Managing Headache Flashcards

1
Q

Headache history

A
Can I classify headache?
Do I need to investigate?
How do I explain the diagnosis?
What are the patient's expectations?
Is treatment appropriate?
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2
Q

Pattern of pain involves two things

A

Onset

Periodicity

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3
Q

Onset types and e.g.

A

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

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4
Q

Periodicity types and e.g.

A

Episodic (a few days between attacks) e.g. migraine/cluster headache

Chronic (headache most days) e.g. medication overuse, chronic migraine, hemicrania continua

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5
Q

What associated features do you get with headache?

A

Diurnal variation/postural element
Nausea and vomiting
Photophobia / phonophobia
Autonomic features (lacrimation, Horner’s, red eye)

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6
Q

Red flags for headache

A
Cognitive effects
Seizures
Fever
Visual disturbance
Vomiting 
Weight loss
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7
Q

What behaviours do people have with headaches

A

Lies down in dark room (migraine)

Agitation/pacing (cluster)

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8
Q

Family history relevant?

A

Yes, migraine is often familial

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9
Q

Medication relevant?

A

Analgesia specifically

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10
Q

Examination - you should search for…

A

Fever/rash/neck stiffness/ higher BP/ organomegaly

Fundal changes (papilloedema)

Cranial nerve signs/Horner’s syndrome

Focal abnormalities

Long tract signs

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11
Q

Primary headache syndromes

A
Migraine
Tension headache
Cluster headache
Paroxysmal hemicrania
Exertional headache
Ice-pick headache
Coital headache
Hypnic headache
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12
Q

Primary headache syndrome and its secondary syndrome: migraine

A

SAH

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13
Q

Primary headache syndrome and its secondary syndrome: tension

A

Intra-cerebral haemorrhage / stroke

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14
Q

Primary headache syndrome and its secondary syndrome: cluster headache

A

Meningoencephalitis

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15
Q

Primary headache syndrome and its secondary syndrome: paroxysmal hemicrania

A

Intracranial venous thrombosis

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16
Q

Primary headache syndrome and its secondary syndrome: exertional headache

A

Giant cell arteritis

17
Q

Primary headache syndrome and its secondary syndrome: ice-pick headache

A

Tumour with raised ICP

18
Q

Primary headache syndrome and its secondary syndrome: coital headache

A

Cervicogenic headache

19
Q

Primary headache syndrome and its secondary syndrome: hypnic headache

A

Benign intracranial hypertension

20
Q

Raised intracranial pressure could be caused by:

A

Mass effect (tumour, abscess)
Brain swelling (hypertensive encephalopathy)
Increased venous pressure
CSF outflow obstruction (hydrocephalus)
Increased CSF production (meningitis/SAH)

21
Q

Symptoms of raised ICP

A

Headache (worse on lying/awakening)
Vomiting
Seizures

22
Q

Signs of raised ICP

A

Papilloedema

Lateralising signs

23
Q

CPP =

A

MAP - ICP

24
Q

Temporal arteritis features

A

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)

25
Q

Management of suspected temporal arteritis

A

Immediate high dose steroids - prednisolone

Arrange temporal artery biopsy

If patient >55 check ESR as part of diagnosis work up

26
Q

Migraine features

A

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

27
Q

How does cortical spreading depression work

A
  1. Spreading depression
  2. Releases chemically active irritants
  3. Triggers sensory fibres in the meninges
  4. Can be felt as pain
28
Q

When would you brain image someone with migraine?

A

Focal symptoms >24hrs
New onset of daily migraine
However, not required routinely - 10% find incidentalomas

29
Q

What conservative measures would you take for migraines?

A

Avoid caffeine, increased water intake
Avoid tyramine foods (cheese, chocolate, red wine)
Sleep, hygiene and regular meals

30
Q

What would you prescribe? What preventative treatment?

A

Prescribe analgesia: triptans, naproxen, paracetamol

Preventative: Propanolol, pizotifen, topiramate, valproate, amitriptiline, botox

31
Q

Trigeminal autonomic cephalgia features

A

Activation of trigeminal / parasym systems

Characteristics: short-lasting headache, variable autonomic features

32
Q

Types of trigeminal cephalgias and distinguishing them

A

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)

33
Q

Management of trigeminal cephalgias

A
Pain relief: sumatriptan (class A)
High flow O2 - 100% O2

Prevention: Prednisolone (60mg/day); verapamil (up to 240mg/day); indomethacin (25-75mg TDS)

34
Q

Tension headache features

A

Featureless headache vs migraine
Commonly described as constricting tight band
Increasingly held view that it is a form of mild/moderate migraine

35
Q

Management of tension headaches

A

Relaxation and massage
If frequent headache, consider amitriptyline
Acupuncture
Ensure patient has recently had optician check

36
Q

New daily persistent headache features

A

Similar to tension
No previous history of episodic headache
Rarely sinister

37
Q

Cause of new daily persistent headache

A

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