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NEURO > Primary Headache > Flashcards

Primary Headache Flashcards

1
Q

Difference between primary and secondary headache? Which is more common?

A
  • Primary headache has no underlying medical cause, secondary has an identifiable structural or biochemical cause
  • Primary is more common (9:1 in GP, 3:2 in A&E)
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2
Q

Is a tension type headache primary or secondary? How severe is it?

A

TTH is a primary headache, the most common kind

It is not disabling and rarely presents to doctors

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3
Q

Describe a tension type headache in terms of location and character

A
  • Mild, bilateral headache. Usually pressing or tightening in character
  • No significant associated features and not aggravated by physical activity
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4
Q

Options for abortive and preventative treatment of tension type headaches?

A

Abortive:
- NSAIDs
- Aspirin or paracetamol
(limit to 10 days/month to avoid medication overuse headache)

Preventative: (rarely requires)
- Tricyclic antidepressants (amitriptyline, dothiepin)

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5
Q

What is the most frequent disabling primary headache?

A

Migrane

WHO rank it in top 20 most disabling conditions

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6
Q

Describe the pattern of recurrence of migraines? What is the basic pathophysiology?

A
  • Migraine is a chronic disorder with episodic manifestation
  • Pathophysiology largely unknown, slides say primary brain dysfunction leads to activation and sensitization of trigeminal system
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7
Q

What symptoms tend to characterize migraines?

A
  • Unilateral location (book says may become diffuse after 1-2hrs)
  • Pulsating/throbbing character
  • Aggravation by routine physical activity
  • Nausea & vomiting
  • Photophobia
  • Phonophobia
  • Some have preceding aura
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8
Q

What is Aura? Does it affect everyone with migraine?

A
  • Aura is a period (usually 15-60mins) of neurological deficit that may be experienced prior to migraine attack. Can affect sensory/motor/speech areas of the brain and is often mistaken for TIA symptoms
  • Affects ~33% if migraine patients
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9
Q

What are the stages of a migraine episode? Brief description for each

A
  1. Premonitory: mood change, fatigue, muscle pain, food craving
  2. Aura: fully reversible neurological deficits
  3. Early Headache: dull pain, nasal congestion
  4. Advanced Headache: unilateral pulsation, nausea, photophobia, phonophobia
  5. Postdrome: fatigue, cognitive changes, muscle pain
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10
Q

What are the classification guidelines for chronic migraine?

A
  • Headache for at least 15 days per month, of which at least 8 must be migraines, for more than 3 months
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11
Q

What tends to happen to a patients migraine symptoms as transforms to chronic migraine?

A
  • Frequency of headaches increases
  • Migrainous symptoms become less frequent and less severe
  • Many patients have episodes of severe migraine on a background of less severe, frequent/daily headache
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12
Q

What is medication overuse headache?

A

Headache present for at least 15 days/month which has developed or worsened whilst taking regular symptomatic medication

  • Can occur in any primary headache, migraine patients more susceptible
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13
Q

Which drugs cause medication overuse headache over what sort of period of time?

A
  • Triptans, ergots, opiods and combination analgesics for more than 10 days a month
  • Simple analgesics for more than 15 days a month
  • Caffeine overuse (coffee/tea/sodas)
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14
Q

Prophylactic treatment of migraines?

A
  • Anti-epileptics (topiramate, valproate)
  • B-Blockers (propranolol)
  • Tricyclic antidepressants (amitriptyline)
  • SSRI’s (venlafaxine)
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15
Q

Abortive/acute treatment of migraines? How frequently should these be taken?

A
  • Analgesics (aspirin, NSAIDs, paracetamol)
  • Triptans
  • Anti-emetics

Limit to 10 days/month

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16
Q

How can migraine symptoms change during pregnancy?

A
  • Migraine without aura usually gets better during pregnancy
  • Migraine with aura usually no change
  • First migraine may occur during pregnancy (particularly migraine with aura)
17
Q

What drug considerations should be taken in women of child bearing age who are experiencing migraines?

A
  • OCP (oral contrac) contraindicated in active migraine with aura (ok if no attacks for >5 yrs, stop if aura recurs)
  • Avoid anti-epileptics in women of child bearing age (if necessary counsel about teratogenicity)
18
Q

Treatment of migraines during pregnancy?

