Managing headaches Flashcards
What percentage of people suffer from migraines?
10%
How common are sinister causes of headache in primary care?
0.1%
What percentage of people seen in neurology clinics have benign headaches?
10%
When asking about the pattern of pain, what are the 2 important areas to cover?
1) onset - acute, evolving (hours to days), chronic (weeks to months)
2) Periodicity - episodic (atleast a few days free between attacks), chronic (headache most days)
An acute headache (seconds to minutes) is commonly due to which 4 causes?
1) SAH
2) Intra-cerebral haemorrhage
3) Coital
4) Thunderclap
What are the 3 common causes of an evolving headache (hours to days)?
1) Infection
2) Inflammatory
3) Increased ICP
What are the 2 common causes of chronic headache (weeks to months)?
1) Chronic daily headache
2) Increased ICP
Episodic headaches (at least a few free days between attacks) are commonly due to which 2 conditions?
1) Migraine
2) Cluster headache
Give 3 common causes of chronic (headaches most days) headaches?
1) Medication overuse
2) Chronic migraine
3) Hemicrania continua
What are 4 common associated features should be asked about when taking a headache history?
1) Diurnal variation/postural element
2) Nausea and vomiting
3) Photophobia/ Phonophobia
4) Autonomic features (lacrimation/Horners/Red eyes)
Name 6 red flag symptoms for someone with headaches?
1) Cognitive effects
2) Seizures
3) Fever
4) Visual disturbance
5) Vomiting
6) Weight loss
Lying down in a dark room is characteristic behaviour of which headache condition?
Migraine
Agitation or pacing are characteristic behaviours of which headache condition?
Cluster headaches
What headache condition is often familial?
Migraine
On examination what 9 things are you looking for?
1) Fever
2) Rash
3) Neck stiffness
4) Increased BP
5) Organomegaly
6) Fundal changes (papilloedema)
7) Cranial nerve signs/Horner’s syndrome
8) Focal abnormalities
9) Long tract signs
Give the 8 primary headache syndromes?
1) Migraine
2) Tension headache
3) Cluster headache
4) Paroxysmal hemicrania
5) Exertional headache
6) Ice pick headache
7) Coital headache
8) Hypnic headache
Name 8 secondary headache syndromes?
1) SAH
2) Intra-cerebral haemorrhage or stroke
3) Meningoencephalitis
4) Intracranial venous thrombosis
5) Giant cell arteritis
6) Tumour with raised ICP
7) Cervicogenic headache
8) Benign intracranial hypertension
A patient with the symptoms of 1) Severe sudden onset headache 2) Vomiting and confused 3) Globally hypereflexic 4) Impaired ocular movements is likely to have what diagnosis?
SAH
What are the 2 investigations in SAH?
1) Bloods - FBC and clotting
2) Unenhanced CT and angiography
In a suspected SAH if the CT is normal what other investigation can be carried out?
An LP to look for xanthochromia (bilirubin released from lysing red cells)
What are the processes in management of SAH?
1) Resuscitation
2) Pain relief
3) Referral to neurosurgical team - clipping of berry aneurysm
What are the 5 common causes of raised intracranial pressure?
1) Mass effect (brain tumour, abscess)
2) Brain swelling (hypertensive encephalopathy)
3) Increased venous pressure
4) CSF outflow obstruction (hydrocephalus)
5) Increased CSF production (meningitis/ SAH)
Give the 3 common symptoms of raised ICP?
1) Headache (worse on lying or awakening)
2) Vomiting
3) Seizures
Give the 2 common signs of raised ICP?
1) Papilloedema
2) Lateralising signs (assymetrical signs)
What equation relates CPP (Cerebral perfusion pressure) MAP and ICP?
CPP = MAP-ICP
What is the normal value of ICP?
7-18cm H2O
Above what level of ICP is CPP affected?
Above 40cm H2O
What are the 4 facets to acute management of an intracranial abscess?
1) Resuscitation
2) Broad spectrum IV Abx (cefotaxime)
3) Steroids (dexamethasone) in patients with strep pneumoniae meningitis
4) Neurosurgical consultations (craniotomy and drainage)
What are the 2 facets to long term management of an intracranial abscess?
1) Cognitive/ psychological sequelae
2) ENT for assessment of hearing loss
A patient who presents with 1) General malaise and left temporal headache for 2 weeks 2)Jaw claudication worsening on eating 3) Tender temporal area and sensitive scalp is likely to be suffering from what?
Temporal arteritis
In which group of patients is temporal arteritis more common?
Females over the age of 60
Temporal arteritis is associated with which condition?
Polymyalgia rheumatica
What are the 5 common signs/symptoms of temporal arteritis?
