Primary and Secondary headache syndromes Flashcards
What is included in a headache history?
Onset/peak
- acute vs subacute vs gradual
Relieving features
- posture, headache behaviour
Exacerbating
- Posture, valsalva (sneezing, couging, straining). Diurnal variation.
Associated features
- autonomic features (N+V), photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness
What are the headache red flags?
- new onset headache >55
- known/previous malignancy
- immuno-suppressed
- early morning headache
- exacerbation by valsalva
What proportions of migraines have aura?
20%
What are the IHS criteria for migraine without aura?
- At least 5 attacks
- duration 4-72 hours
- 2 of: moderate/severe, unilateral, throbbing, pain, worse on movement
- 1 of: autonomic features, photophobia/phonophobia
What is the pathophysiology of migraine?
Both vascular and neural influences cause migraines in susceptible individauls
Stress triggers changes in the brain, these changes cause serotonin to be released.
Blood vessels constrict and dilate.
Chemicals including substance P irritate nerves and blood vessels causing pain.
What is the neurophysiology of migraine with aura
- Cortical spreading depolarisation
- activation trigeminal vascular system- dilatation of cranial blood cessels
- release of substance P, neurokinin A, CGRP
What is aura
Fully reversible visual, sensory, motor or language symptom
Aura duration 20-60 minutes
Visual is most common (positive symptoms usually monochromatic)
What is the typical pattern of migraine with aura?
headach follows aura <1 hour later but can occur simultaneously
What are some examples of a visual aura
Central Scotoma
Central fortification
Hemianopic loss
What are some triggers of migraine?
- sleep
- dietary
- stress
- hormonal
- physical exertion
What is the non-pharmacological treatment for migraine?
Set realistic goals
Education- avoid triggers
Headache diary
Relaxation/stress management
What is the pharmacological treatment for migraine?
Acute- NSAID, triptans
Phrophylactic- amitriptyline, propanolol, topiramate, gabapentin, pizotifen, Na valproate, botulinum toxin, anti calcitoning gene related peptide Ab
Describe use of NSAIDs for abortive treatment of migraines?
Aspirin 900mg
Naproxen 250mg
Ibuprofen 400mg
+/-
anti-emetic
Describe the use of triptans for abortive migraine treatment?
Given: oral, sublingual, subcutaenous- depending on N&V
Treat at start of headache
Rizatriptan = eletriptan > sumatriptan
Frovatriptan for sustained relief
What are triptans?
5-HT agonists
When should migraine prophylaxis be considered?
More than 3 attacks a month or very severe attack
What is the aim of migraine prophylaxis?
Titrate drug as tolerated to achieve efficacy at the lowest dose possibile
How long must migraine prophylaxis be trialed?
Trial all methods for 3 months minimum
What non-pharmacological prophylaxis can be trialed?
Acupuncture
Relaxation exercises
What dose of amitriptyline is used for migraine prophylaxis?
10-25mg (max 75mg)
What are the adverse effects of amitriptyline
Dry mouth, postural hypotension, sedation
What dose of propanolol should be used for migraine prophylaxis?
80-240mg
Which patients cannot use propanolol for migraine prophylaxis?
Patients with; Asthma, PVD, HF
What dose of topiramate can be used for migraine prophylaxis?
25mg-100mg
What class of drug is topiramate?
What are the adverse effect?
Carbonic anhydrase inhibitor (Na/GABA)
Adverse effects: weight loss, paraesthesia, impaired concentration, enzyme inducer
What lifestle changes should be encouraged in migraine sufferers?
- Diet- regular intake, avoid triggers, healthy balanced diet
- Hydration- at least 2 litres a day, decrease caffeine
- Stress- decrease
- Regular exercise
What are the atypical types of migraine?
- acephalgic
- basilar
- retinal
- ophthalmic
- hemiplegic (familial sporadic)
- abdominal
What are the two variations of tension type headach
Episodic vs chronic
What are the characteristics of a tension type headache?
Presssing tingling quality
Mild to moderate
Bilateral
Absence of N&V
Absence of photophobia or phonophobia
What are the treatments for tension type headache?
- relaxation physiotherapy
- antidepressant
- sothiepin or amitriptyline 3 months Rx*
- -* reassurance
What are trigeminal autonomic cephalgias?
Group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features.
What are the prominent ipsilateral cranial autonomic features?
Ptosis
Miosis
Nasal Stuffiness
N&V
Tearing
Eye lid oedema
What are the 4 main types of trigeminal autonomic cephalgias?
Cluster
Paroxysmal hemicrania
Hemicrania continua
SUNCT
Who gets cluster headaches?
Young people 30s-40s
Men > Women
When to cluster headaches occur?
Circadian and seasonal variation
What are the features of cluster headaches?
- severe unilateral headache, duration: 45-90mins (20 mins-3 hours)
- Frequency: 1 to 8 day
- Cluster bout may last from a few weeks to months
What is the treatment for cluster headaches?
- High flow oxygen 100% for 20 mins
- Subcutaenous sumatriptan 6mg
- Steroids- reducing course over 2 weeks
- Verapamil for prophylaxis
Who suffers from paroxysmal hemicrania?
Elderly 50s-60s
Women>men
What are the features of paroxysmal hemicrania?
- severe unilateral headache, unilateral autonomic features
- duration: 10-30minutes (2 mins-45hours)
- Frequency 1 to 40 a day
What is the treatment for paroxysmal hemicrania?
Absolute response to indomethicin
What differentiates paroxysmal hemicrania from cluster headaches
Shorter duration and more frequent
What is SUNCT?
S= short lived (15-120 seconds)
U= unilateral
N= neuralgiaform headache
C= conjunctival injections
T= tearing
What is the treatment for SUNCT?
Lamotrigine, gabapentin
What do those with new onset unilateral cranial autonomic features require?
MRI brain and MR angiogram
Who is affected by idiopathic intracranial hypertension?
F>M
obese
Describe the presentation of idiopathic intracranial hypertension?
Headache
- diurnal variation
- morning N&V
Visual loss
What abnormalities will be found in idiopathic intracranial hypertension?
Elevated pressure of CSF
What is the treatment for idiopathic intracranial hypertension?
- weight loss
- acetazolamide
- ventricular atrial/lumbar peritoneal shunt
- monitor visual fields and CSF pressure
Who is affected by trigeminal neuralgia?
Elderly >60
Women> Men
What triggers trigeminal neuralgia?
Touch, usually V2/V3
What are the features of trigeminal neuralgia?
Severe stabbing unilateral pain
Duration: 1 second to 90 seconds
Frequency: 10 to 100 day
Bouts of pain may last from a few weeks to months before remission.
What is the medical treatment for trigeminal neuralgia?
Carbamazepine, gabapentin, phenytoin, baclofen
What is the surgical treatment for trigeminal neuralgia?
Ablation
Decompression
What are the investigations for trigeminal neuralgia?
MRI brain
What should be taken into consideration when there is facial pain?
Non-neurological structures e.g. eyes, ears, sinuses, teeth, TMJ
