headache ever'
conservative management of cluster headaches
advise avoiding triggers
advise risk of MOH
identify and manage co-morbidities
provide oral and written info on CH and support groups
medical management of cluster headaches
offer subcutaneous or nasal triptans (e.g. sumatriptan)
offer short-burst O2 therapy
describe short-burst O2 therapy
patients provided with 100% oxygen at flow rate of 12-15L per min via a non-rebreather face mask for 15-20 mins
prophylactic medical management of cluster headaches
offer patients verapamil, sodium valproate or prednisolone
common complications of cluster headaches
reduced QoL
mood disorders
serious underlying 2ndary cause
define trigeminal neuralgia
a chronic pain condition characterised by severe shooting or stabbing pain in the distribution of one or more division of CN V
risk factors of trigeminal neuralgia
MS advanced age (>50yrs) female sex FH of trigeminal neuralgia PMH of hypertension and stroke
triggers of trigeminal neuralgia
light touch
eating
wind blowing on persons face
clinical features of trigeminal neuralgia
sudden unilateral recurrent ‘stabbing’ pain in branches of CN V
autonomic symptoms
red flag signs in trigeminal neuralgia
onset < 40yrs pain only in CNV1 FH of MS deafness/ear problems sensory changes
medical management of trigeminal neuralgia
offer carbamazepine (1st) or phenytoin or gabapentin
surgical management of trigeminal neuralgia
microvascular decompression
