Headaches and Pain Flashcards by SN K

What examinations might you do as part of a headache presentation?

Fundoscopy, cranial nerves, BP, temperature (signs of sepsis), HR, skin and neck

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Name three investigations you might do as part of a headache presentation

CT, MRI, inflammatory markers (esp if they have temperature)

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What differentiates a primary from a secondary headache?

Name three types of primary headaches (and identify which are the more common) and six causes of secondary headaches

A primary headache is not caused by underlying disease or structural problems (benign), and are therefore not dangerous. Secondary headaches are caused by underlying disease, and can be harmless or dangerous.

Primary:

Migraine - common
Tension headache - common
Cluster headaches and trigeminal neuralgia

Secondary:

Head trauma
Med overuse
Cancer
Infection (i.e meningitis)
Vascular

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Name six potential mechanisms of a headache

SIT RAT

Skeletal muscle tension
Arterial dilatation
Traction on arteries
Traction or dilation on venous sinuses
Inflammation
Referred pain

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Name some potential causes for extracranial and intracranial

a) arterial dilation
b) inflammation

a) extracranial - migraine
intracranial - hypertension (benign intracranial hypertension), infection

b) extracranial - temporal arteritis
intracranial - meningitis

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Which mechanism of a headache might occur post lumbar puncture?

Traction or dilation on venous sinuses

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Name three things which may cause traction on arteries

Raised intracranial pressure (ICP), tumour, hemorrhage

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How does the prevalence of migraines in M vs F change pre and post puberty? Name one other non-modifiable predisposing factor

Pre-puberty: M=F
Post-uberty: M 1:3 F

Genetics are a strong component

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How commonly are auras experienced in migraines? Which types of auras are most commonly experienced?

20% have auras, usually visual (photophobia) or sensory (hyperacusis)

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Name six possible precipitating factors for a migraine

Foods, alcohol, emotion, menses, bright light, OCP

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Name the two hypothesized theories explaining the pathogenesis for migraines, which is more accepted and why?

Vascular Theory: no longer accepted as studies have shown migraine head pain has some mild intracranial (not extracranial) vasodilation
Central Neural circuitry: problem with the nerves in the brain

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Describe the stages of a migraine

PAHR:

Prodromal fatigue: vague change in mood/appetite
Aura phase
Headache phase
Resolution

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What kinds of acute and chronic management are provided for migraines?

Acute: analgesia (aspirin), triptans, antiemetic

Chronic: precipitant avoidance (headache diary), beta blockers/topiramate, acupuncture

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Which type of headache is most common in primary care? What is the lifetime and chronic risk of having this headache?

Tension headache
Lifetime: 75%
Chronic: 2%

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Describe a tension headache including the following features

a) Time it lasts
b) Sensation
c) intensity
e) frequency

a) 30 min-7 days
b) bilateral pressure, rarely systemic upset and no aura
c) worse during the day
d) ranges from infrequent attacks to daily pain

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How are tension headaches managed?

Lifestyle: stress, alcohol, exercise, mood, med abuse, reassurance

Medication: OTC (paracetamol, ibuprofen), use low dose amitriptyline if experienced for >2days/week

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Compare five differences between a migraine and tension headache

Where?
M - unilateral
T - bilateral

Feeling?
M - pulsatile
T - tight band pressure

Aura?
M - yes
T - no

Triggers
M - yes
T - stress

Responsiveness to migraine meds
M - responsive
T - limited response

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How common are cluster headaches? Which age group and gender is more likely to experience one?

Uncommon: 1/1000
Age group: 30-40s
M 6:1 F

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Describe the sensation and typical frequency of a cluster headache

Bouts of severe orbital pain lasting 15 min-3 hours that occurs frequently (daily for several weeks)

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How might a cluster headache affect one’s routine differently from a migraine?

Cluster headaches often wake people during the night, making them restless

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Name three symptoms that someone with a cluster headache is likely to experience and two symptoms/signs which are occasionally experienced

Likely: Conjunctival injection, lacrimation and nasal blockage

Occasionally: ptosis and horner’s syndrome

How are cluster headaches managed?

Acute: O2 and triptan

Prophylaxis: specialist advice, avoidance of triggers (alcohol, nicotine), verapamil

Name eight types of secondary headaches

TTTMMSSR

temporal arteritis
trigeminal neuralgia
toothache
Med overuse headache
Meningitis
Sinusitis
Subarachnoid hemorrhage
Raised ICP

Name two things which may cause raised ICP

Tumour or idiopathic intracranial hypertension

Name 7 red flags for a secondary headache

Keywords to remember in bold 1. Worsening headache with FEVER 2. Sudden onset headache reaching max intensity in 5 MIN 3. PERSONALITY change 4. Impaired level of CONSCIOUSNESS 5. Recent (typically within 3 month) HEAD TRAUMA 6. ORTHOSTATIC headache (changes with posture) 7. NEW ONSET: cognitive dysfunction, neurological deficit

Name four red flag triggers for a secondary headache (since they weren't in the previous question!)

