Headaches and Migranes Flashcards
What is a primary headache?
2 things it can involve?
what kind of genes can it involve?
No underlying structural abnormality - therefore often not medical emergency!
It is a change in chemical activity in pain centres of brain
Changes can be in nerves, blood vessels or external factors e.g muscles of face + skull, inc. temporomandibular joint tension
Can be polygenetic like migraines
What is a secondary headache + 4 causes of it?
Medical emergencies in most cases
Some structural or biochemical abnormality - MRI scan not always the answer
pa changes within brain
Systemic diseases e.g. giant cell arteritis in >55 years of age
Vascular e.g. bleeds, subarachnoids
Lesions: tumour, although often the headache is due to pa!
Give the headache red flags
Profuse vomiting
Fever
Low conscious levels
Confusion or speech abnormalities
Neurological symptoms e.g. weakness, speech disturbance
Pressure dependent features (worse on lying down, coughing, straining)
If someone comes in with a headache, 9 sign which shows you should do neuroimaging?
Focal neurological symptoms or abnormal neuro exam
New onset headache in patient w malignancy or HIV
Headache with low GCS or new seizure
Thunderclap headache (think SAH)
Headache starts after standing and goes on lying down (low pa)
Significant head injury
Headache with aura lasting >2 hours
New onset cluster headache or headache w aura
What does this show + 2 typical symptoms?
This shows a subarachnoid haemorrhage.
Severe headache over entire head, worse at back + Vomiting.
3 Characteristics of a thunderclap headache?
Very severe pain in head - Instantaneous reaching max intensity in <1 minutes
Lasts >5 minutes
Usually patient is sick by the time they are in front of you-vomiting, reduced consciousness, neck stiffness
3 most significant primary vs secondary headache types
Describe migraines
2 things which happen before migraine?
fMRI has shown migraine attacks start 24 hrs before, usually w yawning, tiredness, irritability, concentration issues, neck/muscle stiffness, dehydration, cravings.
Craving cheese & chocolate before migraine (when headache starts ppl blame the attack on whatever you’ve eaten!)
Impossible to find a trigger - because the attack happened before you even recognised it!
Describe the clinical phases of a migraine attack.
4 histories which help diagnose migraines?
Bad hangover after minimal drinking
Travel sickness
Cyclical vomiting as a child- Children seem fine and then suddenly just start to vomit and then feel a bit tired and lethargic afterwards.
Family history
8 Migraine triggers?
Hormonal therapy dosent work
Migraine management?
Sleep routine (sleep and wake similar times in day)
Food-eat regularly and try not to skip meals
Hydration
Manage stress levels/meditation
Exercise regularly (not necessarily vigorously!)
3 principles of the Treatment of migraines in acute settings?
Start treatment early
Use correct dose! Too many people under-dose, paracetamol isn’t enough
Use for max 2-3 days per week
Describe the pharmacological treatment strategies for migraines in order from least to most severe.
Triptans (sumatriptan 50mg oral, 6mg s/c; zolmitriptan 2.5mg oral etc)
Aspirin / ibuprofen
Naproxen - if headache ongoing for days
Prochlorperazine IV
Opiates e.g. codeine (not for reg use)
Sodium valproate I.V in refractory cases (hardly used)
Corticosteroid e.g. prednisolone as last resort
5 drugs used to prevent migraines?
Topiramate: 50% patient had side effects (causes v bad depression and suicidal ideations in some)
Propranolol: Beta blocker, can cause low libido in men
Amitriptyline: TCA, helps w migraine associated insomnia
BOTOX
CGRP monoclonal antibodies
Describe cluster headaches
4 features, how long they last & frequency + when do they tend to happen, how will patient feel?
2nd most common primary headache (suicidal headache)
Severe unilateral headache usually around eye w:
Eye watering/red/swelling
Facial sweating/redness/swelling
Nasal dripping
pupil of affected eye is smaller
Lasts 15-30 minutes; 1-8 times a day - Usually happens at night after a couple hrs of sleep
Always on same side during that cluster
Patient is restless, agitated, feels like banging head!
How are cluster headaches treated?
High flow oxygen works in most people
s/c sumatriptan 6mg per episode
Steroids mask pain for short period
Greater occipital nerve block by specialist service
For patients with cluster attacks >2 weeks, consider verapamil
4 impacts of chronic headache on mental health
Cause both anxiety and depression
Patients often not taken seriously, nor managed well by those who first see them
Many people are told to have CBT & mental health treatment - rather than headache treatment
Both need to happen together to make an impact outcome
