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_Sem 4. CNS NOTES > S9 L2 Headache > Flashcards

S9 L2 Headache Flashcards

1
Q

What are the different reasons for a headache?

A

Primary → due to a headache disorder

Secondary → caused by something else

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2
Q

What are the examples of primary headache disorders?

A

Non life or sight threatening, many chronic (recurrent)

  • Tension type headaches
  • Migraine
  • Cluster headache
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3
Q

What are the examples of secondary headache disorders?

A

Some are life or sight threatening
Many acute
- Vascular
→ Haemorrhage (subarachnoid, subdural, extradural)
→ Thrombosis (venous sinus thrombosis)
- Infective/ Inflammatory (meningitis, encephalitis, abscess, temporal arteritis
- Ophthalmic (glaucoma)
- Situational (exacerbating factors) - cough, exertion, coitus
Some chronic
- Drug side effects (analgesics, caffeine, vasodilators)
- Trigeminal neuralgia difficult to classify but probably secondary due to vascular anomaly
- Raised ICP
- Temporal/ giant cell arteritis
- Systemic - hypertension, pre-eclampsia, phaemochromocytoma - rare

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4
Q

How do you go about determining the causes of headache?

A

Thorough history taking important
- PC - SQUITARS
- PMH - previous headaches or conditions causing headaches
- DH - analgesic use, other drugs
- FH - migraines
- SH - stress, sleep (lack), diet, hydrations, alcohol and caffeine consumptions
Ensure you enquire about red flag symptoms

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5
Q

What are the red flag symptoms of headache?

A

SNOOP
S- systemic signs and symptoms (meningitis, hypertension, immunosuppresses, pregnant, cancer)
N- Neurological symptoms (SOL, ICH, glaucoma (visual))
O- Onset of new or change and patient >50 years old (malignancy, GCA)
O- Onset in thunderclap presentation (vascular haemorrhage)
P- Papilledema (positional provocation, precipitated by exercise) (indicators of ↑ICP)

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6
Q

What are the clinical examinations you would carry out?

A
  1. Vital signs/ obs → BP, PR, temp, ↑ICP, bradycardia/hypertension
  2. Neurological examination- full peripheral and cranial nerve exam
  3. Other relevant systems, guidance by history
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7
Q

What is a tension headache?

A

Site → Generalised- usually frontal and occipital regions
Quality → Tight/ band like, constricting, +/- radiating into the neck
Intensity → Mild-moderate intensity
Time → Worse at the end of the day, recurrent (30mins- 1hr)
→ Chronic >15 times/month
→ Episodic <15 times/month
Aggravating → stress, poor posture lack of sleep
Relieving → analgesics
Secondary symptoms →Few associated symptoms- nausea

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8
Q

What is the epidemiology of a tension headache?

A

F>M
Common
Young (teenagers) and young adults (20-39yr)
First onset >50yrs is unusual

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9
Q

What is the suspected pathophysiology of a tension headache?

A

Tension in muscles of head and neck

Usually no family history

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10
Q

What are the causes of tension headaches?

A

Stress
Poor posture
Lack of sleep often aggravates

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11
Q

How are tension headaches treated?

A

Clinical examination - normal

Simple analgesics

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12
Q

What is a migraine?

A

Unilateral- temporal or frontal
Throbbing or pulsating
Moderate-severe, often disabling (need to lie down)
Pronlonged headache between 4-72 hours

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13
Q

What is the epidemiology of migraines?

A

F>M (1 in every 5 F)
Common (15 in every 100)
Present early to mid-life
Most have first attack by 30

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14
Q

What is the pathophysiology of a migraine?

A

Possible theories proposed

  • Neurogenic inflammation of trigeminal sensory neurones innervating the large vessels and meninges
  • Alters the way pain is processed, sensitised to otherwise ignored stimuli
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15
Q

What are the clinical features of migraine?

A

Site → Unilateral- temporal or frontal
Quality → Onset can be sudden or gradual, throbbing pulsating pain
Intensity → Moderate
Time → Lasts between 4-72hours, possibly with cyclical character
Aggravating factors → photophobia, phonophobia
Relieving factors → Sleep, number of medications (triptans)
Secondary symptoms → May have aura (characteristic feeling preceding attack), nausea and vomiting

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16
Q

What are the triggers for migraines?

A

Certain foods (cheese, chocolates), menstruation
Lack of sleep
Stress

17
Q

What is the clinical management for migraines?