Exercise, cough, valsalva (trying to breath out with nose and mouth blocked) or sneeze

Name two red flags of a secondary headache that relate the symptoms/signs to other diseases (also wasn't in the previous question)

Giant cell arteritis and acute narrow-angle glaucoma (eye is indicative of changes in the CNS)

Which headaches are most associated with neck pain?

Cluster/tension headaches

How might plasticity influence one's healing process?

Can lead to hyperalgesia and allodynia, which manifests into chronic pain

Compare the two types of complex regional pain syndrome, which is more common?

Type 1: no identifiable lesion | Type 2: after a nerve injury

Name one example of type 2 CRPS

Causalgia: severe burning pain in a limb following injury to a peripheral nerve

Describe the presentation of CRPS and include the following aspects a) location and pattern distribution b) pain

Presentation is complex (varied and dynamic) and regional; doesn't follow dermatomal distribution. Usually involves a single limb Pain involves hyperalgesia and allodynia (out of proportion to precipitating events)

Which age group, gender and other populations are predisposed to experiencing CRPS?

Age: ~41 years F 4:1 M Other: 85% have preceding traumatic injury 10% have a minor injury 5% unknown trigger (occurs spontaneously)

What three ways might CRPS present?

With a triad of symptoms 1. Autonomic: i.e excess/reduced sweating, abnormal temperature sensations 2. Sensory; pain may be spontaneous, hyperalgesia, allodynia 3. Motor: weakness, tremor, dystonia, myoclonus (spasmodic jerky contractions)

Name four signs associated with a CRPS presentation

Abnormal ANS: skin temp and color changes, altered sweating Disuse: bone changes (periarticular osteoporosis, joint stiffness) Distal edema

What are the three general hypotheses explaining the mechanism behind CRPS?

Neurogenic inflammation, autonomic dysfunction, neuroplastic changes in the CNS

How is CRPS managed?

Pharmacological: Steroids, analgesia, neuropathic meds, sympathetic nerve blocks Non pharmacological: physio, occupational therapy, psychotherapy (CBT)

Name four vessels, two general nerve and muscle locations and six other structures of the head and neck which contain pain receptors (and can thus sense pain)

Vessels: extracranial arteries, MMA, large veins, venous sinuses Cranial and spinal nerves Head and neck muscles Meninges, falx cerebri, parts of brainstem, eyes, teeth and lining of mouth

What is thought to be the cause behind tension headaches and cluster headaches?

Tension headaches: activation of peripheral nerves in the head and neck muscles Cluster headaches: over activation of the trigeminal nerve and hypothalamus in the brain (but exact cause is unknown)

What is the mechanism of action for triptan?

Blocks serotonin receptors and constricts blood vessels | *treats migraines

Why give an antiemetic as part of acute management for migraines?

Anti-sickness (prevents vomiting) and for migraine-associated gastroparesis to stimulate gut motility for the analgesic

What is one adverse effect of topiramate?

Its teratogenic

Which inflammatory marker is raised in temporal arteritis and which type of headache does it commonly cause?

CRP, commonly associated with tension headaches

Which symptom is characteristic of trigeminal neuralgia?

Shooting pain through the jaw

Which symptom is characteristic of idiopathic intracranial hypertension?

Increased blind spot due to pressure on the optic nerve

Name five things that can trigger CRPS

Minor trauma, bone fracture, stroke, MI, surgery

Why might someone with CRPS present with numbness in her fingertips and cold extremities?

CRPS is relayed to the sympathetic nervous system

Name five features that a visual aura might have

Zig-zag lines, bright lights, distorted objects, scotoma (dark patches), techopsia (flashes)

Name three features you might expect to see in the clinical history of a patient presenting with a migraine

1. Aura: visual, sensory or speech 2. Headache: unilateral, throbbing, temporal region 3. Associated symptoms: nausea, vomiting, photophobia

# Define the following field defects a) scotoma b) scintillations c) hemianopic field defects

a) blind spots b) flickering/flashes of light c) loss of whole or part of field of vision

Which clinical conditions are the following features of a headache suggestive of? a) Headache worsens on leaning forward b) Headache associated with eye pain c) Reduced GCS (glasgow coma scale) d) associated neurological deficits e) associated with head trauma

a) space occupying lesion b) temporal arteritis c) Acute event (usually compromised vascular supply) d) Space occupying lesion e) compromised vascular supply

Why should women who suffer from migraine be advised not to take the combined contraceptive pill? What is a safer alternative?

Combined pill has a small increase in ischemic stroke which increases in women who experience migraine with aura. Since the risk is from the estrogen component the POP is a safer option