1) Weight loss
2) Myalgia
3) Transient loss of vision
4) Jaw claudication
5) Tender non-pulsatile temporal artery
Which blood test can be elevated in temporal arteritis and should be done in patients over 55 where diagnosis is uncertain?
ESR (erythrocyte sedimentation rate)
What are the 2 parts of immediate managment in suspected temporal arteritis?
1) Commence immediate high dose steroids - high dose prednisolone (60mg OD) for 1st week which slowly taper over 6 weeks to 15-20mg OD
2) Arrange temporal artery biopsy (can be negative even if ESR is high)
Which sex is migraine more common in?
Females
Give 4 common triggers of migraine?
1) Sleep deprivation
2) Hunger
3) Stress
4) Oestrogens
What 3 symptoms can be associated with migraine/
1) Nausea
2) Photophobia
3) Dizziness
Is migraine a unliateral or bilateral headache?
Unilateral
What percentage of people experience a prodrome prior to a migraine?
10% - eg. changes in mood/fatigue
What percentage of people commonly experience an aura with migraine (typically visual)?
30%
What 2 things would suggest focal migraine?
1) basilar - cranial neuropathies/cerebellar signs
2) Hemiplegic
What is the pathophysiology of migraine?
Neurovascular headache
1) Cortical spreading depression (slowing of brain waves)
2) Releases chemically active irritants
3) That trigger sensory fibres in the meninges
4) Which can be felt as pain
In what 2 situations would brain imaging be used to manage migraine - why is it not routine?
1) Focal symptoms or signs lasting for 24 hours or more
2) Newly onset daily migraine
Not required routinely because of the risk of finding an ‘incidentaloma’ (10%)
What 3 conservative measures can be taken to manage migraine?
1) Avoid caffeine/increase water intake
2) Avoid tyramine foods (cheese/chocolate/red wine)
3) Sleep hygiene and regular meals
Name 3 analgesics useful in migraine?
1) Triptans
2) Paracetamol
3) Naproxen
Which drugs can be used as prophylactic treatment for migraine?
Propanolol, pizotifen, topiramate, valproate, amitriptiline, botox
What are trigeminal autonomic cephalgias?
Headaches with activation of trigeminal/parasymapthetic systems
What are the 2 main characteristics of trigeminal autonomic cephalgias?
1) Short lasting headaches
2) Variable autonomic features eg. tachychardia, streaming eye, red eye, lid droop
What are the 3 types of trigeminal autonomic cephalgias?
1) Cluster headache (attacks last 30-180 mins, 1 per 24 hrs)
2) Paroxysmal hemicrania (2-30mins, >5 per 24hrs)
3) SUNCT (v.rare, up to 200 attacks per 24 hrs)
Which 2 things can be used to manage trigeminal autonomic cephalgias?
1) Sumatriptan (Class A)
2) High flow 100%
What 3 drugs can be used in prevention of trigeminal autonomic cephalgias?
1) Prednisolone (60mg/day) then taper
2) Verapamil (up to 240mg/day)
3) Indomethacin (25-75mg TDS)
How is tension headache often described?
Commonly described as ‘constricting’ or ‘tight band’
Is tension headache a form of migraine?
Increasingly held view that it is a form of mild/moderate migraine
Which 4 ways can tension headache be managed?
1) Relaxation and massage
2) If headache frequent consider small dose of amitriptyline
3) Acupuncture
4) Ensure patient has had recent optician check
What is new daily persistent headache, which type of headache is it similar to?
Similar to tension headache, pt starts to experience daily headache with no previous history of episodic headache, rarely sinister
What are the 4 causes of new daily persistent headache?
1) Raised ICP (unlikely to be tumour is only headache, idiopathic intracranial hypertension (IIH))
2) Low ICP (spontaneous intracranial hypotension, post LP headache)
3) Chronic meningitis (infective and non infective)
4) Post head injury
Idiopathic intracranial hypertension is common in which groups?
Women of child bearing age
Is idiopathic intracranial hypertension benign?
No, as there is a risk of going blind
In which patients should you think about idiopathic intracranial hypertension?
Think about this is patients with headache, visual disturbances and no other factors
What 2 things can be used to manage idiopathic intracranial hypertension?
1) Weight loss
2) Diamox (used to treat altitude sickness)
How is chronic daily headache defined?
Headache lasting >4 hours on >15 days per month, for >3 months
Give the 4 causes of chronic daily headache?
1) De novo: new daily persistent headache Previous episodic headache: 2) Transformed migraine 3) Chronic tension type headache 4) Hemi-crania continua
What are the treatment options for chronic daily headache?
Treatment options are limited but you can withdraw analgesia if overuse
Consider amitriptyline/ topiramate for transformed migraine
