Headaches (excluding Migraine) Flashcards by Kirsty Sutherland

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

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Describe the duration of tension headaches

Hours to days

Worse towards end of day

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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

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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

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What is another name for cluster headaches?

Suicide headaches

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Cluster headaches are more common in…

Men
Smokers
Any age

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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

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How frequently do cluster headaches occur during a bout?

Usually once or twice per day

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When does a cluster headache typically come on?

At night waking patient from sleep

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How long does a cluster headache usually last?

10 minutes to 2 hours

Sudden onset, without warning

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Describe the pain experienced in cluster headaches

Severe unilateral pain
Around one eye
May also have temporal pain
Prevents regular activity

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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

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What can trigger cluster headaches?

Alcohol
Strong smells
Exercise or becoming overheated

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How can an acute attack (cluster headache) be treated?

Oxygen via non rebreathe mask

Sumatriptan injections at onset

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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

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People presenting with a first bout of cluster headache need confirmation of diagnosis by specialist. This may include…

Imaging

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What is a chronic tension headache?

When you have a tension headache on at least 15 days every month for at least 3 months

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What is the most common medication used to treat chronic tension headaches?

Amitriptyline

Taken everyday with aim to prevent headaches

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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

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Which medications are most likely to cause medication overuse headaches?

Opioids

Triptans

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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

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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