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Yr2 Neuro MA > Primary Headache > Flashcards

Primary Headache Flashcards

1
Q

What is the difference between a primary and secondary headache?

A

A primary headache has no underlying cause and is far more common than secondary

Secondary headaches have an identifiable structural or biochemical cause

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2
Q

What are the types of primary headache?

A

Tension-type headaches

Migraines

Cluster headaches

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3
Q

What are some causes of a secondary headache?

A

Tumour

Meningitis

Vascular disorders

Systemic infection

Head injury

Drug-induced

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4
Q

What is a tension-type headache?

A

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

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5
Q

What are the 3 different frequency-based-classifications of Tension-type headaches?

A

Infrequent ETTH - <1 day per month

Frequent ETTH - 1-14 days per month

Chronic TTH - 15 or more days per month

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6
Q

How is TTH treated?

A

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
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7
Q

What are migraines?

A

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

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8
Q

What symptoms are seen with migraines?

A

Headache - Unilateral, pulsating, motion-sensitive

Nausea/vomiting, Photophobia, phonophobia

Functional disability - ie cant work

May have Psychological symptoms such as anticipatory anxiety

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9
Q

What are some possible triggers for migraines?

A

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

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10
Q

What symptoms may a patient have before a migraine?

A

Mood changes

Fatigue

Cognitive changes (Aura)

Muscle pain

Food craving

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11
Q

Migraines can be described as with or without ‘Aura’

What is meant by this?

A

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

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12
Q

How does a typical migraine headache progress?

A

Early headache:

  • Dull headache
  • Nasal congestion
  • Muscle pain

Advanced headache:

  • Migraine headache - Unilateral, throbbing
  • Associated symptoms - Photophobia, Phonophobia, Nausea etc
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13
Q

What symptoms characterise the postdrome phase of a migraine?

A

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

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14
Q

What is Chronic migraine?

A

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

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15
Q

What are the causes of Chronic migraine?

A

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^

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16
Q

How is chronic migraine treated?

A

Stop the medication that is causing the problem

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17
Q

What is a medication overuse headache?

A

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)

18
Q

What drugs are associated with medication overuse headaches?

A

Triptans, ergots, opioids and combination analgesics >10 days/month

Simple analgesics > 15 days per month

Caffeine overuse: coffee, tea, cola, irn bru

19
Q

How are migraines abortively/symptomatically treated?

A
  • 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

20
Q

When is prophylactic treatment of migraines indicated?

What does this management include?

A

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
21
Q

What is the effect of pregnancy on migraines?

A

Migraine without Aura - improves with pregnancy

Migraine with Aura - usually does not change

First migraine can occur during pregnancy - particularly migraine with Aura

22
Q

If a woman of childbearing age suffers from migraines. What class of drugs in the normal treatment regime should be avoided?

A

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

23
Q

What are the Trigeminal Autonomic Cephalalgias?

A

Group of primary headache disorders

Characterised by:

  • Unilateral trigeminal distribution pain (usually Ophthalmic area)
  • Prominent ipsilateral autonomic features
24
Q

What are the main types of Trigeminal autonomic cephalalgias?

A

Cluster headache

Paroxysmal hemicrania

SUNCT

  • Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing

SUNA

  • Short-lasting Unilateral Neuralgiform headache with Autonomic Symptoms
25
Q

What is cluster headache and how does it present?

A

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
26
Q

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

A

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

27
Q

What is paroxysmal hemicrania and how does it present?

A

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
28
Q

What is often a trigger of pain in Paroxysmal hemicrania?

A

Bending/rotating the head causes 10% of attacks

29
Q

What drug causes paroxysmal hemicrania to stop?

A

Indometacin

(Indomethacin)

^A type of NSAID

30
Q

What is SUNCT and how does it present?

A

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
31
Q

What can trigger attacks in SUNCT syndrome and Trigeminal neuralgia?

A

Cutaneous triggers:

  • Wind, cold
  • Chewing
  • Touch
32
Q

What is trigeminal neuralgia and what causes it?

A

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)

33
Q

How does Trigeminal neuralgia present?

What is an important differential diagnosis for it?

A

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.
34
Q

What triggers attacks in trigeminal neuralgia?

A

Attacks brought on by cutaneous stimulation in one or more trigger zones in the face

through washing, chewing, shaving etc

35
Q

Complete da taybel

A
36
Q

How are Cluster headaches Abortively treated?

A

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
37
Q

How are cluster headaches preventatively treated?

A
  • Verapamil - high dose if req.
  • Lithium
  • Methysergide - small risk of severe retroperitoneal fibrosis
  • Topiramate - an anti-epileptic
38
Q

How is paroxysmal hemicrania treated?

A

There is no abortive treatment - only prophylaxis with Indometacin

Alternatives – COX-II inhibitors, Topiramate

39
Q

How are SUNCT & SUNA treated?

A

No abortive treatment

Prophylaxis using:

  • Lamotrigine
  • Topiramate
  • Gabapentin
  • Carbamazepine / Oxcarbazepine
40
Q

How is trigeminal neuralgia treated?

A

No abortive treatment

Prophylaxis using:

  • Carbamazepine - anticonvulsant
  • Oxcarbazepine - anti-epileptic

Surgical intervention:

  • Glycerol ganglion injection
  • Stereotactic radiosurgery
  • Decompressive surgery
41
Q
A

Yr2 Neuro MA (35 decks)

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