Managing Headache Flashcards
Headache history
Can I classify headache? Do I need to investigate? How do I explain the diagnosis? What are the patient's expectations? Is treatment appropriate?
Pattern of pain involves two things
Onset
Periodicity
Onset types and e.g.
Acute (s to min) e.g. SAH, intra-cerebral haemorrhage, coital, thunderclap
Evolving (hours to days) e.g. infection, inflammatory, higher ICP
Chronic (weeks to months)
e.g. chronic daily headache
Periodicity types and e.g.
Episodic (a few days between attacks) e.g. migraine/cluster headache
Chronic (headache most days) e.g. medication overuse, chronic migraine, hemicrania continua
What associated features do you get with headache?
Diurnal variation/postural element
Nausea and vomiting
Photophobia / phonophobia
Autonomic features (lacrimation, Horner’s, red eye)
Red flags for headache
Cognitive effects Seizures Fever Visual disturbance Vomiting Weight loss
What behaviours do people have with headaches
Lies down in dark room (migraine)
Agitation/pacing (cluster)
Family history relevant?
Yes, migraine is often familial
Medication relevant?
Analgesia specifically
Examination - you should search for…
Fever/rash/neck stiffness/ higher BP/ organomegaly
Fundal changes (papilloedema)
Cranial nerve signs/Horner’s syndrome
Focal abnormalities
Long tract signs
Primary headache syndromes
Migraine Tension headache Cluster headache Paroxysmal hemicrania Exertional headache Ice-pick headache Coital headache Hypnic headache
Primary headache syndrome and its secondary syndrome: migraine
SAH
Primary headache syndrome and its secondary syndrome: tension
Intra-cerebral haemorrhage / stroke
Primary headache syndrome and its secondary syndrome: cluster headache
Meningoencephalitis
Primary headache syndrome and its secondary syndrome: paroxysmal hemicrania
Intracranial venous thrombosis
Primary headache syndrome and its secondary syndrome: exertional headache
Giant cell arteritis
Primary headache syndrome and its secondary syndrome: ice-pick headache
Tumour with raised ICP
Primary headache syndrome and its secondary syndrome: coital headache
Cervicogenic headache
Primary headache syndrome and its secondary syndrome: hypnic headache
Benign intracranial hypertension
Raised intracranial pressure could be caused by:
Mass effect (tumour, abscess)
Brain swelling (hypertensive encephalopathy)
Increased venous pressure
CSF outflow obstruction (hydrocephalus)
Increased CSF production (meningitis/SAH)
Symptoms of raised ICP
Headache (worse on lying/awakening)
Vomiting
Seizures
Signs of raised ICP
Papilloedema
Lateralising signs
CPP =
MAP - ICP
Temporal arteritis features
Temporal
Patient type = >60 yo (F>M)
Association with PMR
Signs and symptoms: weight loss, myalgia, transient loss of vision, jaw claudication, tender non-pulsatile temporal artery.
With good history get them on steroids
Do ESR which is often elevated (not always)
Management of suspected temporal arteritis
Immediate high dose steroids - prednisolone
Arrange temporal artery biopsy
If patient >55 check ESR as part of diagnosis work up
Migraine features
10% of population (F>M)
Aura (30%) typically visual and lasts up to 60 mins
Unilateral headache
Nausea, photophobia, dizziness
Triggers: sleep deprivation, hunger, stress, oestrogens
Pathophysiology: cortical spreading depression
Watch for focal migrane: basilar = cranial neuropathies/cerebellar signs or hemiplegic
How does cortical spreading depression work
- Spreading depression
- Releases chemically active irritants
- Triggers sensory fibres in the meninges
- Can be felt as pain
When would you brain image someone with migraine?
Focal symptoms >24hrs
New onset of daily migraine
However, not required routinely - 10% find incidentalomas
What conservative measures would you take for migraines?
Avoid caffeine, increased water intake
Avoid tyramine foods (cheese, chocolate, red wine)
Sleep, hygiene and regular meals
What would you prescribe? What preventative treatment?
Prescribe analgesia: triptans, naproxen, paracetamol
Preventative: Propanolol, pizotifen, topiramate, valproate, amitriptiline, botox
Trigeminal autonomic cephalgia features
Activation of trigeminal / parasym systems
Characteristics: short-lasting headache, variable autonomic features
Types of trigeminal cephalgias and distinguishing them
Cluster (attacks last 30-180 mins, 1 per 24hrs)
Paroxysmal hemicrania (2-30 mins, >5 per 24hrs)
SUNCT (v. rare, seconds, up to 200 attacks per 24hrs)
Management of trigeminal cephalgias
Pain relief: sumatriptan (class A) High flow O2 - 100% O2
Prevention: Prednisolone (60mg/day); verapamil (up to 240mg/day); indomethacin (25-75mg TDS)
Tension headache features
Featureless headache vs migraine
Commonly described as constricting tight band
Increasingly held view that it is a form of mild/moderate migraine
Management of tension headaches
Relaxation and massage
If frequent headache, consider amitriptyline
Acupuncture
Ensure patient has recently had optician check
New daily persistent headache features
Similar to tension
No previous history of episodic headache
Rarely sinister
Cause of new daily persistent headache
Raised ICP - (unlikely if tumour if only headache; idiopathic intracranial hypertension (IIH))
Low ICP - spontaneous intracranial hypotension, post LP headache
Chronic meningitis
Post head injury
