Primary Headache Flashcards
What is the difference between a primary and secondary headache?
A primary headache has no underlying cause and is far more common than secondary
Secondary headaches have an identifiable structural or biochemical cause
What are the types of primary headache?
Tension-type headaches
Migraines
Cluster headaches
What are some causes of a secondary headache?
Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced
What is a tension-type headache?
Mild, bilateral headache which is often pressing or tightening in quality
It has no significant associated features and is not aggravated by routine physical activity
It is the most frequent primary headache
What are the 3 different frequency-based-classifications of Tension-type headaches?
Infrequent ETTH - <1 day per month
Frequent ETTH - 1-14 days per month
Chronic TTH - 15 or more days per month
How is TTH treated?
Abortive treatment:
- Aspirin or paracetamol
- NSAIDs
- Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
Preventative treatment (rarely required):
- Tricyclic antidepressants
- amitriptyline, dothiepin, nortriptyline
What are migraines?
A chronic disorder with episodic attacks (migraines)
Very complex pathophysiology involving various parts of the brain - however - generally recognized that migraine arises from a primary brain dysfunction that leads to activation and sensitization of the trigeminal system
What symptoms are seen with migraines?
Headache - Unilateral, pulsating, motion-sensitive
Nausea/vomiting, Photophobia, phonophobia
Functional disability - ie cant work
May have Psychological symptoms such as anticipatory anxiety
What are some possible triggers for migraines?
Dehydration
Diet
Sleep disturbance
Stress
Environmental stimuli
Changes in oestrogen levels in women
Normal life events trigger or are associated with attacks in those predisposed
What symptoms may a patient have before a migraine?
Mood changes
Fatigue
Cognitive changes (Aura)
Muscle pain
Food craving
Migraines can be described as with or without ‘Aura’
What is meant by this?
About 25% of migraine sufferers experience focal neurological symptoms immediately preceding the headache phase
Symptoms of aura kinda progress from visual –> sensory –> speech, motor
Visual symptoms are most common –> typically involving shimmering (and similar) but rarely involving stuff like patches of vision loss
How does a typical migraine headache progress?
Early headache:
- Dull headache
- Nasal congestion
- Muscle pain
Advanced headache:
- Migraine headache - Unilateral, throbbing
- Associated symptoms - Photophobia, Phonophobia, Nausea etc
What symptoms characterise the postdrome phase of a migraine?
Postdrome = after
Migraine goes but patient left feeling fatigued, with muscle pain. May have cognitive changes
Often will have some remaining level of functional disability for 2 or so days
What is Chronic migraine?
Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months
What are the causes of Chronic migraine?
Often develops in a patient who already has migraines infrequently - Transformed migraine:
- History of episodic migraine
- Increasing frequency of headaches - but with less severity/frequency of migraine symptoms
Usually caused by Medication overuse in these patients^
How is chronic migraine treated?
Stop the medication that is causing the problem
What is a medication overuse headache?
Headache present on ≥15 days per month which has developed or worsened whilst taking regular symptomatic medication
Can occur in (from the treatment of) any primary headache - particularly relevant to Migraineurs (who may get it from treating a completely different condition)
What drugs are associated with medication overuse headaches?
Triptans, ergots, opioids and combination analgesics >10 days/month
Simple analgesics > 15 days per month
Caffeine overuse: coffee, tea, cola, irn bru
How are migraines abortively/symptomatically treated?
- Aspirin, Paracetamol, NSAIDs
- Triptans - when simple analgesics^ aren’t good enough
- Unless CVS disease
Limit to 10 days per month/2 per week - to avoid M.O.H
When is prophylactic treatment of migraines indicated?
What does this management include?
Indicated when:
- Migraine episodes are frequent:
- > 1-2 per month
- Significant impact on quality of life
Prophylactic treatment includes:
-
Propanolol, Candesartan - Reduce BP
- Not if CVD, diabetes
-
Anti-epileptics:
- Topiramate, Valproate, Gabapentin
- Tricyclic antidepressants
- Amitryptiline, Dothiepin, Nortriptyline
- SSRI antidepressants
- Venlafaxine
What is the effect of pregnancy on migraines?
Migraine without Aura - improves with pregnancy
Migraine with Aura - usually does not change
First migraine can occur during pregnancy - particularly migraine with Aura
If a woman of childbearing age suffers from migraines. What class of drugs in the normal treatment regime should be avoided?
1) Oral contraceptive pill (OCP) is contraindicated in women who suffer from migraines with aura
2) Avoid Anti-epileptics (eg Topiramate, Valproate, Gabapentin) in women of childbearing age
If have to use - then counsel over teratogenicity & ensure adequate contraceptive education
And obviously don’t give it to pregnant women
What are the Trigeminal Autonomic Cephalalgias?
