Lecture 14 - Headaches Flashcards
What are the 2 broad types of headaches?
Primary
Secondary
What is a primary headache?
Headache due to a headache condition
What is a secondary headache?
Headache due to another condition
What are the 2 types of headache in terms of how threatening they are?
Non life threatening/sight threatentgin (Benign)
Life/sight threatening
What are the 3 main causes of primary non life/sight threatening headaches?
Tension headache
Migraine
Cluster headache
What are some causes of secondary life/sight threatening headaches?
Tumour
Haemorrhage
Meningitis
Giant cell arteritis (temporal arteritis)
Acute glaucoma
How do primary and secondary headaches differ in how they present in clinical examination?
Primary = clincal exam typically normal
Secondary = may have clincal exam findings
What are the normal steps taken when doing a history for a patient with a headache?
History of presenting complaint (SQITARS/SOCRATES)
PMH (previous headache or condtions causing seconadry headache)
DH (Analgesia)
FHx (migraines?)
SHx (stress, sleep, alcohol, caffeine, diet)
RED FLAG ENQUIREIES
What is the pneumonic used to to remember headache red flags?
SNOOP
What does SNOOP stand for to remember life threatening headaches?
Systemic signs and disorders
Neurological symptoms
Onset new or changed patietn > 50yrs
Onset in thunderclap presentation
Papilledema, pulsation tinnitus, Positional, exercise worsens it
What may you be thinking if a patient has a headache with fever and neck stiffness?
Meningitis
What may you be thinking if a pregantn patient has a headache?
Preeclampsia
What may you be thinking if a patietn has a headache with neurological symptoms?
Space occupying lesions
Intra-cranial haemorrhage
Glaucoma (visual)
What may be thought if a patient has a headache with an onset thunderclap headache?
Vascular haemorrhage (subarachnoid haemorrhage)
What is the most common type of headache?
Tension type headache
How does a tension type headache present in terms of:
SQITARS?
Neuro exam?
S. Generalised for frontal and occipital regions
Q. Tight band like constricting radiates to neck
I. Mild-moderate intensity
T. Worse at end of day
A. Stress, poor posture, lack of sleep
R. Analgesia
S. Few associated symptoms maybe slight nausea
Clincal examination is normal
What is thought to be the pathophysiology for tension type headaches?
Tension in muscles in head and neck
Who do tension type headaches commonly affect?
Females for than men
Younger most common first onset
Who do migraines most commonly presetn in?
Women younger than 30
What is thought to be the pathophysiology for migraines?
Vasodilation of meningeal blood vessels
Neurogenic inflammation of Trigeminal senosyr neurones inner acting large vessels and meninges, alters way pain processed by brain
How does a migraine headache present in terms of:
SQITARS?
Neuro exam?
S: unilateral, temporal or frontal
Q: throbbing pulsating
I: moderate-severe and often disabling
T: prolonged headache between 4-72hrs
A: certain food, menstrual cycle, stress, lack of sleep, FHx
R: simple analgesia , may need Triptans
S: Photophobia, Photphonia, AURA, Nauses
Clincal exam normal
What is aura?
Transient period of neurological signs or symptoms like shimmering lights and zig zags
What causes medication over-use headache?
Using regular analgesics where the headache is not responding
What are 2 common analgesics that can cause medication over ruse headache?
Codeine
Co-codamol
How do you treat medication over-use headache?
Discontinue medication
Where the headache worsens before improves
Who do cluster headaches most commonly presetn in?
Men
30-40
Smoking Hx
What is the potential pathophysiology of cluster headaches?
Hypothalamic activation with seconadry Trigeminal and autonomic involvement
How does a cluster headache present in terms of:
SQITARS?
Neuro exam?
S: unilateral around or behind eye
Q: sharp stabbing, penetrating
I: severe, intense, disabling, agitated
T: 15m - 3hrs occur in clusters with periods of remission
A: smoking, alcohol, volatile smells, warm temp, lack of sleep
R: Simple analgesia DOESNT work, O2 and triptans used
S: Ipsilateral autonomic symptoms (red watery eye, blocked runny nose and Ptosis)
Clincal exam may have autonomic features during attack
What are some causes of secondary headaches?
Intracranial haemorrhage
Raised ICP (space occupying lesions)
Trigeminal neuralgia
Temporal (giant cell) arteritis
How does a space-occupying lesion type headache present in terms of:
SQITARS?
Neuro exam?
S: gradual, progressive
Q: Dull, PROGRESSIVE
I: mild in severity and WORSE in morning
T: early morning on waking
A: worse leaning forward, cough, valsalva manoeuvre
R: simple analgesia may work in early stages
S: Nausea, vomiting, focal neurological or visual symptoms (behaviour/personialty change,seizures)
Clincal exam = papilloedmea (focal neurological signs)
Who does Trigeminal neuralgia normally present in?
Women
50-60
What is the pathophysiology of Trigeminal neuralgia?
Compression of Trigeminal nerve due to a loop of a blood vessel;
How does a Trigeminal neuralgia headache present in terms of:
SQITARS?
Neuro exam?
S: unilateral pain felt in at least 1 division of Trigeminal nerve (ophthalmic branch often described as headache)
Q: sharp, stabbing, electric shock (sometimes burning)
I: severe, last few seconds - 2mins
T: sudden onset
A: light touch to face/scalp, eating, cold wind, combing hair
R: simple analgesics not effective
S: tingling, numbness, pain can radiate tot areas within CN V distribution
Clincal exam = normal
What is temporal (giant cell) arteritis?
Vasculitis involving small and medium sized arteries of the head (Branches of External carotid artery)
Who does temporal arteritis commonly. Present in?
Female
Over 50
How does temporal arteritis commonly present?
> 50
Headaches + visual disturbance or jaw claudication (headache with pain in jaw)
May get irreversible loss of vision due to ischaemia of CNII
What artery is affected in slide 21?
What is the most common artery affected in temporal arteritis?
Superficial temporal artery
Superficial temporal artery
How is temporal arteritis normally treated?
Steroids
Biopsy may be done
Do case study on slide 24
Tension headache
Do case study on slide 26:
Raised ICP
What is a headache diary?
Record headaches to determine patttern an possible triggers to aid diagnosis
