Primary Headache Flashcards
Difference between primary and secondary headache? Which is more common?
- 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)
Is a tension type headache primary or secondary? How severe is it?
TTH is a primary headache, the most common kind
It is not disabling and rarely presents to doctors
Describe a tension type headache in terms of location and character
- Mild, bilateral headache. Usually pressing or tightening in character
- No significant associated features and not aggravated by physical activity
Options for abortive and preventative treatment of tension type headaches?
Abortive:
- NSAIDs
- Aspirin or paracetamol
(limit to 10 days/month to avoid medication overuse headache)
Preventative: (rarely requires)
- Tricyclic antidepressants (amitriptyline, dothiepin)
What is the most frequent disabling primary headache?
Migrane
WHO rank it in top 20 most disabling conditions
Describe the pattern of recurrence of migraines? What is the basic pathophysiology?
- Migraine is a chronic disorder with episodic manifestation
- Pathophysiology largely unknown, slides say primary brain dysfunction leads to activation and sensitization of trigeminal system
What symptoms tend to characterize migraines?
- 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
What is Aura? Does it affect everyone with migraine?
- 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
What are the stages of a migraine episode? Brief description for each
- Premonitory: mood change, fatigue, muscle pain, food craving
- Aura: fully reversible neurological deficits
- Early Headache: dull pain, nasal congestion
- Advanced Headache: unilateral pulsation, nausea, photophobia, phonophobia
- Postdrome: fatigue, cognitive changes, muscle pain
What are the classification guidelines for chronic migraine?
- Headache for at least 15 days per month, of which at least 8 must be migraines, for more than 3 months
What tends to happen to a patients migraine symptoms as transforms to chronic migraine?
- 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
What is medication overuse headache?
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
Which drugs cause medication overuse headache over what sort of period of time?
- 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)
Prophylactic treatment of migraines?
- Anti-epileptics (topiramate, valproate)
- B-Blockers (propranolol)
- Tricyclic antidepressants (amitriptyline)
- SSRI’s (venlafaxine)
Abortive/acute treatment of migraines? How frequently should these be taken?
- Analgesics (aspirin, NSAIDs, paracetamol)
- Triptans
- Anti-emetics
Limit to 10 days/month
How can migraine symptoms change during pregnancy?
- Migraine without aura usually gets better during pregnancy
- Migraine with aura usually no change
- First migraine may occur during pregnancy (particularly migraine with aura)
What drug considerations should be taken in women of child bearing age who are experiencing migraines?
- 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)
Treatment of migraines during pregnancy?
- Abortive: paracetamol
- Prophylactic: B-blocker (propranolol) or amitriptyline
What are Trigeminal Autonomic Cephalalgias? (TACs)
- Group of headache disorders characterized by attacks of moderate to severe unilateral pain in the head or face, with associated ipsilateral cranial autonomic features
Types of trigeminal autonomic cephalalgias?
- Cluster Headache
- Paroxysmal Hemicrania
- SUNCT (Short-lasting Unilateral Neuralgiform headache with Conjuctival injection and Tearing)
- SUNA (Short-lasting Unilateral Neuralgiform headache with Autonomic symptoms)
Describe the character of the pain experienced during a cluster headache
- Unilateral
- Orbital and temporal localization
- Excruciatingly severe
- Rapid onset and rapid cessation
- Usually lasts 15mins to 3 hours
How does a cluster headache usually present?
- Unilateral pain (orbital/temporal)
- Prominent ipsilateral autonomic symptoms
- Often have migrainous symptoms as well (vomiting/photophobia/phonophobia)
Describe the pattern of recurrence and remission for cluster headaches
- 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
Describe the frequency, duration and pain quality of cluster headaches, paroxysmal hemicrania and SUNCT
- 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.