Group of primary headache disorders
Characterised by:
- Unilateral trigeminal distribution pain (usually Ophthalmic area)
- Prominent ipsilateral autonomic features
What are the main types of Trigeminal autonomic cephalalgias?
Cluster headache
Paroxysmal hemicrania
SUNCT
- Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing
SUNA
- Short-lasting Unilateral Neuralgiform headache with Autonomic Symptoms
What is cluster headache and how does it present?
Very rare, excruciating headache of unknown cause - typically affecting males of 20-40 years old
Linked to hypothalamus
Presentation:
- Recurrent bouts (clusters) of Excruciating Uni-lateral, retro-orbital/temporal pain
-
Parasympathetic autonomic activation the same eye causing redness/tearing etc
- Sometimes resembles Horner’s syndrome
- Rapid onset and cessation of symptoms
Cluster headaches have an episodic nature - and come in bouts and periods of remission
Describe how often these bouts/remissions can occur in people who suffer from cluster headaches
Episodic in 80-90% of patients:
- Bouts last 1-3 months with remission lasting at least 1 month
- Alcohol triggers an attack during a Bout - but not during remission
Chronic cluster in 10-20% of patients:
- Bouts happen for > 1 year without remission
- Remissions last <1 month
It is worth noting that the Attacks that happen during Bouts can happen at the same time of day each time etc - striking rhythmicity
What is paroxysmal hemicrania and how does it present?
Rare condition with similarities to Cluster headaches…
except attacks are briefer & more frequent (ie several times per day) but do not occur in clusters
Presentation:
- Excruciating pain - Orbital/temporal, Unilateral
- Rapid onset & cessation (2-30mins)
- Prominent ipsilateral autonomic symptoms
- +/- Migraine symptoms
What is often a trigger of pain in Paroxysmal hemicrania?
Bending/rotating the head causes 10% of attacks
What drug causes paroxysmal hemicrania to stop?
Indometacin
(Indomethacin)
^A type of NSAID
What is SUNCT and how does it present?
Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing
Presentation:
- Unilateral pain:
- Orbital, Supraorbital or Temporal
- Stabbing or pulsating
- Short attacks - often occur in bouts
- Ipsilaterl ANS symptoms - conjunctival injection (redness), lacrimation (tear flow), ptosis etc
What can trigger attacks in SUNCT syndrome and Trigeminal neuralgia?
Cutaneous triggers:
- Wind, cold
- Chewing
- Touch
What is trigeminal neuralgia and what causes it?
A type of cranial neuropathy (so not a primary headache) that causes Facial pain
Usually caused by compression of the trigeminal nerve at/near the pons
Hypertension is the big risk factor but can also be caused by MS or tumours (more likely in younger people)
How does Trigeminal neuralgia present?
What is an important differential diagnosis for it?
Paroxysms of Severe stabbing Pain that is:
- Unilateral
- Facial pain:
- Maxillary & mandibular pain most common
Trigeminal Neuralgia has similarities to SUNCT:
- Episodes occur many times a day
- However, it differs from SUNCT in that it has refractory periods & a shorter attack duration
- Furthermore - Trigeminal neuralgia rarely has autonomic features - but SUNCT does.
What triggers attacks in trigeminal neuralgia?
Attacks brought on by cutaneous stimulation in one or more trigger zones in the face
through washing, chewing, shaving etc
Complete da taybel
How are Cluster headaches Abortively treated?
Headache:
- Subcutaneous Sumatriptan or Nasal Zolmatriptan
- 100% oxygen 7-12 l/min via a tight-fitting non-rebreathing max - effective and safe
During Headache bouts:
- Occipital Depomedrone injection on the same side as the head-ache
- Or - Tapering course of oral prednisone
How are cluster headaches preventatively treated?
- Verapamil - high dose if req.
- Lithium
- Methysergide - small risk of severe retroperitoneal fibrosis
- Topiramate - an anti-epileptic
How is paroxysmal hemicrania treated?
There is no abortive treatment - only prophylaxis with Indometacin
Alternatives – COX-II inhibitors, Topiramate
How are SUNCT & SUNA treated?
No abortive treatment
Prophylaxis using:
- Lamotrigine
- Topiramate
- Gabapentin
- Carbamazepine / Oxcarbazepine
How is trigeminal neuralgia treated?
No abortive treatment
Prophylaxis using:
- Carbamazepine - anticonvulsant
- Oxcarbazepine - anti-epileptic
Surgical intervention:
- Glycerol ganglion injection
- Stereotactic radiosurgery
- Decompressive surgery
