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Neurology > Lecture 24 Headache > Flashcards

Lecture 24 Headache Flashcards

1
Q

What are primary causes of headaches

A

No underlying medical causes

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2
Q

What are the types of primary headache

A

Tension Type
Migraine
Cluster Headache

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3
Q

What are the causes of the secondary headache

A 
Tumour
Meningitis
Vascular disorders
Systemic infections
Head injury
Drug induced
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4
Q

What is the most common cause of headaches

A

Primary

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5
Q

Describe a tension-type headache

A

Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity

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6
Q

Treatment for Tension type headaches

A

Abortive treatment
Aspirin or paracetamol
NSAIDs
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache

Preventative treatment
Rarely required
Tricyclic antidepressants
amitriptyline, dothiepin, nortriptyline

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7
Q

Whats the most frequent disabling primary headache

A

Migraine

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8
Q

What are the abortive treatments for tension-type headache

A

Aspirin
Paracetamol
NSAIDs
10 days per month (2 days per week)

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9
Q

What are the preventative treatment for tension type headache

A

Rarely required
Tricyclic antidepressant:
amitriptyline, dothiepin, nortriptyline

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10
Q

What is a migraine

A

A chronic disorder with episodic attacks due to complex changes in the brain

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11
Q

What symptoms are experienced during Migraines

A 
Headache
Nausea
Photophobia 
Phonophobia
Functional disability
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12
Q

What are experienced in between migraine attacks

A

Predisposition to future attacks

Anticipatory anxiety

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13
Q

Name key pain pathways involved in migraine

A

Trigeminal ganglion
Meninges and other peripheral structures
Brain stem
Cortical

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14
Q

Name Migraine triggers

A 
Dehydration
Diet
Environmental stimuli
Changes in oestrogen level in women
Stress
Hunger
Sleep disturbance
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15
Q

What symptoms are seen in Premonitory headaches

A 
Mood changes
Fatigue
Cognitive changes
Muscle pain
Food craving
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16
Q

What symptoms are seen in the aura stage of the headache

A

Fully reversible
Neurological changes:
Visual somatosensory

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17
Q

What symptoms are seen in early headache

A

Dull headache
Nasal congestion
Muscle pain

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18
Q

What are the symptoms of an advanced headache

A 
Unilateral
Throbbing
Nausea 
Photophobia
Phonophobia
Osmophobia
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19
Q

What are symptoms are seen in postdrome headache

A

Fatigue
Cognitive changes
Muscle pain

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20
Q

What is an Aura

A

Transient neurological symptoms resulting from cortical or brainstem dysfunction. May involve visual, sensory, motor or speech systems

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21
Q

What is the duration of an aura

A

15-60 minutes

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22
Q

What can an Aura be confused with and why

A

TIA
Loss of function
Sudden onset
Symptoms all start at same time and can be localised to a specific vascular area

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23
Q

Define a chronic migraine

A

Headache longer than 15 days per month of which more than 8 days have to be a migraine for more than 3 months

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24
Q

Define transformed headache

A

Increasing frequency of headaches over weeks/months/years. Symptoms become less frequent and severe
Can occur with or without escalation in medication use

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25
Q

In patients with medication overuse what can dramatically improve headache frequency

A

Discontinuing overused medication

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26
Q

Define Medication Overuse Headache

A

Headache present longer than 15 days which has developed or worsened whilst taking regular symptomatic medication

27
Q

What can cause Medication Overuse headaches

A

Primary headache
Triptans, ergots, opioids and combination analgesics for longer than 10 days
Simple analgesics for longer than 15 days
Caffeine overuse

28
Q

Name abortive treatment for migraine

A

Aspirin
NSAIDs
Triptans
(limit to 10 days per month/ 2 days per week)

29
Q

Name prophylactic treatment for Migraine

A

Propranol
Candersartan
Anti-epileptics (Topiramate, Valproate, Gabapentin)
Tricyclic antidepressants (amitriptyline, dothiepin, nortriptyline)
Venlafaxine

30
Q

During pregnancy what happens when a women gets a Migraine without aura

A

Gets better

31
Q

During pregnancy what happens when a women gets a migraine without an aura

A

Usually does not change

32
Q

What can typically occur during pregnancy

A

First migraine, particularly migraine with aura

33
Q

What is a contraindication in active migraine with aura

A

Combined OCP

34
Q

Women of child-bearing age should avoid what

A

Anti-epileptics

35
Q

What can women of child bearing age take instead of anti-epileptics

A

Paracetamol- acute

Propranol or amitriptyline- preventative

36
Q

Define Trigeminal Cephalagias

A

A group of headache disorders characterised by attacks of moderate to severe unilateral pain in the head or face, with associated ipsilateral cranial autonomic features (lacrimation, conjunctival injection, rhinorrhoea, nasal congestion, eyelid oedema and ptosis)

37
Q

Name the types of Trigeminal Autonomic Cephalagias

A

Cluster Headache
Paroxysmal Hemicrania
SUNCT
SUNA

38
Q

Name Cranial autonomic symptoms

A
  • Conjunctival injection / lacrimation
  • Nasal congestion / rhinorrhoea
  • Eyelid oedema
  • Forehead & facial sweating
  • Miosis / ptosis (Horner’s syndrome)
39
Q

