Neurology: Headaches Flashcards
Explain the difference between primary and secondary headaches
- Primary headaches: not associated with an underlying condition for example migraine, tension-type headache, and cluster headache.
- Secondary headaches: occur as a result of underlying local or systemic pathology for example due to trauma, intracerebral infection, vascular disorders, medication overuse or neoplasm.
State some examples of primary headache disorders
- Tension headache
- Migraine
- Cluster headache
State some examples of secondary headache disorders
- Raised ICP e.g. due to SOL in brain
- Intracranial haemorrhage
- Intracranial infections e.g. meningitis, encephalitis
- Ophthalmic e.g. acute glaucoma
- Temporal arteritis
- Sinusitis
- Pre-eclampsia
- Medication overuse
- Hypertension
- Hypoxia
- Exposure to withdrawal from a substance such as carbon monoxide, cocaine, opioids, ergotamines, triptans, simple analgesics, or alcohol
State some key questions/aspects of a headache history
- The history should include questions on:
- Onset
- Duration
- Frequency and temporal pattern
- Site
- Nature of headache e.g. sharp, dull, throbbing
- Aggravating factors (in women ask about relationship to menstruation)
- Relieving factors
- Associated features such as aura, nausea, tearing, swelling of the eyelid or rhinorrhoea.
- Explore red flags
- Past medical history including immunosuppression and malignancy.
- Drug history including drugs used for headache and others e.g. anticoagulants, glucocorticoids, and cocaine.
What should you examine in someone with a headache?
*NOTE: might not do all of this dependent on symptoms and differential diagnoses
- Vital signs
- Fundoscopy
- Neuro examination (cranial nerves, upper, lower, cerebellar)
- Extracranial signs e.g. pulseless temporal artery
State some red flags for headaches and for each indicate what it is a red flag for
- Fever, photophobia or neck stiffness (meningitis or encephalitis)
- Non-blanching rash (meningitis)
- New neurological symptoms (haemorrhage, malignancy or stroke)
- Dizziness (stroke)
- Visual disturbance (temporal arteritis or glaucoma)
- Thunderclap headache (subarachnoid haemorrhage)
- Worse on coughing or straining (raised intracranial pressure)
- Postural, worse on standing, lying or bending over (raised intracranial pressure)
- Severe enough to wake the patient from sleep
- Vomiting (raised intracranial pressure or carbon monoxide poisoning)
- History of trauma (intracranial haemorrhage)
- Pregnancy (pre-eclampsia)
- Cognitive dysfunction
- Impaired level of consciousness
NICE suggest that if two or more of the ‘red-flag’ criteria are present then an urgent CT scan should be performed as the likelihood of a serious intracranial pathology being the cause of a presentation is high
In the 2012 guidelines NICE suggest the following:
- compromised immunity, caused, for example, by HIV or immunosuppressive drugs
- age under 20 years and a history of malignancy
- a history of malignancy known to metastasis to the brain
- vomiting without other obvious cause
- worsening headache with fever
- sudden-onset headache reaching maximum intensity within 5 minutes - ‘thunderclap’
- new-onset neurological deficit
- new-onset cognitive dysfunction
- change in personality
- impaired level of consciousness
- recent (typically within the past 3 months) head trauma
- headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise
- orthostatic headache (headache that changes with posture)
- symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
- a substantial change in the characteristics of their headache
For a tension headache, discuss:
- Where pain is
- How pain is described
- Associations
- Management
- Band like pattern around head
- Mild ache, may come and go, resolves gradually
- Associations:
- Stress
- Depression
- Alcohol
- Lack of sleep
- Skipping meals
- Dehydration
- Management:
- Reassurance
- Simple analgesia
- Identify and manage assocations
State some different types of migraine
- Migraine without aura
- Migraine with aura
- Silent migraine
- Hemiplegic migraine
State some common triggers for migraines
- Tiredness
- Stress
- Lack of food
- Dehydration
- Certain foods e.g. cheese, chocolate, red wine, citrus fruit
- Alcohol
- Bright lights
- Menstruation
- COCP
How long do migraine headaches usually last?
