Primary and Secondary Headache Syndromes Flashcards
What are important facts to elicit in the history of a headache?
Onset/ peak: acute vs subacute
Relieving features: posture, headache
Exacerbating features: posture, valsalva, diurnal variation
Assoc features; autonomic, photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness
Consider demographic
What are the red flags in terms of headaches?
New onset headache >55yrs Known/ previous malignancy Immunosuppressed; think about intracranial infection Early morning headache Exacerbation by valsalva
What is the demographics of a migraine?
Commoner in women
Most will have an attack once a month
Migraine without aura: 80%
Migraine with aura: 20%
What is the IHS criteria for a migraine without aura?
At least 5 attacks of duration 4-72 hours
2 of: moderate/severe pain, unilateral, throbbing, worse with movement
1 of: autonomic features, photophobia, phonophobia, N+V
What is the pathophysiology of migraines?
Vascular and neural influences
Stress will trigger changes in the brain resulting in the release of serotonin
Blood vessels constrict and dilate
Chemicals including substance P, neurokinin A and CGRP irritate nerves and blood vessels resulting in pain
In what stages of a migraine will the blood vessels constrict and dilate?
Constrict: aura phase
Dilate: headache phase
What are common triggers of migraines?
Lack of sleep Dietary; dark chocolate, cheese, alcohol, hangovers Stress Hormonal; menstrual cycle Physical exertion
What are the non-pharma treatments of migraines?
Set realistic goals Education; avoid triggers CHOCOLATE: Chocolate Hangovers Orgasms Cheese/ caffeine OCP Lie-ins Alcohol Travel Exercise Headache diary Relaxation/ stress management
What are the pharmacological principles to treating migraines?
Acute treatment
Prophylactic treatment
What drugs are used in the acute management of a migraine?
NSAID; 900mg aspirin, 350mg naproxen, 400mg ibuprofen
+/- antiemetic
Triptans - selective 5-HT agonists
Do NSAIDs help with migraine pain?
60% significant reduction in headache at 2 hours
Only 25% to complete pain relief
What are triptans?
5-HT agonist
When should triptans be give?
At the start of the headache; similar efficacy to NSAIDs
What are examples of triptans?
Rizatriptan
Eletriptan
Sumatriptan
Fovatriptan
How can triptans be given?
Oral
Sub-lingual
Subcut
When should you consider prophylaxis for migraines?
More than 3 attacks a month or very severe
What is the aim with prophylaxis?
Titrate drug as tolerated to achieve efficacy at the lowest dose possible
Must trial each for a minimum of 3 months
GO SLOW AND KEEP LOW
What are examples of migraine prophylaxis?
Amitriptyline Propranolol Topiramate Gabapentin Pizotifen Sodium valproate Botulinum toxin Anti calcitonin gene related peptide (CGRP) Ab
What dose of amitriptyline is given in migraine prophylaxis and what are the adverse effects?
10-25 mg - max 75mg
Adverse: dry mouth, postural hypotension, sedation: Anticholinergic effects
What dose is given on propranolol in migraine prophylaxis and what are the contraindications?
80-240 mg daily
Avoid in asthma, PVD
What mechanism of action of topiramate?
Carbonic anhydrase inhibitor
What dosage of topiramate is given in migraine prophylaxis and what are the adverse effects?
25-100mg
Adverse: weight loss, paraesthesia, impaired concentration, enzyme inducer, teratogenic
Should you give sodium valproate in young women?
No - highly teratogenic
Give in menopausal women
What lifestyle factors can be used as prophylaxis of migraines?
Diet; regular intake, avoid triggers, healthy balanced diet
Hydration; at least 2 L/ day, decrease caffeine
Stress - decrease
Regular exercise
What are the rare subtypes of migraines?
Basilar
Retinal/ ophthalmic
Hemiplegic
Abdominal
What is a tension type headache?
Episodic vs chronic Pressing tingling quality Mild to mod Bilateral Absence of N+V Absence of photophobic or phonophobia
What is the treatment for tension type headaches?
Relaxation physiotherapy
Antidepressant; dothiepin or amitriptyline
Reassure
What are trigeminal autonomic cephalgias (TAC)
Primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in assoc with prominent ipsilateral cranial autonomic features
What are ipsilateral cranial autonomic features?
Ptosis Miosis Excess lacrimation Injection of conjuntiva Nasal stuffiness N+V Eye lid oedema
What are the 4 main types of TACs?
Cluster
Paroxysmal hemicrania
Hemicrania continua
SUNCT
What is the demographic of cluster headaches?
Young - 30s/40s
Men more than women
When will people get cluster headaches?
Striking circadian and seasonal variation
What are the features of cluster headaches?
Severe unilateral headache
Duration of 45-90 mins
Frequency of 1-8 a day
Cluster bout can last from a few weeks to months
What is the treatment of cluster headaches?
High flow oxygen 100% for 20mins
Subcut sumatriptan 6mg
Steroids; reducing course over 2 weeks
Verapamil for prophylaxis
What is the demographic of paroxysamal hemicrania headaches?
Elderly 50s/60s
Women more than men
What are the features of paroxysmal hemicrania headaches?
Severe unilateral headache, unilateral autonomic features
Duration of 10-30 mins
Frequency of 1-40 a day
What is the treatment for paroxysmal hemicrania headaches?
ABSOLUTE RESPONSE to indomethacin
What does SUNCT stand for?
Short lived Unilateral Neuralgioaform headache Conjunctival injections Tearing
What is the treatment for SUNCT?
Lamotrigine
Gabapentin
Describe the duration of all headaches
Migraine: hours
Cluster: 45-90 mins
Paroxysmal hemicrania: 10-30 mins
SUNCT: seconds
What are the indications for imaging in headaches?
ALL those with new onset unilateral cranial autonomic features requires imaging; MRI brain or MRA
Who is likely to get idiopathic intracranial hypertension?
Females
Obese
What are the symptoms of idiopathic intracranial hypertension?
Diurnal variation
Morning N+V
Visual loss`
Why will all those with idiopathic intracranial hypertension get a scan?
To ensure not tumour or obstructive hydrocephalus
What will be seen in fundoscopy of IIH?
Papilloedema
What will be seen on LP in IIH?
Increased pressure
Normal constituents; white cells, protein and glucose
What investigations should be done in IIH?
MRI brain with MRV sequence
LP
Visual fields
Do you do an LP in increased ICP?
NO: UNLESS CT SCAN IS NEGATIVE
What is the treatment for IIH?
Wt loss
Acetazolamide
Ventricular atrial/ lulmbar peritoneal shunt only if going blid
What is the demographic of trigeminal neuralgia?
Elderly (>60yrs)
Women more than men
What can trigger trigeminal neuralgia?
Touch in V2/3
Chewing
Eating
Swallowing
What are the features of trigeminal neuralgia?
Severe stabbing unilateral pain
Duration: 1 to 90 secs
Frequency: 10-100 day
Bouts pain may last from a few weeks to months before remission
What are the medical treatments of trigeminal neuralgia?
Carbamezapine
Gabapentin
Phenytoin
Baclofen
What are the surgical treatments of trigeminal neuralgia?
Ablation
Decompression
What investigations should be done in trigeminal neuralgia?
MRI brain