A
  • Abortive: paracetamol

- Prophylactic: B-blocker (propranolol) or amitriptyline

19
Q

What are Trigeminal Autonomic Cephalalgias? (TACs)

A
  • Group of headache disorders characterized by attacks of moderate to severe unilateral pain in the head or face, with associated ipsilateral cranial autonomic features
20
Q

Types of trigeminal autonomic cephalalgias?

A
  • Cluster Headache
  • Paroxysmal Hemicrania
  • SUNCT (Short-lasting Unilateral Neuralgiform headache with Conjuctival injection and Tearing)
  • SUNA (Short-lasting Unilateral Neuralgiform headache with Autonomic symptoms)
21
Q

Describe the character of the pain experienced during a cluster headache

A
  • Unilateral
  • Orbital and temporal localization
  • Excruciatingly severe
  • Rapid onset and rapid cessation
  • Usually lasts 15mins to 3 hours
22
Q

How does a cluster headache usually present?

A
  • Unilateral pain (orbital/temporal)
  • Prominent ipsilateral autonomic symptoms
  • Often have migrainous symptoms as well (vomiting/photophobia/phonophobia)
23
Q

Describe the pattern of recurrence and remission for cluster headaches

A
  • Episodic in 80-90%: attacks cluster into bouts lasting 1-3 months, remission periods last at least 1 month. During bouts 1 attack every other day up to 8 attacks/day
  • Chronic cluster in 10-20%: bouts last more than a year without remission OR remissions last less than a month
  • Striking circadian rhythmicity: bouts occur same time each year, attacks at same time each day
24
Q

Describe the frequency, duration and pain quality of cluster headaches, paroxysmal hemicrania and SUNCT

A
  • Cluster headache: 1-8 attacks per day, lasting 15-180mins, sharp, throbbing pain
  • Paroxysmal Hemicrania: 1-40 attacks/day, lasting 2-30mins, sharp, throbbing pain
  • SUNCT: 3-200 attacks/day, lasting 5-240secs, stabbing, burning pain.
25
Q

How can paroxysmal hemicrania be distinguished from a cluster headache?

A
  • Similar symptoms, onset, location
  • Attack frequency in PH can be higher, with CH attacks lasting longer. PH attacks can be precipitated by rotating the head
  • 80% of PH patients have chronic PH, only 20% episodic. CH much more episodic
  • PH responds absolutely to indometacin
26
Q

How does SUNCT tend to present?

A
  • Unilateral orbital, supraorbital or temporal pain. Stabbing/pulsating quality
  • 10-240 second attack duration, 3-200 attacks/day
  • Pain can have cutaneous triggers (cold/wind/touch)
  • Pain is accompanied by conjunctival injection and lacrimation
27
Q

What are some of the cranial autonomic symptoms that can occur during trigeminal autonomic cephalalgias?

A
  • Conjunctival injection / lacrimation
  • Nasal congestion / rhinorrhoea
  • Eyelid oedema
  • Forehead and facial sweating
  • Miosis / ptosis (Horners syndrome)
28
Q

Treatment of cluster headaches?

A
  • Abortive for headache: 100% oxygen via tight fitting, non-rebreathing mask. Or subcutaneous sumatriptan / nasal zolmatriptan
  • Abortive for bout: occipital depomedrone injection (ipsilateral). Or tapering course of oral prednisone
  • Preventative: verapamil, lithium, methysergide, topiramate
29
Q

Treatment of paroxysmal hemicrania?

A
  • No abortive treatments
  • Prophylaxis with INDOMETACIN
    (alternatives: COX-II inhibitors, topiramate)
30
Q

Treatment of SUNCT/SUNA:

A
  • No abortive treatment

- Prophylaxis: lamotrigine, topiramate, gabapentin, carbamazepine

31
Q

How does trigeminal neuralgia tend to present?

A
  • Similar to SUNCT, stabbing pain, 3-200 attacks/day, can have cutaneous triggers
  • Attacks tend to last 5-10 seconds
  • Pain tends to be more localized to maxillary & mandibular divisions of trigeminal, less so for opthalmic
  • Autonomic features are uncommon
32
Q

Treatment of trigeminal neuralgia?

A
  • No abortive treatment
  • Prophylaxis: carbamazepine / oxcarbazepine
  • Surgical intervention: glycerol ganglion injection, steriotactic radiosurgery, decompressive surgery

NEURO (52 decks)

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