A
  • Clinical examination - normal between attacks, probably normal during attacks unless neurological signs or symptoms
  • Variety of medication (triptans)
  • Want to lie down
18
Q

What is a headache due to medication over-use?

A

Headache present on >15 days/month
Patient with pre-existing headache disorder
Using regular analgesics a least 10 days/month with no response
Variable character → dull, tension-type or migraine like
Often co-exist with depression or sleep disturbances

19
Q

What are the epidemiology of a medication over-use headache?

A

3rd most common
F>M
30-40yrs olds
1-2% of UK population

20
Q

What is the pathophysiology of medication over-use headaches?

A

Upregulation of pain receptors in the meninges

21
Q

How are medication over-use headaches managed?

A

Discontinuation of medication
Headache often worse before it improves
Typically resolves completely by 2 months

22
Q

What are cluster headaches?

A

Site → Unilateral, around/ behind one eye, no radiation
Quality → Sharp, stabbing and penetrating
Intensity → Very severe, constant intensity
Time → Rapid onset, 15mins-3hrs, 1-2times per day, often at night, remission 3m-3years
Aggravating factors → Head injury, alcohol, smoking
Relieving factors → Simple analgesics often ineffective, oxygen and triptans used
Secondary symptoms → ipsilateral sympathetic symptoms- red, watery eye, blocked runny nose, ptosis

23
Q

What is the epidemiology of cluster headaches?

A

M>F
Smoking history= risk factors
1/1000
Usually begins 30-40 years

24
Q

What is the pathophysiology of cluster headaches?

A

Unknown

Potentially hypothalamic activation with secondary trigeminal and autonomic involvement

25
Q

What are the triggers for cluster headaches?

A 
Smoking 
Alcohol 
Histamine (hayfever) 
GTN
Heat 
Exercise 
Solvent inhalation 
Lack of sleep
26
Q

What is the management for cluster headaches?

A

Clinical examination- evidence of autonomic features

Simple analgesics are often ineffective - oxygen and triptans

27
Q

What are the space occupying lesions?

A

RARE
Result in raised intracranial pressure
Gradual, progressive
Dull but often variably described- key is progressiveness of severity
Maybe mild in severity, worse in the mornings
Headache rarely occurs in the absent of other neurological signs
Worsened with posture - leaning forward, cough, valsalva manoeuvre, straining
Secondary symptoms→ focal neurological or visual symptoms
Clinical examinations → focal (unilateral) neurological signs, papilloedema
Simple analgesics -maybe effective in the early stages

28
Q

What is trigeminal neuralgia?

A

Unilateral pain felt in >1 division of CNV (if involved CNV1 often described as headache)
Site → Over one eye, radiates to eyes, lips, nose and scalp
Quality → Sharp and stabbing, electric shock feeling
Intensity → Severe
Time → Sudden onset, lasts a few seconds to 2 minutes
Aggravating factors → light touch to face, eating, cold wind, vibrations, combing hair
Relieving factors → Difficult, simple analgesics don’t work
Secondary symptoms → can have numbness and tingling preceding an attack
Clinical examination normal

29
Q

What is the epidemiology of trigeminal neuralgia?

A

F>M
25/100,000 population
50-60years

30
Q

What is the pathophysiology of trigeminal neuralgia?

A

Compression of trigeminal nerve by vascular malformation- loop of blood vessel
Few cases caused by tumour (5%), MS or skull base abnormalities
Most common in those with history of chronic pain (central sensitisation??)

31
Q

What is temporal arteritis?

A

Vasculitis of large and medium sized arteries in the head - usually involving the superficial temporal artery
F>M
>50 yrs

32
Q

What specific symptoms should alert you to potential temporal arteritis?

A

Abrupt onset of headache + visual disturbances or jaw claudication (pain)
Risk of irreversible loss of vision die to involvement of blood vessels supplying the CNII (optic nerve)

33
Q

What investigations can be done for headaches?

A

Clearly, dependent on cause (e.g. subarachnoid haemorrhage then investigate accordingly)
Headache diary can be useful for chronic headaches
Imaging may be indicated in red flags

34
Q

What are the treatment options?

A

Dependent on underlying cause
Simple analgesia
Triptans for migraine
Cluster headaches may respond to high flow oxygen

35
Q

What is the criteria for referral?

A

Focus on principles, not necessarily on the specifics
Headaches need to be referred if there is
- suspicion of tumour
- suspicion of raised ICP
- recent onset of seizure
- previous cancer
- unexplained focal deficit
- unexplained cognitive/personality changes

_Sem 4. CNS NOTES (21 decks)

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