Lecture 15- Headaches Flashcards
Headaches
- Common presenting complain
- Majority are benign (non life threatening and due to primary headache disorder
Causes of headache
- Primary (due to headache disorder)
- Secondary to another condition
- Non-life threatening
- Life or sight threatening
(1) Primary headache disorders
Non-life or sight threatening- many chronic
- Tension headache
- Migraine
- Cluster headache
(2) Secondary due to another condition
Some are life or sight threatening- many acute
Life threatening
- Intracranial lesion
- Tumour (benign/malignant or metastasis)
- Haemorrhage (trauma or aneurysm)
- Meningitis
Site threatening
- Giant cell (temporal) arteritis)
- Acute glaucoma
Non-life or sight threatening
- Sinusitis
- Medication-overuse headache
- Trigeminal neuralgia
- Drug side effect e.g. CCB and statins
Life threatening- secondary
- Intracranial lesion
- Tumour (benign/malignant or metastasis)
- Haemorrhage (trauma or aneurysm)
- Meningitis
Site threatening- secondary
- Giant cell (temporal) arteritis)
- Acute glaucoma
Non-life or sight threatening- secondary
- Sinusitis
- Medication-overuse headache
- Trigeminal neuralgia
- Drug side effect e.g. CCB and statins
Diagnosing cause of headache: Patients history is key
History taking
- History of presenting complaint (HPC)
- SQITARS/SOCRATES
- Site
- Onset
- Character
- Radiate?
- Associated symptoms
- Timing (day/night)
- Exacerbating factors
- Severity
- SQITARS/SOCRATES
- Past medical history (PMH)
- Prev. headaches, conditions causing secondary headache
- Drug history (DH)
- Analgesic use (medication over use)
- Other drugs causative or headache?
- Family history (FH)
- Migraines?
- Social history (SH)
- Sleep? Stress?
- Alcohol and caffeine consumptions, diet (triggers)
Red flags
Clinical examination
- Vital signs
- BP
- PR
- Temp
- Neurological examination (cranial and peripheral nerve exam, Glasgow-coma scale)
- Other relevant systems, guidance by history
red FLAGS of headaches
- vital signs
- BP
- PR
headache types from common to least common
tension headaches
primary headaches
- F>M
- Common
- Young (teenagers) and young adults (20-39yrs)
- First onset >50 yrs unusual
pathophysiology of tension heafaches
- Due to tension in muscles of the head and neck
features of a tension type headache
migraine
primary headache
- F>M (1 in every 5F_
- Common
- Present early to midlife
- Most have first attack by 30
pathophysiology of migraine
- Pathophysiology
- Unclear
- Possible theories
- Neurogenic inflammation of trigeminal sensory neurones innervating large vessels and meninges
- Alters way pain processed by brain, sensitised to otherwise ignored stimuli
features of migraines
Associated symptoms of migraines
- Photophobia
- Nausea
- Aura- peculiar sensory signs
Medication over-use headache
secondary headache
- Medication used to treat headaches
- F>M
- 30-40 yrs
- Headache present on at least 15 days/month (constant)
- Using regular analgesics (at least 10 days/month)
- Headache not responding
- Occurs in pts with pre-existing headache disorder
Pathophysiology of medication overuse heaches
Regular use of analgesics leads to upregulation of pain receptors in the meninges e.g. codeine
featues of medication over-use headaches
- Variable character can be dull, tension-type or migraine-like
- Co-exists with depression and sleep disturbance
- Treatment: discontinue medication (headache worsens before improves)- resolves completely by 2 months
Cluster headaches
primary headache disorder
- M>F
- Smoking history= risk factor
- 1 in 1000
- Usually begins 30-40 years
Pathophysiology of cluster headaches
- Unknown
- Hypothalamic activation with secondary trigeminal and autonomic involvement
features of cluster headaches
Secondary headaches
- Intracranial haemorrhage- meningism
- Raised ICP (e.g. space occupying lesion)
- Trigeminal neuralgia
- Temporal (giant cell) arteritis
Raised intracranial pressure- space occupying lesion
Rarely occurs in absence of other suspicious historical or exam findings
Trigeminal neuralgia aetiology
- F>M
- 50-60 years
trigeminal neuralgia pathophysiology
- Most caused by compression of CN V due to loop of blood vessels
- 5% due to tumours/skull base abnormalities or AV malformations
trigeminal neuralgia features
Temporal arteritis
- Vasculitis of large and medium sized arteries of head
- Superficial temporal artery commonly involved.
- F>M
- >50 years (most common >75 yrs)
major risk associated with temporal arteritis
Risk of irreversible loss of vision due to involvement of blood vessels supplying CN II (optic)
General approach to headache
- History and examination
- Identify if red flag present
- Build illness script for clinical features that would indicate to particular primary headache disorder or secondary causes
- Treatment and management will depend on underlying cause
- Simple analgesics, triptans, high flow oxygen (cluster) vs urgent referral for further investigation
example scenario- most likely diagnosis
- Recurrent
- Tight band
- Can carry on activities
- Coughing doesn’t make it worse
- No family history of note
- No medication
- Clinical exam normal
- Recent stress
Diagnosis? Tension headache most likely
example scenario- most likely diagnosis
- Unilateral
- Morning headache
- Certain positions make headache worse
- Hypertension
- Upper motor neurone signs
Diagnosis?
- Sign of ICP
