Primary & Secondary headache syndrome Flashcards
How does subarachnoid hemorrhage present
Instant peak in pain
What are some red flags for headache?
- New onset >55 y/o
- Known/previous malignancy
- Immunosuppressed
- Early morning headache
- Exacerbated by valsava
How often do migraine attacks generally occur?
once a month
Is a migraine with aura effecting both or one eye?
Both
How likely is it that a migraine has ‘aura’ (visual involvement)?
20%
What is the criteria for a migraine with aura?
- At least 5 attacks
- Last 4-72hrs
- 2 of: Moderate/severe, unilateral, throbbing pain, worse movement
- 1of: autonomic features, photophobia/phonophobia
What is the biggest trigger for migraines?
Stress
How does stress cause migraine?
- Stress triggers changes in the brain leading to serotonin release
- Blood vessels constrict and dilate
- Chemicals including substance P irritate nerves and blood vessels causing pain
Where is the migraine center?
Dorsal raphe nuclei & Locus coeruleus
How is migraine treated non-pharmacologically?
- setting goals
- avoid triggers
- headache diary
- Relaxation/stress management
How is migraine treated pharmacologically?
Acute
- NSAID (aspirin, naproxen, ibuprofen) +/- Anti-emetic
- Triptans (rizatriptan, fovatriptan)
Prophylaxis
- Amitriptyline (10-25mg normally)
- Propranolol (80-240mg)
- Topiramate (25-100mg)
When is prophylaxis considered for migraine?
> 3 attacks a month
OR
Very severe attack
How long does each method of prophylaxis need to be trialed for in migraine?
at least 3 months
What are some contraindications to propranolol use in migraine?
Asthma
PVD
Heart failure
What are adverse effects of amitriptyline?
- Dry mouth
- Postural hypotension
- Sedation
What are some adverse effects of topiramate?
- Weight loss
- Paresthesia
- Impaired concentration
- Enzyme inducer
What does CGRP do?
Triggers receptors which open up pain pathways to start migraine attacks
When can anti-CGRP be given to a patient?
After three prior prophylactics
Name some ‘Atypical’ migraines
Acephalgic
Basilar
Retinal
Ophthalmic
Hemiplegic (familial/sporadic)
Abdominal
When are abdominal migraines common?
Kids
Are migraines unilateral or bilateral headaches?
Unilateral
Are tension type headaches unilateral or bilateral?
Bilateral
How are tension headaches managed?
Relaxation physio
Anti-depressants
- Dothiepin or Amitriptyline
- 3 months
What are trigeminal autonomic cephalgia’s (TACs)?
Primary headache disorders characterized by unilateral trigeminal distribution of pain with ipsilateral autonomic features
What are the types of trigeminal autonomic cephalgia’s?
Cluster headache
Hemicrania
What age do cluster headaches usually occur?
30-40
When do cluster headaches occur?
Around sleep
Tends to be seasonal
How does cluster headache present?
Severe unilateral headache
Lasts 45-90 mins
Every 1-8 days
How are cluster headaches treated?
High flow oxygen
Sub cut sumatriptan 6mg
Steroids
Verapamil (prophylaxis)
What age do hemicrania normally present at?
50-60s
How does hemicrania present
Severe unilateral headache
Unilateral autonomic features
10-30 mins
How often do hemicrania happen?
Every 1 to 40 days
How is hemicrania treated?
Indomethacin
How does idiopathic intracranial hypertension present?
- Obese
- Headache
- Visual loss
What investigations are there for idiopathic itracranial hypertension?
MRI brain with MRV sequence
CSF
- Increased pressure
Visual field
How is idiopathic intracranial hypertension managed?
- Weight loss
- Acetazolamide
- Ventricular atrial / Lumbar peritoneal shunt
- Monitor visual field & CSF pressure
What age does trigeminal neuralgia present at?
> 60
How does trigeminal neuralgia present?
Severe stabbing unilateral pai in distribution of trigeminal nerve
How is trigeminal neuralgia treated medically?
- Carbamazepine
- Gabapentin
- Phenytoin
- Baclofen
How is trigeminal neuralgia treated surgically?
Ablation decompression
Is giant cell arteritis a secondary or primary headache?
Secondary
How does GCA present?
- Temporal headache
- Jaw claudication
- Elevated CRP/Plasma viscosity
How is GCA treated?
Steroids