State some characteristics of migraine headaches
Headaches last between 4 and 72 hours. Typical features are:
- Moderate to severe intensity
- Pounding or throbbing in nature
- Usually unilateral but can be bilateral
- Discomfort with lights (photophobia)
- Discomfort with loud noises (phonophobia)
- With or without aura
- Nausea and vomiting
***NOTE: in children attacks may be shorter, headache more commonly bilateral and GI disturbance more prominent
What do we mean by aura when talking about migraines?
Visual changes associated with migraines that can last 5-60 minutes e.g:
- Sparks in vision
- Blurred vision
- Lines across vision
- Loss of visual fields
Describe the migraine diagnostic criteria
Outline the 5 stages of migraines (NOTE: not all pts have all stages)
- Prodromal/premonitory: can begin 3/7 before with vague symptoms such as fatigue, mood changes and yawning
- Aura: visual changes last up to 60 mins
- Headache: lasts 4-72hrs
- Resolution: headaches fades or resolves often by vomiting or sleeping
- Post-dromal/recovery
Discuss the acute management of migraines
- Paracetamol
- NSAIDs (e.g. ibuprofen)
- Triptans (e.g. sumatriptan)
- Antiemetics (e.g. metoclopramide)
Pts may also have other management techniques e.g. go to dark, quiet room
How do triptans work in migraines?
- 5HT3 receptors agonists (serotonin receptor agonists)
- Various mechanisms (not sure which is responsible for effect on migraine):
- Vasoconstriction
- Inhibit activation of peripheral pain receptors
- Reduce neuronal activity in CNS
- **
- ***Wouldn’t worry about details*
Discuss the prophylactic/preventative management of migraines
- Using a headache diary to identify triggers and then avoiding triggers
- Medications:
- Propranolol
- Amitriptyline
- Topiramate
- Acupuncture
- Prophylaxis with NSAIDS or triptans if triggered around menstruation
- Supplementation with vitamin B2 may reduce frequency & severity
State some contraindications to triptans
- Coronary vasospasm/ischaemic heart disease
- mild uncontrolled hypertension; moderate and severe hypertension
- peripheral vascular disease
- previous cerebrovascular accident or TIA
- previous myocardial infarction
**Can cause vasospasm
For a hemiplegic migraine, discuss:
- What it may mimic
- Symptoms
- Mimic stroke so important to rule out a stroke quickly
- Symptoms:
- Typical migraine symptoms
- Hemiplegia
- Ataxia
- Changes in consciousness
Discuss the prognosis of migraines
Generally improves with increasing age
For a cluster headache, describe:
- Where pain is
- Quality of pain
- Pattern of headaches
- Triggers
- Associated symptoms
- Risk factors
- Prognosis
- Unilateral, usually around eye
- Sharp, stabbing, penetrating pain- very severe & often disabling
- Rapid onset and can last between 15mins to 2-3 hours, 1-2 times per day/ Cluster attacks typically last 4-12 weeks. Remissions could be months to years.
- Triggers:
- Alcohol
- Cigarettes
- Lack of sleep
- Exercise
- Warm temp
-
Ipsilateral autonomic features:
- Red, watery eye
- Nasal congestion
- Ptosis & eyelid oedema
- Facial sweating
- Risk factors:
- MALE
- Smoking
- Tend to remit with age (usually present age 20-50yrs)
Discuss the acute management of cluster headaches
- Short burst oxygen therapy (100% oxygen at a flow rate of 12–15 litres per minute via a non-rebreather face mask for 15 to 20 minutes)
- SC or nasal triptans
*NOTE: avoid oral triptans, paracetamol, nonsteroidal anti-inflammatories, opioids
Discuss the prophylactic management of cluster headaches
- Avoiding triggers
- Verapamil
Neurologists may talk about trigeminal autonomic cephalgia; what conditions are included in this overarching term?
