Primary and secondary headache syndromes Flashcards
What is the most common cause of episodic headache?
Migraine
What are some triggers of migraine?
Sleep deprivation
Diet (E.g. Caffeine, Chocolate)
Stress
Hormonal changes
Physical exertion
Oral contraceptive
Hunger
Describe the pathophysiology of migraine without aura
- Triggers cause changes in the brain which causes release of serotonin
- Blood vessels constrict and dilate
- Chemicals including substance P irritate nerves and blood vessels, causing pain
- This causes sensitisation of trigeminal neurones, making normally innocuous stimuli (E.g. Movement, light and sound perception) painful and uncomfortable
Describe the pathophysiology of migraine with aura
- Cortical spreading depolarisation in the migraine centre of the brain (dorsal raphe nucleus, locus coeruleus)
- Activation of the trigeminal vascular system causes dilation of blood vessels
- Release of substance P, neurokinin A, CGRP
- This causes sensitisation of trigeminal neurones, making normally innocuous stimuli (E.g. Movement, light and sound perception) painful and uncomfortable
How will a migraine present?
Unilateral throbbing headache, occasionally preceded by an aura, associated with nausea, vomiting, photophobia and photophobia
What is a migraine prodrome?
A condition occurring 24-48 hours before the onset of a migraine headache, affecting 1 in 10 migraine sufferers
What are some symptoms of migraine prodrome?
- Mood changes
- Behavioural changes
- Yawning
- Hunger
- Cravings
- Fatigue
- Hyperactivity
What is a migraine aura?
A fully reversible visual, sensory, motor or language symptom, lasting 20-60 minutes associated with migraine onset
What are some aura symptoms?
Scotoma
Central fortification
Hemianopic loss
What are the diagnostic criteria for migraine without aura?
- At least 5 attacks
- 4-72 hours
- 2 of: moderate/severe, unilateral, throbbing pain, worst movement
- 1 of: autonomic features, photophobia/phonophobia
What are some forms of atypical migraine ?
- Acephalgic - no headache
- Basilar - very nauseating, vertigo
- Retinal, opthalmic
- Hemiplegic (familial/sporadic)
- Abdominal - more common in young children
What are some non-pharmacological management options for migraine?
- Set realistic goals
- Education - avoid triggers
- Headache diary
- Relaxation/stress management
What are some acute pharmacological management options for migraine?
NSAIDS (Taken as early as possible)
Triptans (5HT agonist)
Anti-emetic is gastroparesis
What are some examples of triptans?
Rizatriptan
Eletriptan
Sumatriptan
What are some prophylactic management options for migraine?
- Amitriptyline
- Propranolol
- Topiramate
- Acupuncture
- Relaxation exercises
What are some other pharmacological management options for chronic migraine
Botulinum toxin
Anti-calcitonin gene related peptide (Anti CGRP)
How do anti-CGRP drugs work?
- CGRP is a protein that triggers receptors which open up pain pathways related to the start of migraine
- Anti-CGRP agents designed to stop this action
What are some examples of anti-CGRP drugs?
Atogepant
Rimgepant
What is a tension headache?
An attacks headache (usually bilateral) which is pressing or tightening in quality and of mild to moderate intensity lasting minutes to days
What are some associations with tension headache?
- Stress
- Depression
- Alcohol
- Skipping meals
- Dehydration
How does tension headache usually present?
- Bilateral non-throbing headache
- Episodic or chronic
- Pressing tingling quality
- Mild to moderate
- Absence of N+V
- Absence of photophobia or phonophobia
What are some possible clinical signs of tension headache?
They may be associated with tenderness of the scalp muscles, as their contraction is the primary source of the pain
How are tension headaches managed?
- Simple analgesics
- Relaxation physiotherapy
- Reassurance
- Anti-depressants (Dothiepin, amitriptyline)
What is intercranial pressure?
The pressure exerted by the cranium onto brain tissue, CSF and intracranial circulating blood volume
What are some possible causes of raised ICP?
- Mass efect (E.g. tumour)
- Brain swelling (E.g. due to ischaemia)
- Increase in central venous pressure (E.g. Venous sinus thrombosis)
- Problems with CSF flow
What are some abnormalities of CSF flow that can cause raised ICP?
Obstructive hydrocephalus - Masses, chiari syndrome
Increased production - Choroid plexus papilloma
Decreased absorption (Communicating hydrocephalus) - SAH, Meningitis, malignant meningeal disease
What is the normal ICP?
7-15mmHg
What is the Monroe-Kellie doctrine?
A compensatory mechanism for expanding masses:
- Immediate: decrease in CSF volume by moving it out of FM, decrease in blood volume by squeezing sinuses
- Delayed: decrease in ECF
Calculation for cerebral perfusion pressure
MAP - ICP
Calculation for cerebral blood flow
CPP ÷ Cerebral vascular resistance
What are some mechanisms that can allow for auto regulation of cerebral blood flow?
Pressure auto regulation - arterioles dilate or constrict in response to changes in BP or ICP
Metabolic autoregulation - arterioles dilate in response to chemicals e.g. CO2