Primary and Secondary Headache Syndromes Flashcards
Red flags in patient presenting with headache
- New onset headache >55
- Previous tumour/malignancy
- Exacerbation - early morning (raised ICP)
- Exacerbation - valsalva (raised ICP)
- Immunosuppression
Demography and incidence of migraine
More common in females (1:25)
1 year prevalence
Age: <40 yo/
Aura - 20%; without aura - 80%
Pathophysiology of migraine headache
Vascular & neural causes in susceptible individuals
- Stress triggers changes in the brain
- Serotonin is released
- Blood vessels constrict in aura phase and then dilate
- Release of pain substances
- Irritation of nerves and BV –> PAIN
Genetic influences (+ve family history) Hormonal influences (preponderance in women, correlation with menstrual cycle)
Pathophysiology of migraine aura
D/t dysfunction of ion channels –> cortical front of depolarisation (excitiation) spreads –> hyperpolarization (depression of electrical activity)
This occurs at 3mm/minute which corresponds with the spread of the symptoms of aura
List the triggers of a migraine (5)
Sleep Dietary - cheese, chocolate, alcohol, excercise Stress Hormonal Physical exertion
Method to identify triggers of a migraine?
Headache diary
Clinical features of classical migraine
SYMPTOM TRIAD:
- Headache - paroxysmal, unilateral (hemicranial)
- N & V
- Aura - reversible; visual (most common), sensory, motor or language symptoms lasting 20-60 minutes
- General malaise/irritability (just before aura)
- Photophobia
- Transient aphasia (if dominant hemisphere involved)
- limb weakness (hemiplegic migraine)
Clinical features of common migraine
NO AURA
At least 5 attacks
Duration: 4-72hrs
2 of: moderate/severe headache, unilateral, throbbing pain, worse on movement
1 of: autonomic features, photo/phonophobia,
What are the relieving factors of classical migraine?
dark room
Silence
Sleep
Common visual symptom of aura?
Zig-zig lines march across visual field
Non-pharmacologic treatment options for migraines
Set realistic goals
Education - avoid triggers
Headache diary
Lifestyle - avoid alcohol, regular excercise, reduce stress, increase hydration
Treatment for acute episode of migraine
Abortive NSAID +/ - anti emetic
NSAID - Aspirin(900mg), ibuprofen (400mg), naproxen (250mg)
Anti-emetic (NICE - consider administering this even in the absence of N and V) - metoclopramide, domperidone
Treatment for severe migraine
TRIPTAN (alone or in combination with NSAID/paracetamol)
1st line = sumatriptan
Rizatriptan = elatriptan > sumatriptan
Note: consider route of administration in patients with N & V (non-oral forms to be used)
What is the MOA of triptans?
Vasoconstrictors of extra-cranial arteries
What should patients be advised on regarding efficacy of medications?
- Acute medication to be taken when the pain is mild
- If aura is present, triptan should be taken at start of headache and not the start of aura (unless the two occur simultaneously)
Indications for prophylactic management of migraine
If >3 attacks/month or very severe
List the drug classes to be used in migraine prophylaxis
- Tricyclic - amitriptyline (postural HTN, dry mouth, sedation)
- Beta-blocker - propranolol (CI in asthma, PVD, HF)
- Carbonic anhydrase inhibitor - topiramate (weight loss, paraesthesia, impaired concentration, enzyme inducer)
- Others: gabapentin, botulinum toxin, anti-calcitonin, pizotifen, Na valproate
Which migraine prophylactic drug causes dependency?
Gabapentin
Which migraine prophylactic drug is contraindicated in pregnancy?
Na valproate - teratogenicity
What is the side effect of pizotifen?
Weight gain
What is the most common type of headache?
Tension type
Pathophysiology of tension headache
Emotional stress or anxiety
Anxiety about the headache worsens the symptoms
Patients are convinced of a serious underlying condition
Clinical features of tension headache
Bilateral Radiating from occiput Constant and generalised Character - 'dull', 'tight', 'like a pressure' More troublesome as the day goes on Less noticeable when patient is occupied
Negative association - photo/phonophobia, nausea and vomiting
Management of tension-type headache
Reassure patient - no serious underlying pathology
Simple analgesia - paracetamol, aspirin, NSAID
Relaxation physiotherapy + stress management
Low dose antidepressant (amoxicillin or dothiapin, 3 months)
What is the umbrella term for headache syndromes with unilateral trigeminal distribution pain?
Trigeminal autonomic cephalgia
Which feature do all autonomic cephalgias have in common?
Unilateral trigeminal distribution pain
List the 4 autonomic cephalgias
- Cluster headache
- Paroxysmal hemicrania
- SUNCT
- Hemicrania continua
Epidemiology of cluster headace
Age: younger
Gender: M>F
More common in heavy smokers and higher than usual alcohol consumption
Clinical features of cluster headache
Headache: periodic, severe, unilateral
Unilateral peri-orbital pain + unilateral lacrimation, nasal congestion, conjunctival infection
Duration: 45-90mins, striking circadian (about to sleep) or seasonal variation
Pain score: 10/11
Frequency: 1 to 8/day
Cluster bout may last from a few weeks to months followed by a respite for a number of months before another cluster occurs.
Treatment of cluster headache
ACUTE
High flow oxygen (100%) for 20 mins
Subcut sumitriptan (6mg)
PROPHYLAXIS
Steroids reducing course over 2 weeks
Verapamil
Epidemiology of paroxysmal hemicrania
Elderly (50-60 y/o)
Women >men
Clinical features of paroxysmal hemicrania
Severe unilateral headache
Unilateral autonomic features
Duration: 10 to 30 mins
Frequency: 1 to 4/day
Investigations & treatment for paroxysmal hemicrania
MRI brain and MR angiogram for new onset unilateral cranial autonomic features
Absolute response to indomethacin
Clinical features and treatment of SUNCT
S - short-lived U - unilateral N - neuralgia from headache C - conjunctival infections T- tearing
Treatment: carbamazepine, lamotrigine
Clinical features of idiopathic cranial HTN
Obese
F>M
Headache - diurnal variation, N & V
Visual loss
Investigations for idopathic cranial HTN
MRI with MRV sequence - normal
CSF - elevated pressure, normal constituents
Visual fields
Management of idiopathic cranial HTN
Weight loss
Acetolazamide
Ventricular atrial/lumbar peritoneal shunt
Monitor visual field & CSF pressure
Epidemiology of trigeminal neuralgia
Elderly (>60)
Women > men
Pathophysiology of trigeminal neuralgia
Aberrant loop of cerebellar arteries compress on trigminal nerve as it enters brainstem
Other compressive lesions (usually benign)
In MS - plaques of demyelination in the trigeminal root entry zone
Clinical features of trigeminal neuralgia
Pain - lancinating pain in 2nd and 3rd division of CN V (severe, brief, repetitivel unilateral
Precipitated by touching trigger zones - (cold wind on face, eating)
Causes patient to flinch as with motor tic
Duration - 1 to 90 s
Frequency - 1-100/day
High tendency of relapse and remission
Management of trigeminal neuralgia
• Carbamazepine: 1200mg daily
- Start with low dose and increase gradually
• Gabapentin: In those who cannot tolerate carbamazepine
• Phenytoin
• Baclofen
• Surgical: ablation, decompression
• Investigations: MRI brain
