Headaches and Migraines Flashcards
Red flags of headaches
(SNOOP)
S: systemic symptoms, illness or cancer
N: neurological symptoms or abnormal signs
O: onset = new (>40 y.o.) / sudden (thunderclap- possibly due to subarachnoid or intracerebral haemorrhage, vasospasms (RCVS))
O: other assoc. conditions or features
P: previous headaches, hx with a progressive headache (worried about growing mass lesion - symptoms & signs of raised ICP (headaches worse with coughing, N&V, Papilloedema)) or with a change in character
Tension headache
- Pathophysiology
- Clinical features
- Management
Pathophys:
- Most common
- Emotional strain, stress & depression
- No Assoc. with vomiting or photophobia
Clinical features:
- Pain constant & generalised
- “Dull”, “tight”, “band around the head”
- May last weeks or months w/o interruption
Management:
- may not respond to analgesics
- Excessive codeine use can cause analgesic headaches
- Physiotherapy & stress management
- Low dose amitriptyline (tricyclic anti-depressant
Migraine
- Pathophysiology
- Clinical Features
- Management
Pathophysiology:
- 20% F; 6%M
- Genetically determined recurrent pain syndrome w/ neuro/gastro symptoms & external triggers
- Aura- defective ion channels; cycles of depolarization & hyperpolarization
- Headache due to vasodilation of extracranial vessels
Clinical Features:
- Presents <40 y.o.
- Triad of
- paroxysmal headache
- nausea +/- vomiting,
- focal neurological events (usually visual)
- Classical Migraine
- malaise/irritability
- then aura of the neurological event
- then severe throbbing hemicranial headache w/ photophobia & vomiting
Management:
- Identification & avoidance of triggers
- Acute attacks: analgesic (paracetamol or aspirin) + anti-emetic (metoclopramide or domperidone)
- Triptans - 5HT agonists which vasoconstrict extracranial arteries
- Frequent attacks- prevented with propranolol, amitryptiline or topimirate
Cluster headaches
Pathophysiology:
- “Migrainous neuralgia”
- 5:1 M:F ratio
- Smoking = major risk factor
- Query neuronal abnormality in the hypothalamus
Clinical features:
- Onset- 3rd decade
- Periodic, severe unilateral periorbital pain (30-90mins)
- unilateral lacrimation & nasal congestion
- Has regularity e.g. time of the day
- Attacks can come in weeks & then lay off for a for months before coming again
Management:
- Subcutaneous injections of triptans + O2 therapy - can halt acute attacks
- Preventative therapies
- verapamil (CCB)
- oral CCS
CN 5 Neuralgia
Pathophysiology:
- Abberent loop of cerebral arteries compressing the CN5 in the brainstem
- Possibly due to MS- demyelination of the trigeminal root in the pons
Clinical Features:
- Lancinating i.e. cutting/sharp pain in the 2nd & 3rd division of CN5: Relapses + remits
- Age: >50 y.o.
- Characteristics- severe, brief + repetitive bursts of pain that cause flinching
Management:
- Carbamazepine (anti-convulsant)
- If cannot tolerate above, Gabapentin (GABA analogue used in neuropathic pain)
- Invasive procedures- injection of alcohol to a peripheral branch or posterior craniotomy
Post-coital
Pathophysiology:
- Men in 30s, 40s
- unknown aetiology
- during intercourse or physical activity, particularly in unfit
Clinical features:
- severe headache during intercourse or physical activity w/o vomiting or neck stiffness
- Brief pain: 10-15 mins
Management:
- Propanolol or indomethacin (NSAID)
What are some characteristics of Trigeminal autonomic cephalalgias (TACs)? (2)
- Strictly unilateral, side-locked headaches
- Ipsilateral autonomics features
What are some ipsilateral autonomic features of TACs?
- Conjunctival injection and/or lacrimation
- Nasal congestion and/or rhinorrhoea
- Papilloedema
- Forehead sweating/flushing
- Horners syndrome (ptosis + miosis i.e. constriction)
What are the 5 types of TACs?
- Cluster headaches
- Paroxysmal hemicrania - lasts minutes
- SUNCT (Short-lasting neuralgiform headache attacks w/ conjunctival injection & tearing) - lasts seconds to minutes
- SUNA (Short-lasting neuralgiform headache attacks w/ cranial autonomic symptoms)
- Hemicrania continua- continuous headaches lasting for weeks to years
What is the suspected pathophysiology of TACs?
Neurogenic inflammation of the walls of the cavernous sinus
What are the characteristics of cluster headaches?
- More common in men
- Onset = teens/twenties
- Attacks = episodic, severe unilateral pain lasting for 15–90min
- Alcohol - possible triggers
- Autonomics features- ipsilateral Horner’s syndrome, conjunctival injection, lacrimation & nasal congestion
- Comes in exact same time at day/night (clockworklike regularity)
- Bouts often come at the same time every year
Management of cluster headaches?
- Must diagnose
- Treatment
- Oxygen (= most effective!)
- inhalation of 100% O2 at 7-12L/min via a non-rebreathing mask
- relieves 80% in 15 mins
- Sumatriptan
- Prophylaxis = Veperamil (CCB), topiramate (anti-convulsant)
- Oxygen (= most effective!)
Define CHDs?
Headaches occurring for >15 days/month for 3 or more months
How do Chronic Migraines evolve?
They are migraine attacks which lose their typical migraine features as the fx increases
Initially, there is high attack frequency & medication overuse
List some modifiable & non-modifiable risk factors for migraines?
Non-modifiable:
- female
- caucasian
- low SES
Modifiable:
- Obesity
- smoking
- Caffeine intake
- acute headache medication overuse
- opiates (codeine)
- Ask how much? how frequent?
- Manage: education + discontinue use
