Primary Headache Flashcards by Sarah Anderson

What is the two categories of headaches

Primary headache - No underlying medical cause

Secondary headache - has an identifiable structural or biochemical cause

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What is the mot frequent primary headache

Tension headache

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What is the clinical presentation of tension type headaches

Mild, bilateral headache which is often pressing or tightening in quality

No significant associated features

Not aggravated by routine physical activity

Not disabling

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What is the usual time frame for a episodic tension type headache, and when is it chronic

Infrequent: less than 1 day a month

Frequent: 1-14 days a month

Chronic:>15days a month

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What is the abortive treatment for Tension type headaches

Aspirin

Paracetamol

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What is the preventative treatment used in tension type headaches

Tricyclic antidepressants used in low dose

amitriptyline,
dothiepin,
nortriptyline

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What is the most frequent and disabling primary headache

Migraine

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Define Migraine

Migraine is a neurologic chronic disorder with episodic manifestation characterized by recurrent and reversible attacks of pain and associated symptoms

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What is the pathology of a a migraine

Primary brain dysfunction that leads to the activation and sensitisation of the trigeminal system

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What further central nervous system structures are involved in the pain pathway of a migraine, and what do these determine

-Brainstem

-Meninges and other
peripheral structures

-Cortical events

The activation of these then determine how we feel

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In a migraine what are the additional features experienced during an attack

Phono-phobia
Photophobia
Nausea

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What are triggers of migraines

Sleep disturbance 
Dehydration 
Diet 
Environmental stimuli 
Changes in oestrogen level in woman 
Stress 
Hunger

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Why is migraines more common for women between puberty and menopause

Due to periods changing oestrogen levels, as the female hormone cycle acts as a trigger

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What is the requirements for a migraine to be diagnosed

A head attack to occur with or without an aura

Lasting between 4-72 hours

With the following 2 features:

unilateral location,
pulsating quality,
moderate or severe pain intensity,
causing avoidance of routine physical activity

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What is the premonitory phase of a migraine

Mood changes

Fatigue

Cognitive changes

Muscle pain

Food craving

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What is the features of Aura phase in a migraine

Fully reversible

Neurological changes

Slow evolution of symptoms: from vision - sensory - motor - speech

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What are the features of an early headache in a migraine

Dull headache
Nasal congestion
Muscle pain

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What are the signs of an advanced headache in a migraine

Unilateral

Throbbing

Nausea

Photophobia

Phonophobia

Osmophobia

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What is the postdrome features of a headache

Fatigue

Cognitive changes

Muscle pain

significant disability can last 1 or 2 days

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In an aura what causes the neurological symptoms

Cortical or brainstem dysfunction

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What is the duration of an aura phase

15-60 minutes

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What is pathologically occuring in an aura phase

Electrical disturbance called Cortical spreading depression

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What features of an aura causes it to be confused with an transit ischameic attack

Loss of function
Sudden onset
Symptoms all start at same time and can be localised to a specific vascular area

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Not all acres are followed by headache pain, what is this called

acephalgic migraine or migraine aura without headache.

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What is the most common aura symptoms

Visual somatosensory - visual disturbance starts in the periphery and spreads in

What is the clinical definition of a chronic migraine

Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months

How do you treat patients with migraines induced by medication overdue

Discontinuing the overused medication often (but not always) dramatically improves headache frequency

Define medication overuse headache

Headache present on ≥15 days / month which has developed or worsened whilst taking regular symptomatic medication

What is the abortic migraine treatment

Aspirin or NSAIDs | Triptans

What is the prophylactic migraine treatment

Propranolol, Candesartan Anti-epileptics -Topiramate, -Valproate, -Gabapentin Tricyclic antidepressants - amitriptyline, - dothiepin, - nortriptyline Venlafaxine

What is the problem with the combined OCP and migraines in woman

The combined OCP is contraindicated in active migraine with aura

When is it okay for migraine patients to take the OCP

ok if no attacks for > 5 years, but stop if aura recurrs

Why should anti-epileptics be avoided in women of child bearing age

There is a risk of tetratogenecity if fall pregnant

What medication should be avoided in the treatment of migraines in pregnant woman

Acute attack: Paracetamol Preventative: Propranolol or Amitriptyline

What is the symptoms experienced in children and elderly with migraines

Children - confusion, ataxia, aphasia Elderly - may experience aura without headache

What is the different types of trigeminal autonomic cephalalgias

Cluster headache Paraoxysmal Hemicrania SUNCT SUNA

Trigeminal autonomic cephalalgias is a group dog headache disorders characterised by

