Headaches and migraines Flashcards
What are the different types of headaches?
Tension-type
Cluster headache
Migraine
Miscellaneous
Describe a tension headache.
This it the most common type and is thought to be due to muscle spasms in the neck/scalp.
- Can be caused by emotional stress- tension, anxiety, tiredness
Pain:
- mild to moderate
- Non-throbbing, vice-like- tightening or squeezing
- Usually both sides of head
- may worsen throughout the day or by stress
Describe a cluster headache.
These are rare- but 6-9x more common in men.
Pain:
- Excruciating pain, severe unilateral pain
- Often around nose, eyes- can also cause lacrimation, red eye, nasal congestion, runny nose, facial sweating, miosis, droopy eyelids- may be mistaken for an eye injury
- Duration: sudden onset- may wake up from sleep.
- Also intermittent onset- can occur up to 8x a day
- lasts between 10mins to 3 hours
- need to rule out meningitis, bleeds, and cranial arterisis
Differential diagnosis for meningitis: fever, dislike of bright light, N+V, rash, neck stiffness
Differential diagnosis for CA/bleed: head trauma, loss of consciousness, jaw pain on side of face
What differential diagnoses must be rule out in a suspected cluster headache?
- need to rule out meningitis, bleeds, and cranial arterisis
Differential diagnosis for meningitis: fever, dislike of bright light, N+V, non-blanching rash (glass test), neck stiffness. Ask if patient can put their chin onto their chest.
Differential diagnosis for CA/bleed: head trauma, loss of consciousness, jaw pain on side of face
Discuss the use of the pain ladder in headaches.
Pain score 1 - mild pain:
- Paracetamol 1g (4-6 hourly) (max 8 tabs per day)
Pain score 2- mod pain:
- Paracetamol 1g (4-6 hourly) (max 8 tabs per day)- this stays throughout the ladder
+ codeine (weak opioid)- 30-60mg 4-6 hourly (As POM, OTC dose doesn’t reach evidence based dose)
+ Plus Ibuprofen 400mg 6-8 hourly (Or other NSAID- where not Cid)
Pain score 3: severe pain:
- Paracetamol 1g (4-6 hourly) (max 8 tabs per day)
+ Appropriate opioid e.g. morphine, fentanyl, oxycodone- slow titration
+ Plus Ibuprofen 400mg 6-8 hourly (Or other NSAID- where not Cid)
For breakthrough pain: 1/6th of the main opioid daily dose e.g. if have 40mg per day, may give 6-7mg as a breakthrough PRN dose as an oramorph liquid
How do you give breakthrough pain relief?
For breakthrough pain: 1/6th of the main opioid daily dose e.g. if have 40mg per day, may give 6-7mg as a breakthrough PRN dose as an oramorph liquid
Describe a migraine?
- Episodic
- Symptoms- prodrome (sensations before), aura, headache, postdrome
Headache: - Unilateral- usually once side
- Pulsatile, throbbing pain
- Associated with N+V, photophobia
What gender is more likely to have migraines?
migraines are 3x more likely in women
What age group is common for migraines?
Onset peaks at 5-6 years old, but a lot go into remission after childhood.
Then there is another peak around 25
This gradually drops off- very rare to experience first migraine at age of 50-55+
What are the different types of migraines?
CLASSICAL:
- Migraine with aura- preceded by focal neurological disturbance (nerves in part of brain not firing properly) e.g if in visual centre- see zigzags, blurry spots
Only about 15% HAVE AN AURA
COMMON:
- Migraine without aura
ABDOMINAL MIGRAINE:
- Childhood migraine in about 3-10% of school children.
Often associated with gi symptoms e.g. nausea, cramps, loss of appetite.
May withdraw from play, not like noises
What is the pathophysiology being migraines and the different theories?
There are more theories than an exact known MOA.
- There is a genetic link- chromosomal defects from 10 possible polymorphisms that impair calcium channels- involve serotonin release
- Is a trigger threshold
- Vasoconstriction and vasodilation by Wolf:
Vascular constriction across the head/brain = Aura
Dilation = headache
This theory was disproved as the headache actually begins before dilation occurs. - Brain hypothesis:
That there is a cortisol spread of depression due to an increase in extracellular K+ cones and a decrease in blood flow = which leads to neuronal inhibition. - Sensory nerve hypothesis:
Trigeminal nerve that goes to the meninges is fired which increases inflammatory mediators e.g. cytokines, prostaglandins etc = pain
None of these explain the initiation of a migraine
Seratonin- see an increase in seratonin metabolites in urine during a migraine attack = blood concs of serotonin decreases.
If injected with serotonin, it can relieve a migraine
Thalamus and hypothalamus:
these are the emotional centres of the brain that regulate sleep, temp, hormonal activity etc
if start changing sleep cycle and diet = this is detected by the thalamus and hypothalamus causing the firing of nerves to GIT= N+V, to the trigeminal nerve = inflammatory mediators and to the brain = corticol spreading of depression, aura, pain
Describe the trigger threshold in migraines
Ask patient to keep a headache diary to identify triggers:
Food- caffeine, chocolate, alcohol, dairy
Hormonal changes- HRT, contraceptive pill, pregnancy
Environmental- emotion, weather
Migraines are often a result of changes in standard routines e.g. significant life event
Has a points system
e.g.
if a patient was stressed = 1 point
Walked past a strong petrol smell = 1 point
Had an alcoholic drink = 1 point
This alcohol at the end of the day, may have pushed them over the trigger threshold = migraine
What are the phases of a typical migraine?
- Prodrome- before the migraine, may have heigtened sensations, sense of foreboding, cravings
- Aura- fortification spectra e.g. zig-zag lines, flashing lights, scotoma (spots in vision), pins and needles
- Headache- unilateral, pulsatile, throbbing pain. Also may have photophobia, photophobia, N+V, speech difficulties
- Postdrome- wash out phase= tired, worn out
How are migraines diagnosed?
International headache Society criteria:
- Repeated attacks of headaches lasting 4-72 hours which has the at least 2 of the following features:
Unilateral pain
throbbing pain
Aggrevated by movement
Moderate-severe intensity- impacting daily function
And at least one of:
N+V
photophobia/phonophobia
5 attacks meet criteria for official diagnosis
When would you refer a headache to the GP?
- Not easing over after 24 hours
- Headache that eases as the day progresses especially with effortless morning vomitting- can be a central cause e.g. cancerous growth squashing the CTZ at night when laying down = pressure, but is relieved in the morning.
- Children with unsteadiness on feet
- Children under 12 where paracetamol is not happening
- Suspected ADRs of drug e.g. GTN, CCBs,