- Cluster headaches
- Paroxysmal hemicrania
- SUNCT (short-lived unilateral neuralgiform headache with conjunctival injection and tearing)
*If you suspect any of these it’s recommended to refer as specific treatment may be required e.g. indomethacin for paroxysmal hemicrania. Don’t need to worry about details, just know what is included in this term
What characteristics/features may make you think a headache is due to sinusitis?
What is the management?
- Characteristics:
- Facial pain behind nose, forehead & eyes
- Tenderness over sinus
- Sinusitis symptoms
- Management:
- Most is viral and resolves on own
- Nasal irrigation can help
- Nasal steroids if prolonged
- Antibiotics if think bacterial
For medication overuse headaches, discuss:
- Diagnostic criteria
- Presentation
- Management
-
Diagnostic criteria: headache occurring on 15 or more days per month for which a pt has been regularly overusing medication for at least 3 months
- Triptans, opioids, ergotamine: 10 days per month or more
- Simple analgesics: 15 days per month or more
- Association:
- Depression
- Sleep disturbance
- Most common cause= co-codamol (but pts taking opioids & triptans most at risk)
- Management:
- Explain diagnosis & educate pt on what to expect during withdrawal
- Withdraw simple analgesics & triptans abruptly
- Withdraw opioids gradually
*Withdrawal symptoms: vomiting, sleep disturbance, anxiety, palpitations
For trigeminal neuralgia, discuss:
- Possible causes
- Presentation
- Triggers
- Management
- May be idiopathic, due to compression of CNV (by tumour or vascular loop [90%]), presentation of MS
- Presentation:
- 90% unilateral
- Electric shock/sharp pains limited to one or two divisions of trigeminal nerve
- Sudden onset & abrupt ending
- Lasts few seconds-minutes
- Recurrent (may have symptom free periods between)
- Triggers:
- Cold
- Light touch
- Eating
- Talking
- Brushing teeth
- Shaving
- Kissing
- Management:
- First line= carbamazepine
- Surgery to decompress or intentionally damage nerve
For cervical spondylosis, discuss:
- What it is
- Presentation
- Osteoarthritis of cervical spine
- Presentation:
- Neck pain exacerbated by movement
- Headache (back of neck/occipital region)
- Radiating arm pain
- Cervical muscle pain & spasm
For hormonal headaches, discuss:
- What hormone associated with
- When worse
- Management
- Low oestrogen
- Worse:
- 2-3 days before menstruation
- Menopause
- First few weeks pregnancy
- COCP can help
For hormonal headaches, discuss:
- What hormone associated with
- When worse
- Management
- Low oestrogen
- Worse:
- 2-3 days before menstruation
- Menopause
- First few weeks pregnancy
- COCP can help
What proportion of pts get a headache post lumbar puncture?