Excruciatingly severe Unilateral pain in the head or face, with associated ipsilateral cranial autonomic features

What differentiate the trigemnial autonomic cephalagias

Attacks frequency and duration

What is the cranial autonomic symptoms of a trigeminal autonomic cephalagias

Conjunctival injection / lacrimation Nasal congestion / rhinorrhoea Eyelid oedema Forehead & facial sweating Miosis / ptosis (Horner’s syndrome)

What is the clinical presentation of a cluster headache

Pain - located mainly orbital and temporal Attacks are strictly unilateral Rapid onset Duration: 15 mins to 3 hours Rapid cessation of pain excruciatingly severe patients are restless and agitated during an attack Prominent ipsilateral autonomic symptoms Migranious symptoms

What are the premonitory and associated Migrainous symptoms often present with trigeminal autonomic cephalagias headache disorders

Premonitory: Tiredness Yawning ``` Associated: Vomiting Nausea Photophobia Phonophobia ```

What is usually present in a cluster headache

Typical aura

What is the 3 different bout patterns a cluster headache can present

Episodic Striking circadian rhythmicity Chronic cluster

What is the definition of episodic cluster headache

Attacks “cluster” into bouts typically lasting 1-3 months with periods of remission lasting at least 1 month Background pain in remission

What is the frequency of episodic cluster headaches

1 every other day to 8 per days

What is the features of striking circadian rhythmicity cluster headaches

Attacks occur at the same time each day bouts occur at the same time each year

What is the features of chronic cluster

Bouts last >1 year without remission or Remissions last <1 month

What is the clinical presentation of paroxysmal hemicrania

Pain: mainly orbital and temporal Attacks are strictly unilateral Rapid onset Duration: 2-30 mins Rapid cessation of pain Excruciatingly severe 50% are restless and agitated during an attack Prominent ipsilateral autonomic symptoms Migrainous symptoms may be present Background continuous pain present

How do cluster headaches and paroxysmal hemicrania differ

Paraoxysmal hemicrania is shorter and more frequent paraoxysmal hemicrania is more likely to be chronic

What is a precipitated sign isn some paroxysmal hemicranial

Bending or rotating the head

What is the clinical presentation of SUNCT | Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing

Unilateral, orbital, supraorbital or temporal pain Stabbing or pulsating pain (burning) Duration 10-240seconds occurs frequently

What is the frequency of SUNCT

Attack frequency from 3-200/day, no refractory period

What signs accompany pain in SUNCT/SUNA

Conjuctivial injection - red eye Lacrimation - recreation of tear

What is the cutaneous triggers of SUNCT/SUNA

Wind Cold Touch Chewing

Where does the unilateral head pain preliminary occur in trigeminal autonomic cephalagias

Affects predominantly trigeminal nerve ophthalmic division

What trigeminal autonomic cephalagias is circadian periodicity absent

SUNCT

What is the clinical presentation of Trigeminal neuralgia

Unilateral maxillary or mandibular division pain Stabbing pain duration 5-10seconds Occurs frequently with refractory period (autonomic features are uncommon)

How is trigemnial neuralgia not considered under Trigeminal Autonomic Cephalagias' Headache disorders

maxillary or mandibular division pain > ophthalmic division

What is the cutaneous triggers of trigeminal neuralgia

Wind Cold Touch Chewing

Why is SUNCT and trigeminal neuralgia triggered by cutaneous sensation

Due to blod vessel touching a nerve

What is the abortive treatment of a cluster headache

Subcutaneous injection sumatriptan 6mg Nasal zolmatriptan 5mg 100% oxygen 7-12 l/min via a tight fitting non-rebreathing max is effective and safe

What is the over all treament of a cluster headache episodic bout

Occipital depomedrone injection (same side as the headache) Tapering course of oral prednisone

What is the preventative medication of

Verapamil (high doses may be required) Lithium Methysergide Topiramate

What is the side effect of methysergide

Risk of retroperitoneal fibrosis

What is the abortive treatment for paroxysmal hemicranial and SUNCT/SUNA

There is none

What is the prophylaxis treatment for paroxysmal hemicranial

Indometacin COX-II-inhibitors Topiramate

What is the prophylaxis treatment for SUNCT/SUNA

Lamotrigine Topiramate Gabapentin Carbamazepine Oxcarbazepine

What is the prophylaxis treatment for trigeminal neuralgia

Carbamazepine | Oxcarbazepine

What is the surgical intervention treatment in trigeminal neuralgia

Glycerol ganglion injection (nerve damged to stop pain) Steriotactic radiosurgery Decompressive surgery