Describe the features of a cluster headache

A 
Orbital and temporal pain
Sharp, throbbing
Unilateral
Rapid onset
15mins-180mins
Rapid cessation
Severe pain
Ipsilateral autonomic symptoms
Circadian rhythm
40
Q

Describe the features of a Paroxysmal Hemicrania

A 
Mainly orbital and Temporal 
Sharp, throbbing
Unilateral
Rapid onset
2-30mins
Rapid cessation
Severe pain
Ipsilateral autonomic symptoms
10% precipitated by bending or rotating
No circadian rhythm
41
Q

Treatment for Paroxysmal Hemicrania

A

Indomethacin

42
Q

Name the features of SUNCT

A

Unilateral orbital, supraorbital or temporal pain
Stabbing pulsating pain
10-20secs
Triggered by wind, clod, touch and chewing
No refractory period
Conjunctival injection
Lacrimation

43
Q

Abortive treatment for cluster headaches

A

– Subcutaneous sumatriptan 6mg or nasal zolmatripan 5mg

– 100% oxygen 7-12 l/min via a tight fitting non-rebreathing max is effective and safe

44
Q

Abortive (headache bout) treatment for cluster headaches

A

– Occipital depomedrone injection (same side as the headache)
– Or tapering course of oral prednisone

45
Q

Preventative treatment for cluster headache

A

– Verapamil (high doses may be required)
– Lithium
– Methysergide (risk of retroperitoneal fibrosis)
– Topiramate

46
Q

Treatment for Paroxysmal Hemicrania

A
  • No abortive treatment
  • Prophylaxis with indometacin
  • Alternatives – COX-II inhibitors, Topiramate
47
Q

Treatment for SUNCT/SUNA

A 
•	No abortive treatment
•	Prophylaxis:
–	Lamotrigine
–	Topiramate
–	Gabapentin
–	Carbamazepine / Oxcarbazepine
48
Q

Treatment of Trigeminal Neuralgia

A 
•	No abortive treatment
•	Prophylaxis:
–	Carbamazepine
–	Oxcarbazepine
•	Surgical intervention:
–	Glycerol ganglion injection
–	Steriotactic radiosurgery
–	Decompressive surgery
49
Q

What features predict a sinister headache

A 
–	Associated head trauma
–	First or worst
–	Sudden (thunderclap) onset
–	New daily persistent headache
–	Change in headache pattern or type
–	Returning patient
50
Q

Red flags for headache

A 
•	new onset headache
•	new or change in headache
–	aged over 50
–	Immunosupression or cancer
–	change in headache frequency, characteristics or associated symptoms
•	focal neurological symptoms
•	non-focal neurological symptoms
•	abnormal neurological examination
•	neck stiffness / fever
•	high pressure
GCA
51
Q

Name situations that would highlight high pressure within skull

A

– headache worse lying down
– headache wakening the patient up
– headache precipitated by physical exertion
– headache precipitated by valsalva manoeuvre
– risk factors for cerebral venous sinus thrombosis
– low pressure
– headache precipitated by sitting / standing up

52
Q

What are the features of Giant Cell Arteritis

A

– jaw claudication or visual disturbance

– prominent or beaded temporal arteries

53
Q

Define a Thunderclap headache

A

A high intensity headache reaching maximum intensity in less than 1 minute

54
Q

Name some differential diagnosis for Thunderclap headache

A 
–	Primary (migraine, primary thunderclap headache, primary exertional headache, primary headache associated with sexual activity)
–	Subarachnoid haemorrhage
–	Intracerebral haemorrhage
–	TIA / stroke
–	Carotid / vertebral dissection
–	Cerebral venous sinus thrombosis
–	Meningitis / encephalitis
–	Pituitary apoplexy
–	Spontaneous intracranial hypotension
55
Q

Thunderclap is a potential indicator for what

A

Subarachnoid haemorrhage

56
Q

How do you investigate a suspected subarachnoid haemorrhage

A

CT 12hrs/24hrs
LP done >12 hrs after headache onset
Angiography
Unreliable 2 weeks beyond this time

57
Q

When should you suspect Meningitis or Encephalitis

A

Headache/Fever
– Meningism: nausea +/- vomiting, photo/phono phobia, stiff neck
– Encephalitis: altered mental state / consciousness, focal symptoms / signs, seizures
– Look for a rash!

58
Q

What are the causes of raised intracranial pressure

A
  • Glioblastoma multiforme
  • Cerebral abscess
  • Venous infarct with focal area of haemorrhage
  • Meningioma
  • Hydrocephalus
  • Pappiloedema
59
Q

What causes Intracranial Hypotension

A

Dural CSF leak

Spontaneous or post lumbar puncture

60
Q

Features of Intracranial Hypotension

A

Postural components
Resolves lying down
Once chronic loses postural component

61
Q

How would you investigate Intracranial hypotension

A

MrI brain and spine

62
Q

How would you treat Intracranial Hypotension

A

– Bed rest, fluids, analgesia, caffeine (e.g. 1 can red bull qds)
– i.v. caffeine
– Epidural blood patch

63
Q

Specific features of Giant Cell Arteritis

A 
Scalp tenderness
Jaw claudication
Visual disturbances
>50 years
Elevated ESR
Raised CRP and platelet count
64
Q

How is Giant Cell Arteritis managed

A

High dose prednisolone

Temporal artery biopsy

Neurology (44 decks)

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