Headaches: Tension, Cluster, Migraine, IHH, Temporal arteritis, Medication Overuse, Cavernous Sinus Thrombosis Flashcards
IHH
-presentation
Persistant frontal, retroorbital
Bilateral, dull
Worsened by coughing, physical activity, pressing
Papilloedema => Ongoing progressive visual loss - different to migraine
Enlarged blind spot
If CNVI involved => diplopia
N+photophobia
IHH
-pathophysiology
-risk factors
High ICP
Most common - obese females in 20-30s
Pregnancy
Drugs
-COCP, CS, tetracycline, VitA, Li
IHH
-investigations, diagnosis
-management
Find any underlying causes
CT, MRI
ICP monitoring
IIH diagnosis of exclusion - increased opening pressure on LP
Lifestyle - weight loss
Medication - acetazolamide, antiepileptic (topiramate)
Surgical
-repeated lumbar puncture
-optic nerve sheath decompression and fenestration
Migraine
-epidemiology, pathophysiology
Young females
Result of abnormal brain activity affecting nerve signals, chemicals, blood vessels => pain
Migraine
-diagnosis
Min 5 attacks lasting 4-72hrs
Min 2 of
unilateral
pulsation
moderate/severe
worse with activity
Min 1 of
N+V
photophobia/phonophobia
Clinical course of migraine
Prodrome - 48hrs due to hypothalamic involvement
-fatigue
-cravings
Aura - 20min per symptom, last for 1hr - hypothalamic activity spreads to other brain areas
-marching progression through visual => sensory => motor, aphasia
-LOSS OF FUNCTION
Headache - 72hrs
-photophobia, phonophobia
-N+V
Resolution
-fatigue
Migraine management
-acute
-preventative
Acute treatment
1st line - paracetamol, ibuprofen at first signs of headache
2nd line - triptan (before its at its worse+ antiemetics (metoclopramide or domperidone)
Preventative
-topiramate OD (antiepileptic)
others - propanolol/amitriptyline
Identify and avoid triggers - migraine diary
-date, time, duration
-warning signs
-symptoms
-medication
Common migraine triggers
Tired/stress
Alcohol
COCP, periods
Hungry, thirsty
Bright light
Cheese, chocolate, red wine, citrus
Medication overuse headache
-prevalence
-pathophysiology
More common in women
Pathophysiology a mystery :(
Medication overuse headache criteria
Preexisting headache disorder
15+ headache days/month
Regular overuse of 3 months+ of acute/symptomatic headache treatment
Medication overuse headache management
Definitive - withdrawal of overused drug
-IMMEDIATELY - simple + triptans
-GRADUAL - opioids
warn that symptoms may initially worsen but should improve over weeks
Keep headache diary
Reassess underlying cause
Cluster headache
-diagnostic criteria
Min 5 attacks with the same presentation
15mins-3hrs
Severe unilateral eye pain, same side everytime
Restlessness/agitation
Ipsilateral to pain
-Tears, runny nose. sweating
-Eyelid edema
-miosis, ptosis
Frequency ranging from 1 every other day - 8 a day
-attacks will cluster
Cluster headache management
-acute
-preventative
Acute - high flow O2
-2nd line - triptan (SC, IN) - can only use it 2x a day due to increased risk of side effects with prolonged use
Confirmation needed with neuroimaging
-often there is an underlying brain lesion
Preventative - verapamil whilst they have episodic clusters
taper off when clusters end
alts - topiramate, lithium
Primary vs secondary headache
Primary more likely if
headache type known for years
gradual onset
no neuro deficit
Secondary more likely if
new unknown headache
sudden onset (as if something fell on your head = ASSUME VASCULAR UNLESS PROVEN OTHERWISE WITH CT, LP
electric shock-like - trigeminal?
neuro deficit, altered consciousness
50+
positional changes, precipitated by something
systemically unwell
Thunderclap headache
-possible causes
SAH
ICH
Cerebeal venous thrombosis
Arterial dissection - intracranial/extracranial
Headache due to CSF pressure change
-differentiating between high and low pressure headaches
Raised pressure - SOL, bleed, abscess, IIH
worse in morning
better upright
worse with Valsalva
Low pressure - dural tear (idiopathic/trauma)
worse as day progresses
better recumbent
Differentiating between primary headaches
-duration
-localisation
-accompanying symptoms
-intensity
Duration
constant - tension?
seconds - trigeminal?
mins to hours - cluster?
Localisation
same unilateral attacks - trigeminal?, cluster?
bilateral - tension?
unilateral - migraine
Accompanying symptoms
-nausea, photophobia, lacrimation, aura?
Intensity, changes with physical activity?
worsens on mv - migraine?
improves on mv - tension? cluster?
Trigeminal neuralgia
-presentation
-pathophysiology
-management
-when to refer urgently for neuro input
Severe unilateral pain limited to divisions of CNV
-electric shock like
Evoked by light touch (washing, shaving, talking, brushing teeth)
Most idiopathic
Compression by tumour/vascular (common: superior cerebellar artery)
Carbemazepine
Failure to respond => neuro referral
Red flegs
-sensory changes
-deafness or ear involvement
-Hx of skin/oral lesions that could spread via the nerves
-pain isolated to opthalmic division, or bilateral
-optic neuritis
-FHx MS
-onset U40
Tension
-epidemiology
-pathophysiology
-presentation
-management
Common in both sexes, 40-50
Pathophysiology unclear but related to increased central sensitization
Tight band-like pressure, bilateral
Lower intensity
No aura, N/V
Not worsened by physical activity
Acute
-aspirin/paracetamol/NSAID
Prophylaxis
-address triggers - stress, poor sleep, anxiety, depression
-up to 10 sessions of acupuncture over 5-8wks
Temporal arteritis/GCA
-epidemiology and associations
-pathophysiology
70, white females
Associated with PMR
Genetic, environmental (seasonal, geographic clustering?), immune dysregulation => vascular inflammation and damage
Temporal arteritis/GCA
-presentation
Rapid onset headache
Jaw claudication
Tender palpable temporal artery
VISION TESTING VITAL
-temporary visual loss
-sudden permanent visual loss - most feared complication
Consitutional - tired, depression, low-grade fever, anorexia, night sweats
PMR - aching, morning stiffness in proximal limbs, no weakness
Cavernous sinus thrombosis
-what is it
-presentation
-key investigations
-management
Clot in cavernous sinuses
-venous plexus surrounding ICA, CN3, 4, 5v1, 5v2
Can be caused by facial or skull infection
-sinusitis
Sharp severe headache around eye
Swelling, bulging eye
Double vision
FEVER
FBC, cultures
Contrast CT and MRI
ABx + IV CS
