S9 L2 Headache Flashcards
What are the different reasons for a headache?
Primary → due to a headache disorder
Secondary → caused by something else
What are the examples of primary headache disorders?
Non life or sight threatening, many chronic (recurrent)
- Tension type headaches
- Migraine
- Cluster headache
What are the examples of secondary headache disorders?
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
How do you go about determining the causes of headache?
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
What are the red flag symptoms of headache?
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)
What are the clinical examinations you would carry out?
- Vital signs/ obs → BP, PR, temp, ↑ICP, bradycardia/hypertension
- Neurological examination- full peripheral and cranial nerve exam
- Other relevant systems, guidance by history
What is a tension headache?
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
What is the epidemiology of a tension headache?
F>M
Common
Young (teenagers) and young adults (20-39yr)
First onset >50yrs is unusual
What is the suspected pathophysiology of a tension headache?
Tension in muscles of head and neck
Usually no family history
What are the causes of tension headaches?
Stress
Poor posture
Lack of sleep often aggravates
How are tension headaches treated?
Clinical examination - normal
Simple analgesics
What is a migraine?
Unilateral- temporal or frontal
Throbbing or pulsating
Moderate-severe, often disabling (need to lie down)
Pronlonged headache between 4-72 hours
What is the epidemiology of migraines?
F>M (1 in every 5 F)
Common (15 in every 100)
Present early to mid-life
Most have first attack by 30
What is the pathophysiology of a migraine?
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
What are the clinical features of migraine?
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
What are the triggers for migraines?
Certain foods (cheese, chocolates), menstruation
Lack of sleep
Stress
What is the clinical management for migraines?
- Clinical examination - normal between attacks, probably normal during attacks unless neurological signs or symptoms
- Variety of medication (triptans)
- Want to lie down
What is a headache due to medication over-use?
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
What are the epidemiology of a medication over-use headache?
3rd most common
F>M
30-40yrs olds
1-2% of UK population
What is the pathophysiology of medication over-use headaches?
Upregulation of pain receptors in the meninges
How are medication over-use headaches managed?
Discontinuation of medication
Headache often worse before it improves
Typically resolves completely by 2 months
What are cluster headaches?
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
What is the epidemiology of cluster headaches?
M>F
Smoking history= risk factors
1/1000
Usually begins 30-40 years
What is the pathophysiology of cluster headaches?
Unknown
Potentially hypothalamic activation with secondary trigeminal and autonomic involvement
What are the triggers for cluster headaches?
Smoking Alcohol Histamine (hayfever) GTN Heat Exercise Solvent inhalation Lack of sleep
What is the management for cluster headaches?
Clinical examination- evidence of autonomic features
Simple analgesics are often ineffective - oxygen and triptans
What are the space occupying lesions?
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
What is trigeminal neuralgia?
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
What is the epidemiology of trigeminal neuralgia?
F>M
25/100,000 population
50-60years
What is the pathophysiology of trigeminal neuralgia?
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??)
What is temporal arteritis?
Vasculitis of large and medium sized arteries in the head - usually involving the superficial temporal artery
F>M
>50 yrs
What specific symptoms should alert you to potential temporal arteritis?
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)
What investigations can be done for headaches?
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
What are the treatment options?
Dependent on underlying cause
Simple analgesia
Triptans for migraine
Cluster headaches may respond to high flow oxygen
What is the criteria for referral?
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