Describe characteristics of headache
State some factors that may contribute to headache (make it worse)
- ⅓ of patients
- Develops in 24-48hrs of LP:
- Worsen with upright position
- Improves with lying down
- Associated neck pain, nausea, vomiting
- Last few days
- See image for factors
- Management:
- Supportive (analgesia, rest)
- If continues >72hrs options include IV caffeine, epidural blood patch, epidural saline
State some features that suggest headache is due to raised ICP
- Worse on leaning forward
- Worse on cough
- Worse on valsalva
- Wake up with headache
- Wake from sleep
- Pulsatile tinnitus
- Papilledema
For benign intracranial hypertension, discuss:
- Who common in
- Associations
- Presentation
- Management
- Women aged 20-40yrs
- Associations
- Obesity
- Endocrine disorders (e.g. Cushing’s, hypothyroid etc…)
- Medications e.g. steroids, COCP
- …. and others
- Presentation:
- Throbbing headache
- Wake up with it
- Worse when cough or strain
- Better when stand up
- Nausea
- Management:
- Lifestyle/conservative: losing weight, stopping medications that may be associated etc…
- Carbonic anhydrase inhibitors
- Surgery (insertion of a shunt or fenestration of optic nerve)
- Lumbar puncture may be done to ease symptoms
For benign intracranial hypertension, discuss:
- Who common in
- Associations
- Presentation
- Management
- Women aged 20-40yrs
- Associations
- Obesity
- Endocrine disorders (e.g. Cushing’s, hypothyroid etc…)
- Medications e.g. steroids, COCP
- …. and others
- Presentation:
- Throbbing headache
- Wake up with it
- Worse when cough or strain
- Better when stand up
- Nausea
- Management:
- Lifestyle/conservative: losing weight, stopping medications that may be associated etc…
- Carbonic anhydrase inhibitors
- Surgery (insertion of a shunt or fenestration of optic nerve)
- Lumbar puncture may be done to ease symptoms
Other causes of headache which are covered in more detail in other flashcards:
- Subarachnoid haemorrhage
- Post-traumatic headaches (e.g. subdural & extradural haemorrhage)
- Acute angle glaucoma
- Temporal arteritis
*
For benign intracranial hypertension, discuss:
- Who common in
- Associations
- Presentation
- Management
- Main risk
- Women aged 20-40yrs
- Associations
- Obesity
- Endocrine disorders (e.g. Cushing’s, hypothyroid etc…)
- Medications e.g. steroids, COCP
- …. and others
- Presentation:
- Throbbing headache
- Wake up with it
- Worse when cough or strain
- Better when stand up
- Nausea
- Management:
- Lifestyle/conservative: losing weight, stopping medications that may be associated etc…
- Carbonic anhydrase inhibitors
- Surgery (insertion of a shunt or fenestration of optic nerve)
- Lumbar puncture may be done to ease symptoms
- Main risk= loss of vision
For benign intracranial hypertension, discuss:
- Who common in
- Associations
- Presentation
- Management
- Women aged 20-40yrs
- Associations
- Obesity
- Endocrine disorders (e.g. Cushing’s, hypothyroid etc…)
- Medications e.g. steroids, COCP
- …. and others
- Presentation:
- Throbbing headache
- Wake up with it
- Worse when cough or strain
- Better when stand up
- Nausea
- Management:
- Lifestyle/conservative: losing weight, stopping medications that may be associated etc…
- Carbonic anhydrase inhibitors (reduce CSF production)
- Surgery (insertion of a shunt or fenestration of optic nerve)
- Lumbar puncture may be done to ease symptoms
State some contraindications to lumbar puncture
Do not perform a lumbar puncture without consultant instruction if any of the following contraindications are present:
- signs suggesting raised intracranial pressure or reduced or fluctuating level of
- consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 points or more)
- relative bradycardia and hypertension
- focal neurological signs
- abnormal posture or posturing
- unequal, dilated or poorly responsive pupils
- papilloedema
- abnormal ‘doll’s eye’ movements
- shock
- extensive or spreading purpura
- after convulsions until stabilised
- coagulation abnormalities or coagulation results outside the normal range or platelet
- count below 100x109/litre or receiving anticoagulant therapy
- local superficial infection at the lumbar puncture site
- respiratory insufficiency in children.
NICE suggest that if two or more of the ‘red-flag’ criteria are present then an urgent CT scan should be performed as the likelihood of a serious intracranial pathology being the cause of a presentation is high
In the 2012 guidelines NICE suggest the following:
- compromised immunity, caused, for example, by HIV or immunosuppressive drugs
- age under 20 years and a history of malignancy
- a history of malignancy known to metastasis to the brain
- vomiting without other obvious cause
- worsening headache with fever
- sudden-onset headache reaching maximum intensity within 5 minutes - ‘thunderclap’
- new-onset neurological deficit
- new-onset cognitive dysfunction
- change in personality
- impaired level of consciousness
- recent (typically within the past 3 months) head trauma
- headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise
- orthostatic headache (headache that changes with posture)
- symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
- a substantial change in the characteristics of their headache
