Primary and Secondary Headache Syndromes Flashcards
What are some important features of the history of a patient with a headache?
Onset/peak = acute, subacute or gradual
Relieving features = posture, headache behaviour
Exacerbating features = posture, sneezing, coughing
Family history of migraine
What are some potential associated features of headaches?
Nausea and vomiting, photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness
What are the red flags in a patient with a headache?
New onset headache in patient >55 Known or previous malignancy Immunosuppression Early morning headache Exacerbated by valsalva
What are some features of migraines?
More common in women
Most people have 1 attack per month = 20% have aura, 80% do not
What is the criteria for diagnosing a migraine without an aura?
At least 5 attacks = duration 4-72 hours
2 from = moderate/severe, unilateral, throbbing, worse on movement
1 from = autonomic features, photophobia, phonophobia
What causes migraines in susceptible individuals?
Both vascular and neural influences
How does stress trigger migraines?
Stress triggers changes in brain = serotonin release
Chemicals like substance P irritate nerves and blood vessels causing pain
What is the migraine centre of the brain?
Dorsal raphe nucleus and locus coeruleus
What is the flow of depolarisation that occurs in a migraine?
Cortical spreading depolarisation - activation of trigeminal vascular system causing cranial vessel dilation - release of substance P, neurokinin A and CGRP
What are some features of migraines with auras?
Reversible visual, sensory, motor or language symptoms
Duration 20-60 minutes
headache follows <1hr later but aura can occur simultaneously
What are the most common type of aura?
Visual auras = central scotomata, central fortification, hemianopic loss
What are some triggers of migraines?
Headache diary may help identify triggers = sleep, diet, stress, hormonal, physical exertion
What are some drugs used to treat migraines acutely?
NSAIDs and triptans
What are some features of using NSAIDs to treat migraines?
Analgesia = aspirin 900mg, naproxen 250mg, ibuprofen 400mg, may give anti-emetic
Take as early as possible = 60% have significant reduction in headache at 2hours
Consider anti-emetic if gastroparesis present
What are some features of using triptans to treat migraines?
5-HT agonists = oral, sublingual or subcutaneous
Treat at start of headache
Rizatriptan best option but give frovatriptan for sustained relief
When should you consider prophylaxis for migraines?
If more than three attacks per month or very severe = aim is to titrate drug as tolerated to achieve efficacy at lowest dose possible
How long must you trial prophylactic migraine drugs for?
3 months
What are some drugs given for migraine prophylaxis?
Amitriptyline, propanolol and topiramate mainly
Others = gabapentin, pizotifen, botox, anti-calcitonin gene related peptide antibody
What are some features of using amitriptyline as migraine prophylaxis?
10-25 mg = max is 75mg
May cause dry mouth, sedation or postural hypotension
What are some features of using propanolol as migraine prophylaxis?
80mg given daily
Reduces migraine frequency in 60-80%
Avoid in asthma, PVD or heart failure
What are some features of using topiramate as migraine prophylaxis?
Carbonic anhydrase inhibitor = 25-100mg daily
Start slowly as poor side effect profile = weight loss, paraesthesiae, impaired concentration
What are some lifestyle changes that may help migraines?
Healthy diet, decrease caffeine, 2L of water per day, decrease stress, regular exercise
What are migraines?
Common unilateral headaches of the young
What are some examples of more complicated migraines?
Acephalic = aura without headache
Basilar, retinal/ophthalmic. hemiplegic, abdominal
What are some features of tension type headaches?
Episodic or chronic = may be mild or moderate
Pressing tingling quality, bilateral, no nausea/vomiting, absence of photophobia or phonophobia
How are tension type headaches treated?
Relaxation physiotherapy, dothiepin or amitriptyline for three months
What are the types of trigeminal autonomic cephalgias?
Cluster, paroxysmal hemicrania, hemicrania continua. SUNCT
What are the ipsilateral cranial autonomic features of trigeminal autonomic cephalgias?
Ptosis, miosis, nasal stuffiness, nausea and vomiting, tearing, eye lid oedema
What are some features of cluster headaches?
More common in men aged 30-40
Striking circadian and seasonal variation
Severe unilateral headache = 45-90mins, 1-8x daily
Cluster bout may last from few weeks-months
How are cluster headaches treated?
High flow 100% oxygen for 20mins
Subcutaneous sumatriptan 6mg
Steroids for 2 weeks
Verapamil for prophylaxis
What are some features of paroxysmal hemicrania?
More common in women aged 50-60
Shorter duration and more frequent than cluster type
Severe unilateral headache = 10-30min duration, 1-40x a day, unilateral autonomic features
How is paroxysmal hemicrania treated?
Absolute response to indomethicin
What is SUNCT?
Short lived = 15-20s
Unilateral Neuralgiaform headache
Conjunctival injections and Tearing
How is SUNCT treated?
Lamotrigine or gabapentin
What investigations should any patient with a new onset unilateral cranial autonomic feature get?
Brain MRI and MR angiogram
What are some features of idiopathic intracranial hypertension?
More common in women
Headache with morning nausea/vomiting and visual loss = shows diurnal variation
Empty sella and flattened optic disc
What investigations may be done for idiopathic intracranial hypertension?
Normal MRI brain with MRV sequence
CSF = normal constituents, elevated pressure
How is idiopathic intracranial hypertension treated?
Weight loss, acetazolamide, ventricular atrial or lumbar peritoneal shunt
What are some features of trigeminal neuralgia?
More common in women aged >60
Triggered by touch = usually V2 or V3
Investigate with MRI of brain
What is the character of the pain felt in trigeminal neuralgia?
Severe stabbing unilateral pain = duration of 1-90s, occurs 10-100 times a day
Pain bouts may last from few weeks to months
What is the treatment for trigeminal neuralgia?
Drugs = carbamazepine, gabapentin, phenytoin, baclofen Surgery = ablation, decompression
What is the first line treatment for uncomplicated migraines?
Symptomatic over the counter medication
