HEADACHES AND CRANIOFACIAL PAIN Flashcards
What is a primary headache?
One where the headache and its features are the disease itself.
What is a secondary headache?
Headache is a result of another pathological process.
What are some examples of primary headaches syndrome?
Migraines
Tension-type headaches
Cluster headaches
What are some examples of secondary headache causes?
Systemic infection Head injury Subarachnoid haemorrhage Vascular disorders Brain tumours
What are the features of a tension-type headache?
Bandlike dull headache Scalp tenderness Aggravated by noise and light Lasts hours to days No abnormal physical signs
What are the management options for someone experiencing tension-type headaches?
Physical treatment such as massage and relaxation therapy.
Simple analgesics: paracetamol, aspirin, other NSAID
When chronic (lasting more than 15 days per month): Amitriptyline
What are the paradoxical causes of a tension-type headache?
Chronic use of analgesics such as paracetamol and opiate based painkillers.
What is a migraine?
A common, often familial, condition characterised by an episodic unilateral throbbing headache.
How long does a migraine typically last?
4 to 72 hours
What are the clinical features of a migraine?
Unilateral subacute throbbing Exacerbated by movement Vomiting/nausea Vertigo Photophobia Phonophobia Osmophobia (sensitivity to odours) Preceded by aura
What are some of the known triggers for a migraine?
Bright light Strong smells Loud sounds Sleep deprivation Sleep excess Exercise Tiredness Hunger Dehydration Menstruation
What is the current theory on the underlying pathology of a migraine headache?
Neurovascular basis related to the release of vasoactive sustances by trigeminovascular system.
What happens to the levels of 5HT before and during a migraine attack?
The levels of 5HT increase with the prodromal symptoms and then fall during the headache.
What are the two most common subdivisions of migraine?
Classic - migraine with aura
Common - migraine without aura
What are the commonly reported features of a migraine aura?
Moving lights
Fortification spectra - flickering image
Paraesthesia
Numbness in limb and face
How long before the headache does the aura start?
40 minutes and lasts about 20 minutes
What are the features of a basilar migraine?
Brainstem aura causes symptoms that arise from dysfunction in the territory of the posterior cerebral circulation.
Aura consist of bilateral visual symptoms, ataxia, dysarthria, vertigo, limb parasthesia and weakness.
There may be loss of consciousness before, during or after the headache.
What are the features of a hemiplegic migraine?
Lateralised weakness throughout the aura and headache that can persist.
Autosomal dominant transmission in some cases.
Presentation similar to stroke or TIA and must be assumed to be such until proven otherwise.
What are the drugs that are recommended for management of a migraine?
Mild: Paracetamol, NSAIDs
Moderate/severe: Triptans eg sumitriptan, almotriptan
What drugs are not recommended for use by migraine patients?
Too much codeine may actually induce chronic analgesic headache.
What are the drugs that are prescribed for management of more severe or refractory migraine attacks?
5 HT agonists such as: Sumatriptan Naratriptan Zolmitriptan Rizatriptan Eletriptan
What drugs can be used in the prophylaxis of migraine attacks?
Propanolol (beta-blocker) Amitriptyline (tricyclic) Pizotifen (5HT antagonist) Sodium valproate Verapamil (calcium antagonist) Methysergide (5HT antagonist) - rarely used because it can cause retroperitoneal fibrosis
What are the features of a cluster headache?
Severe unilateral pain
Localised around the eye
Ipsilateral autonomic features such as bloodshot eyes (conjunctival injection)
Lacrimation
Rhinorrhoea
Transient Horner’s syndrome
Lasting between 15 minutes and 3 hours
Typically occur 1 to 8 times daily in clusters lasting 8 to 10 weeks
Patient often feels like pacing around rather than lying in bed
How long are the intervals between cluster headaches?
Can be several years
Why do patients who suffer from cluster headaches need neuroimaging?
Because they are sometimes associated with underlying pituitary pathology.
What are the management options for a patient suffering cluster headaches?
100% oxygen at 10-15L/min for 15-20 minutes
Sumatriptan injections
Sumatriptan/zolmitriptan nasal spray
What are the prophylactic options for someone who has suffered from cluster headaches?
Verapamil
Lithium
Limited courses of corticosteroids
Methysergide can be used for resistant cases
What is the really important side effect of methysergide?
It can cause retroperitoneal fibrosis
What are the features of headache of raised intracranial pressure?
Generalised ache
Aggravated by bending, coughing or straining
Worse in the morning or after prolonged recumbency
May awaken patients
Severity gradually progresses (not sudden)
Vomiting
Visual obscurations
Papilloedema (enlarged blind spots)
Risk of herniation
What do you do with a patient with features of raised intracranial pressure?
Urgent imaging of the brain with CT or MRI
What are the features of a low pressure headache?
Typically following lumbar puncture or spinal surgery
No pain whilst recumbent
Headache when they sit or stand up
What are the management options for someone suffering from low pressure headaches?
Bed rest
Intravenous caffeine
Autologous blood patches around the lumbar puncture site
