Primary Headache Flashcards
What is the two categories of headaches
Primary headache - No underlying medical cause
Secondary headache - has an identifiable structural or biochemical cause
What is the mot frequent primary headache
Tension headache
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
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
What is the abortive treatment for Tension type headaches
Aspirin
Paracetamol
What is the preventative treatment used in tension type headaches
Tricyclic antidepressants used in low dose
- amitriptyline,
- dothiepin,
- nortriptyline
What is the most frequent and disabling primary headache
Migraine
Define Migraine
Migraine is a neurologic chronic disorder with episodic manifestation characterized by recurrent and reversible attacks of pain and associated symptoms
What is the pathology of a a migraine
Primary brain dysfunction that leads to the activation and sensitisation of the trigeminal system
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
In a migraine what are the additional features experienced during an attack
Phono-phobia
Photophobia
Nausea
What are triggers of migraines
Sleep disturbance Dehydration Diet Environmental stimuli Changes in oestrogen level in woman Stress Hunger
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
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
What is the premonitory phase of a migraine
Mood changes
Fatigue
Cognitive changes
Muscle pain
Food craving
What is the features of Aura phase in a migraine
Fully reversible
Neurological changes
Slow evolution of symptoms: from vision - sensory - motor - speech
What are the features of an early headache in a migraine
Dull headache
Nasal congestion
Muscle pain
What are the signs of an advanced headache in a migraine
Unilateral
Throbbing
Nausea
Photophobia
Phonophobia
Osmophobia
What is the postdrome features of a headache
Fatigue
Cognitive changes
Muscle pain
significant disability can last 1 or 2 days
In an aura what causes the neurological symptoms
Cortical or brainstem dysfunction
What is the duration of an aura phase
15-60 minutes
What is pathologically occuring in an aura phase
Electrical disturbance called Cortical spreading depression
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
Not all acres are followed by headache pain, what is this called
acephalgic migraine or migraine aura without headache.
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
