Managing Headaches Flashcards
How many people are affected by headaches in their lifetime?
95%.
What normally causes acute onset headaches (secs-mins)? (4)
- SAH
- Intra-cerebral haemorrhage
- Coital
- Thunderclap
What normally causes evolving onset headaches (hours-days)? (3)
- Infection
- Inflammation
- Increased ICP
What normally causes chronic onset headaches (weeks-months)? (2)
- Chronic daily headache
- Increased ICP
What types of headache are episodic? (2)
- Migraine
- Cluster headache
What types of headache are chronic? (3)
- Medication overuse
- Chronic migraine
- Hemicrania continua
What are autonomic associated features of headaches? (3)
- Lacrimation
- Horners
- Red eye
What are red flag symptoms?
- Cognitive effects
- Seizures
- Fever
- Visual disturbance
- Weight loss (systemic)
What sort of behaviour does a migraine normally cause?
Patient lies down in dark room.
What sort of behaviour does a cluster headache normally cause?
Patient in agitated/pacing.
What sort of headache often has a family history (60%)?
Migraine.
Give some examples of 1* headache syndromes.
Migraine
Tension headache
Cluster headache
Coital headache
What is a secondary headache syndrome?
A headache that is caused by another condition.
Give some examples of secondary headache syndromes.
SAH
Stroke
Meningoencephalitis
CASE 1:
- woke with severe sudden onset head pains
- vomiting & confused
- hyper-reflexive
- ocular movements impaired (R eye down & dilated)
DIAGNOSIS: occulomotor (III) nerve palsy & migraine
MANAGEMENT: pain relief & refer to neurology
CASE 2:
- diabetic
- 72 hours evolving headache & nausea
- hyper-reflexia in right arm & leg
TEST: S. pneumoniae in blood culture DIAGNOSIS: infection/abscess MANAGEMENT: -broad spectrum antibiotics (cefotaxime) -steroids -Neurosurgical consultation
What causes raised intra-cranial pressure? (4)
- Mass effect (e.g. tumour)
- Brain swelling
- Increased venous pressure
- CSF build up
What are the symptoms of raised intra-cranial pressure? (3)
- Headache (worse when lying)
- Vomiting
- Seizures
What are the signs of raised intra-cranial pressure? (2)
- Papilloedema
- Lateralising signs
CASE 3:
- Left temporal headache for 2 weeks (» jaw)
- Visual disturbance this morning
- Fees nauseated
DIAGNOSIS: temporal arteritis
MANAGEMENT: -high dose steroids (prednisolone)
-temporal artery biopsy
What is temporal arteritis?
Condition where medium/large arteries in the head and neck become inflamed.
What are the signs & symptoms of temporal arteritis?
- Weight loss
- Myalgia
- Transient vision loss
- Jaw claudication
- Non-pulsatile temporal artery
CASE 4:
- 3 month episodic headache (R temporal/occipital)
- Nausea & dizziness
- Black dots in vision
- Left hemi-sensory disturbance
DIAGNOSIS: migraine
MANAGEMENT: -brain imaging
-analgesics (e.g. triptans)
-Preventative treatment (e.g. propanolol)
What are the triggers for migraines?
- Sleep deprivation
- Hunger
- Stress
- Oestrogen
What is the pathophysiology of migraines?
Cortical spreading depression (brain waves slow down).
What are coloured dots in the visual field likely to be due to?
Occipital seizures.
What are black and white dots in the visual field likely to be due to?
Likely to be due to migraines.
CASE 5:
- severe gradual onset unilateral right orbital pain
- agitated & tachycardia
- streaming red eye with eyelid droop
- smoker
DIAGNOSIS: trigeminal autonomic cephalgias
CHARACTERISTICS: short-lasting headaches & autonomic features (e.g. eyelid droop)
MANAGEMENT: -pain relief (sumatriptan)
-prevention (prednisolone)
What is trigeminal autonomic cephalgias?
Pain on one side of head.
-activation of trigeminal systems.
What are the 3 types of trigeminal autonomic cephalgias?
- Cluster headache
- Paroxysmal hemicrania
- SUNCT
CASE 6:
-intermittent bilateral headache for few months
('tight band around head')
-hypertension
-IBSDIAGNOSIS: tension headache (mild migraine)
MANAGEMENT: -relaxation
-consider amitriptyline
What is new daily persistent headache?
- Similar to tension headache
- No previous headache history
- Rarely sinister
What are the causes of new daily persistent headache?
- Raised ICP
- Low ICP
- Chronic meningitis
- Head injury
What is idiopathic intracranial hypertension?
Increased intracranial pressure in the absence of tumour/disease.
Who is idiopathic intracranial hypertension common in?
Women of child bearing age.
-too much CSF»_space; headache
What is chronic daily headache?
Headache lasting >4 hours on >15 days per month, for >3 months.
What causes chronic daily headache?
- De novo
- Previous episodic headache (transformed migraine, etc.)
What are treatment options for chronic daily headache?
Limited
- withdraw overused analgesia
- consider amitriptyline/topiramate for transformed migraine
