Headaches (excluding Migraine) Flashcards
What are the characteristics of tension headaches?
A band across forehead Diffuse, dull ache Aggravated by touching scalp, noise Usually does not disturb sleep Can manage usual activities Simple analgesics usually effective
Describe the duration of tension headaches
Hours to days
Worse towards end of day
What can cause tension headaches?
Anything that makes muscle over scalp or back of neck tense
Persistent contraction e.g clenching teeth, head posture, furrowing brow
Stress
Anxiety
Depression
Poor sleep
How can tension headaches be managed?
Explain that self limiting and not serious
Exercise
Improve posture
Simple analgesics: Ibuprofen as first choice Other NSAIDS sometimes indicated Paracetamol if intolerant of NSAIDS Aspirin can also be used
Do not offer opioids
What is another name for cluster headaches?
Suicide headaches
Cluster headaches are more common in…
Men
Smokers
Any age
In cluster headaches, the bouts or “clusters” of head pain last how many weeks typically?
4 to 12 weeks once a year at the same time and often in spring or autumn
In between periods of no symptoms
How frequently do cluster headaches occur during a bout?
Usually once or twice per day
When does a cluster headache typically come on?
At night waking patient from sleep
How long does a cluster headache usually last?
10 minutes to 2 hours
Sudden onset, without warning
Describe the pain experienced in cluster headaches
Severe unilateral pain
Around one eye
May also have temporal pain
Prevents regular activity
Other than pain, what other symptoms are associated with cluster headaches?
Eye may become blood shot and watery Drooping eyelid Lid swelling Rhinorrhoea Facial flushing Miosis +/- ptosis
What can trigger cluster headaches?
Alcohol
Strong smells
Exercise or becoming overheated
How can an acute attack (cluster headache) be treated?
Oxygen via non rebreathe mask
Sumatriptan injections at onset
What preventative treatment can be used in the case of cluster headaches?
Corticosteroids (short term only) - attempt to break the cycle
Verapamil - will need ECG monitoring initially while dose established
Lithium at low dose
People presenting with a first bout of cluster headache need confirmation of diagnosis by specialist. This may include…
Imaging
What is a chronic tension headache?
When you have a tension headache on at least 15 days every month for at least 3 months
What is the most common medication used to treat chronic tension headaches?
Amitriptyline
Taken everyday with aim to prevent headaches
Describe medication overuse headaches
Caused by taking regular painkillers for headache - body responds by making more pain sensors - so very sensitive
This headache typically present for 15 days or more per month
Which medications are most likely to cause medication overuse headaches?
Opioids
Triptans
How are medication overuse headaches managed?
Stop the medication - headache likely to get worse initially, then reduce
Best to stop altogether than cutting down gradually
Can medication overuse headaches occur even if taking medication as instructed?
Yes
How many days per month of taking painkillers is considered overuse?
Ten days per month
What is hemicrania continua?
Persistent headache, without pain free periods
Unilateral pain
Moderate intensity but with exacerbations
During exacerbation may get autonomic features on side of pain - conjunctival injection, lacrimation, rhinorrhoea, miosis/ptosis
Migrainous symptoms may be present e.g nausea, light sensitivity
How is hemicrania continua treated?
Indomethacin - an NSAID
Positive response to this drug is part of criteria for diagnosis
What are primary stabbing headaches? (Ice pick)
Short, stabbing headaches
Very sudden and severe
Last between 5 and 30 seconds
Often occur behind ear
Primary stabbing headaches are more common in people who have…
Migraines
How are primary stabbing headaches managed?
Too short to treat
Migraine medication may reduce number
What is trigeminal neuralgia?
Paroxysms of intense, stabbing pain lasting seconds in the trigeminal nerve distribution
In trigeminal neuralgia, what divisions of the trigeminal nerve are typically affected?
Maxilllary
Mandibular
In trigeminal neuralgia where is the pain often located?
Around cheek and jaw on one side typically (but can be both)
What can happen after an attack of pain in trigeminal neuralgia?
Dull ache or tenderness of affected area
In trigeminal neuralgia, there are often trigger points. Where are they and what can trigger pain?
Where: often around nose and mouth
What: eating, talking, washing, shaving, dental prosthesis
In trigeminal neuralgia how frequent are the pains?
Varies - can be 100s per day or just occasional
Often occur in bouts with periods of normalcy
What are some secondary causes of trigeminal neuralgia?
Compression of trigeminal nerve - aneurysm, tumour
MS
Zoster
Skull base malformations e.g chiari
How is trigeminal neuralgia diagnosed?
Based on typical symptoms
If secondary cause possible - MRI
How is trigeminal neuralgia managed?
Carbamazepine is the usual treatment - lessens nerve impulses (taken for approx one month after pain stopped)
Alternative - gabapentin, baclofen, lamotrigine
Normal painkillers do not work
If very severe and not responding to medication: deep brain stimulation
Decompression surgery - relieve pressure on the nerve
Ablative surgery
What is another name for giant cell arteritis?
Temporal arteritis
What causes GCA?
A form of vasculitis
Inflammation of arteries in temple and behind the eye
Autoimmune condition - large and medium size arteries undergo giant cell infiltration with fragmentation of lamina and narrowing of lumen, resulting in distal ischaemia and pain sensitive fibre stimulation
Who typically gets GCA?
Over 50 (average onset is 74)
Women 2x more common
Northern Europeans
What symptoms are associated with GCA?
New, and persistent headache over temple region - severe and throbbing
Tenderness over temple and scalp e.g when combing hair
Tongue/ jaw claudication (fatigue or discomfort of jaw during chewing)
Sudden vision loss in one eye - amaurosis fugax
Risk of sudden blindness
Flu like symptoms at onset - fatigue, fever, appetite loss
Weight loss
Unequal or weak pulses
Pain and stiffness in neck, hips, shoulders which is worse in morning - PMR symptoms
GCA typically affects vessels in scalp and neck (especially temples). It can also affect…
Aorta and its large branches to head, arms and legs
Why is early treatment vital in GCA?
Can cause blindness or stroke - so urgent referral necessary
What do blood tests typically demonstrate in GCA?
ESR and CRP elevated
Platelets elevated
Increased ALP
Decreased Hb
How is GCA diagnosed?
Temporal artery biopsy
- negative biopsy does not exclude diagnosis as skin lesions occur
How is GCA managed?
Immediate prednisolone 60mg/ d
Or IV methyl prednisolone is evolving vision loss or history of amaurosis fugax
Typically 2 year course then complete remission
Reduce dose once symptoms resolved and ESR reduced
With long term steroid use - PPI, bisphosphonate, calcium and vit d
What can cause an acute single headache episode?
Meningitis Encephalitis SAH Head injury Sinusitis Glaucoma - acute closed angle
What usually causes a SAH?
Ruptured berry aneurysm
Describe the headache seen in SAH
Sudden onset
THUNDERCLAP headache ie worst ever and explosive
Often occipital region
Other symptoms: neck stiffness, N&V, photophobia, focal signs, reduced consciousness, seizures
What can chronic progressive headaches indicate?
Raised ICP
Headaches associated with raised ICP have what features?
Chronic progressive
Worse on waking
Worse on bending, coughing
Also: vomiting, seizures, papilloedema, odd behaviour
Headaches that recur tend to be…
Benign
What symptoms are associated with sinusitis
Dull constant ache all over frontal or maxillary sinuses Tenderness Post nasal drip Pain worse on bending Pain usually last 1-2 weeks
Ethmoid or sphenoid sinus pain felt deep in midline at root of nose
What should you consider with acute eye pain, visual disturbance, red and hard eye?
Acute closed angle glaucoma
