Primary and Secondary Headaches Flashcards
what are the red flags of a headache?
new onset headache >55
known / previous malignancy
immunosuppressed
early morning headache
exacerbated by valsalva (coughing, sneezing - raises ICP)
what should you be aware of in terms of past medical history when someone has headache?
cancer - predisposition to thrombosis
what is family history particularly important in?
migraine
what gender is migraine more common in?
women
on average, most migraine sufferers have how many attacks per month?
1
what % of migraines are those with aura (specific warning signs)?
20
80% are without aura
how do you diagnose migraine without aura by IHS criteria?
at least 5 attacks (duration 4-72 hours)
2 of: moderate / severe, unilateral, throbbing pain, worst movement
1 of: autonomic features, photophobia / phonophobia
what is the pathophysiology of a migraine?
both vascular and neural influences cause migraines in susceptible individuals
stress - serotonin released
blood vessels constrict and dilate
chemicals inc substance P irritate nerves and vessels causing pain
what areas in brain are known as migraine centre?
dorsal raphe nucleus
locus coeruleus
what is “aura”?
fully reversible visual, sensory, motor or language symptoms
what is the duration of aura and when does this occur in relation to headache?
aura duration 20-60 mins
headache follows <1 hour later but aura can occur simultaneously
what is most common aura symptom?
visual (positive symptoms usually monochromatic)
eg central scotomata, central fortification, hemianopic loss
what tends to trigger a migraine?
sleep diet stress hormonal physical exertion
what may help patient to identify triggers?
headache diary
what are types of non-pharmacological management of migraine?
realistic goals avoid trigger balanced diet and hydration avoid caffeine relaxation / stress management regular exercise
what are two types of pharmacological management of migraine?
acute
prophylaxis
what 2 types of medications can be given as abortive treatment of migraine?
NSAIDs
Triptans (5HT agonist)
what types of NSAIDs can be given as migraine abortive treatment?
aspirin 900mg
naproxen 250mg
ibuprofen 400mg
when should NSAIDs be taken for a migraine?
as early as possible
when should anti emetic be considered when giving NSAIDs?
if gastroparesis
how can triptans be administered?
oral, sublingual and subcutaneous
consider method of administration in those with N&V
when should triptans be given for migraine?
at start of headache
what is name of triptans given for migraine?
rizatriptan, eletriptan, sumatriptan
frovatriptan for sustained relief
when should you consider prophylaxis for migraine?
more than 3 attacks per month or very severe
how long must you trial each prophylaxis drug for?
minimum of 3 months
aim is to titrate drug as tolerated to achieve efficacy at lowest dose possible
what non-pharmacological methods of prophylaxis should you consider?
acupuncture
relaxation exercises
what are the main medications that can be given for migraine prophylaxis?
amitriptyline
propranolol
topiramate
how much amitriptyline should be given for migraine prophylaxis?
10-25mg (max 75mg)
what are the adverse effects of amitriptyline?
dry mouth
postural hypotension
sedation
how much propranolol should be given for migraine prophylaxis?
80-240mg daily
when should propranolol be avoided?
asthma
peripheral vascular disease
heart failure
what class of drug is topiramate?
carbonic anhydrase inhibitor
how much topiramate should be given for migraine prophylaxis?
25mg - 100mg daily
start slowly due to poor side effect profile
what are the adverse effects of topiramate?
weight loss
paraesthesia
impaired concentration
enzyme inducer
what types of “fancy” migraine can you get?
acephalgic basilar retinal ophthalmic hemiplegic (familial / sporadic) abdominal
what is difference in symptoms of tension type headache and migraine?
tension type is bilateral
absence of N&V, photophobia and phonophobia
what type of pain is tension type headache?
pressing tingling quality
how sore is a tension type headache?
mild to moderate
how can tension type headache be treated?
relaxation physiotherapy
reassure
antidepressant - 3 months of dothiepin or amitryptyline
what is trigeminal autonomic cephalgias (TACs)?
group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features
give examples of ipsilateral cranial autonomic features seen in TACs?
ptosis miosis nasal stuffiness nausea / vomiting tearing eye lid oedema
what are the 4 main types of trigeminal autonomic cephalgias (TACs)?
cluster
paroxysmal hemicrania
hemicrania continua
SUNCT
who gets a cluster headache?
young (30-40s)
men > women
when do cluster headaches often occur?
striking circadian (around sleep) and seasonal variation
what are the features of a cluster headache?
severe unilateral headache
duration: 45-90 mins
frequency: 1 to 8 per day
cluster bout may last from few weeks to months
what is the treatment for a cluster headache?
high flow oxygen 100% for 20 mins
sub cut sumatriptan 6mg
steroids - reducing course over 2 weeks
verapamil for prophylaxis
who gets paroxysmal hemicrania?
elderly (50s-60s)
women > men
what are the features of paroxysmal hemicrania?
severe unilateral headache, unilateral autonomic features
duration: 10-30 mins
frequency: 1 to 40 per day
ie shorter duration and more frequent than cluster
what is treatment of paroxysmal hemicrania?
indomethicin
what are features of SUNCT headache?
short lived (15-120 secs) unilateral neuralgiaform headache conjunctival injections tearing
what is treatment of SUNCT headache?
lamotrigine, gabapentin
what patients that present with headache require imaging?
those with new onset unilateral cranial autonomic features
what imaging is carried out for these patients?
MRI brain and MR angiogram
who is more likely to be affected by idiopathic intracranial hypertension?
F > M
obese
what are symptoms of IIH?
headache - diurnal variation
morning N & V
visual loss
what investigations should take place in IIH?
MRI brain with MRV sequence - normal
CSF - elevated pressure, normal constituents
visual field
how should IIH be treated?
weight loss
acetazolamide
ventricular atrial / lumbar peritoneal shunt
monitor visual fields & CSF pressure
who gets trigeminal neuralgia?
elderly (>60)
women > men
when does trigeminal neuralgia occur?
triggered by touch, usually V2/3
what are features of trigeminal neuralgia?
severe stabbing unilateral pain
duration: 1 sec to 90 secs
frequency: 10 per day to 100 per day
bouts pain may last from a few weeks to months before remission
what investigation should take place in trigeminal neuralgia?
MRI brain
what is medical and surgical treatment options for trigeminal neuralgia?
medical - carbamazepine, gabapentin, phenytoin, baclofen
surgical: ablation or decompression
when someone presents with facial pain, you must consider non-neurological structures such as what?
eyes ears sinuses teeth TMJ etc
how is diagnosis of primary headache syndromes (inc TCA) established?
clinically based on demographics, duration, frequency and triggers
what is 1st line for uncomplicated migraine?
symptomatic OTC medication
