Primary and Secondary Headache Flashcards
important questions in headache history?
what happened before the headache?
any strange symptoms as headache was developing?
how did it evolve? (getting worse or better or changing)
how suddenly did it arise?
exacerbating/relieving factors? (posture, behaviours etc)
severity?
PMH
FH (esp migraine)
DH
SH
headache diary
headache when lying down which is relieved by standing up, what may be the cause?
raised ICP
name 5 red flags?
new onset headache in >55 known/previous malignancy immunosuppressed early morning headache exacerbation by valsalva
who is migraine most common in?
young females
most migraine sufferers have how many attacks per month?
around 1
does migraine always have aura?
no, 80% don’t have any aura
aura can by anything really
criteria for migraine without aura?
at least 5 attacks lasting 4-72 hours 2 of: - mod/severe - unilateral -throbbing pain - worse on movement 1 of - autonomic features - photophobia/photophonia
cluster headaches vs migraine?
cluster headache patients prefer to be up and about, almost banging head off wall
migraine prefer to be still
peak ages in women for migraine?
early teenage years
around menopausal years
(hormonally driven)
pathophysiology of migraine?
vascular and neural influences in susceptible individuals
stress triggers changes in brain which cause serotonin to be released
blood vessels then constrict and dilate (constrict early on in aura phase)
chemical pain substances (including substance P) are released which irritate nerves and blood vessels causing pain
pathway in migraine with aura?
cortical spreading depolarization > activation of trigeminal vascular system > dilation of cranial blood vessels > release of substance P, neurokinin, CGRP (pain chemicals)
features of migraine with aura?
aura = fully reversible visual, sensory, motor or language symptom (usually visual)
aura lasts 20-60 mins
headache follows <1 hr later but aura can occur simultaneously
types of visual aura?
central scotoma (blurred centre) central fortification (distorted centre) hemianopic visual loss (loss of left/right field)
what can trigger migraine?
sleep dietary (chocolate, cheese) stress hormonal physical exertion
non-pharmacological treatments for migraine?
set realistic goals
education - avoid triggers
headache diary
relaxation/stress management
pharmacological management of migraine?
acute
prophylaxis
acute migraine management?
stepwise approach
NSAID +/- antiemetic
- 900mg aspirin/250mg naproxen/400mg ibuprofen
triptans (5-HT agonist)
how are triptans used?
oral/sublingual/SC
treat at start of headache
efficacy similar to NSAID
types of triptan?
rizatriptan = eletriptan > sumatriptan
frovatriptan for sustained relief
when is prophylaxis considered for migraine?
more than 3 attacks per month
each method is trialled for min 3 months
non-pharmacological prophylaxis?
acupuncture
relaxation
exercises
pharmacological prophylaxis of migraine?
amitriptyline (10-25mg, 75mg max) propanalol (80-240mg) topiramate (25-100mg) (CA inhibitor) gabapentin pizotifen Na valproate botox anti-calcitonin gene related toxin Ab
adverse effects of amitriptyline?
dry mouth
postural hypotension
sedation
propanalol adverse effects?
PVD nightmares avoid in asthma heart failure raynauds
side effects of topiramate?
weight loss depression paraesthesia impaired concentration enzyme inducer
Na valproate can only be used in which people?
menopausal
only if no possibility of pregnancy
what is anti-calcitonin gene related peptide Ab?
monoclonal antibody newly liscened
what lifestyle factors can help migraines?
diet (regular intake, avoid triggers)
hydration (2L day, decrease caffeine)
stress relief
regular exercise
fancy types of migraine?
acephalgic (speech, vision, nausea)
basilar (vertigo, unsteady, incapacitated)
retinal
ophthalmic
hemiplegic (familial/sporadic, channelopathy, stroke like features, lasts days-weeks, encephalopathic, drowsy/unresponsive)
abdominal (abdo pain, common in kids)
how does tension headache present?
episodic or chronic pressing, tingling quality mild-mod bilateral no nausea/vomiting no photophobia/phonophobia
management of tension headache?
relaxation therapy
antidepressant
reassure
migraine relates syndrome which aren’t migraine?
trigeminal autonomic cephalgias
- group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features
trigeminal autonimic cephalgias features?
partial ptosis (often have smaller pupil on same side) miosis nasal stuffiness nausea/vomiting tearing eye lid oedema
what are the 4 main types of trigeminal autonomic cephalgia?
cluster
paroxysmal hemicrania
hemicrania continua
SUNCT
who is cluster headache most common in?
men 30s-40s
features of cluster headache?
striking circadian (around sleep) with seasonal variation
severe unilateral headache lasting 45-90 mins
frequency 1-8 days
cluster bout may last from few weeks to months
how can cluster headache be managed?
high flow oxygen (100% for 20 mins)
S/C sumatriptan 6mg
steroids (reducing course over 2 weeks beginning at start of cluster bout)
verapamil for prophylaxis
who is paroxysmal hemicrania most common in?
elderly women
features of paroxysmal hemicrania?
severe unilateral headache unilateral autonomic features lasting 10-30 mins frequency = 1-40 per day shorter duration and more frequent than cluster normal scan
management of paroxysmal hemicrania?
absolute response to indomethacin
features of SUNCT?
SUNCT
- short lived (15-120 secs)
- unilateral
- neuralgiaform headache
- conjunctival injections
- tearing
treatment of SUNCT?
lamotrigine
gabapentin
how is headache investigated?
new onset unilateral cranial autonomic features require imaging
MRI brain and MR angiogram
what is idiopathic intracranial hypertension?
high pressure in spaces that surround brain and spinal cord
associated with hypertension and obesity
causes diurnal headache, visual loss and morning N & V
what is seen on fundoscopy in IIH?
loss of disc margin
papilloedema
how is IIH investigated?
MRI brain with MRV sequence (will be normal)
CSF sample (elevated pressure, normal constituents)
- only do in raised ICP if IIH suspected and scan is normal (must be scanned first)
visual fields
management of IIH?
weight loss
acetazolamide (CA inhibitor)
ventricular atrial/lumbar peritoneal shunt (not first line, if weight loss fails etc, only done to save vision)
monitor visual fields and CSF pressure
who gets trigeminal neuralgia?
elderly women
features of trigeminal neuralgia?
triggered by touch, chewing, swallowing etc, usually V2/3
severe, sharp, stabbing
unilateral nerve pain lasting 1 sec-90secs
frequency = 10-100 per day
bouts of pain may last from a few weeks to months before remission
how is trigeminal neuralgia managed?
investigate = MRI carbamazepine (1st?) gabapentin phenytoin baclofen surgical in few cases (ablation/decompression)
