W21 Headache and Migraine Flashcards
What are headaches categorised into?
- Categorised by International Classification of Headache Disorders (ICHD)
-
Primary Headaches – not associated with underlying condition (most common)
Migraine, Tension headache, cluster headache - Secondary Headaches – Caused by underlying issue/condition
- Trauma/injury to head/neck area, intracranial haemorrhage, giant cell arteritis, stroke/TIA, brain malignancy
- Substance exposure, misuse/overuse, withdrawal
- Infection, glaucoma, psych. disorders, HTN
Examples of primary headaches? (3)
-
Primary Headaches – not associated with underlying condition (most common)
Migraine, Tension headache, cluster headache
Examples of causs of secondary headaches? (3)
- Secondary Headaches – Caused by underlying issue/condition
- Trauma/injury to head/neck area, intracranial haemorrhage, giant cell arteritis, stroke/TIA, brain malignancy
- Substance exposure, misuse/overuse, withdrawal
- Infection, glaucoma, psych. disorders, HTN
How can you assess a headache?
- Identify RED FLAGS that suggest a serious secondary cause – for further specialist assessment
- Pain – Onset, duration, frequency, pattern, location, severity, quality
- Associated symptoms – Aura, N&V, motion problems, photophobia, phonophobia
- Autonomic symptoms – Lacrimation, conjunctival injection, rhinorrhoea
- Precipitated or associated with a trigger?
- Comorbidity present?
- Medication taken for symptom relief?
- Symptoms relieved?
- Impact on daily activity/QoL?
- Examination – Vital signs, mental state, alertness, neck/face/intracranial structure, Neuro exam, fundoscopy
- Headache diary – Useful if primary diagnosis unclear but secondary cause ruled out – period of 8 weeks
What is a Migraine?
with aura?
- Common Primary headache disorder
- Episodes of Moderate/Severe headache – unilateral mostly, pulsating or throbbing
- Associated with photophobia, phonophobia, N&V
Aura
-Sensation experienced before or during a migraine attack
-Visual aura – Blind spot, blurred vision, zigzag lines
-Sensory aura – Pins & needles
2 types of migraine?
What are the triggers? (6)
- Episodic – attacks occur less than 15 days/month
- Chronic – attacks on at least 15 days per month for more than 3 months
Triggers:
Factors that can start an attack
Poor sleep
Irregular/missed meals
Excess caffeine
Menstruation
Stress
What are the factors increasing risk of chronic migraine?
- High frequency of episodic migraine
- Overuse of medication to treat acute episodes
- Excess caffeine
- Obesity
- Snoring/sleep disorders
- Co-morbidity – head injury, pain disorder, anxiety, depression
- Life events – divorce, marriage, job loss
Prevalence and Prognosis of migraine
(for info)
Prevalence;
1 in 7 sufferers globally
2-3 times more common in women
Most common in age 25-55years
Around 8% of migraine sufferers have chronic migraine
Prognosis;
Improves with age
Improves after menopause in women
Pregnancy improvement – reduced frequency or severity of attacks in trimesters 2&3
Migraine without Aura Diagnosis:
At least 5 attacks of:
Headache lasting 4-72hours in Adults (2072hrs in adolescents)
Headache with at least 2 of:
Unilateral location, pulsating/throbbing/banging, moderate or sever pain, aggravated by or affects daily activities
Headache with nausea & vomiting, photophobia and phonophobia
Headache not accounted for by another diagnosis
Migraine with aura diagnosis:
What are the conditions?
2 attacks of..?
3 of?
At least 2 attacks of:
1+ fully reversible aura sympom – Visual, sensory or speech
At least 3 of:
1+ aura symptom spreading over 5 mins
2+ aura symptoms in succession
Each aura symptom lasts 5-60 mins
At least one symptom is unilateral
At least one symptom is positive
Headache not accounted for by another diagnosis
Atypical aura:
What are the non-regular aura symptoms? (5)
Motor weakness
Double vision
Visual symptoms in one eye only
Poor balance
Reduced consciousness
Admission or urgent specialist advice needed
Aura with no headache:
- Attack of aura but without headache
- No headache makes it difficult to exclude other causes
- Further investigation needed
What are
Prodromal symptoms?
Postdromal symptoms?
Menstrual related migraine?
Symptoms occur from 2 days up to hours before other migraine symptoms
-Fatigue, poor concentration, neck stiffness, yawning
Occur AFTER headache and can last up to 48 hours
-Fatigue, elation, depressed mood
Women or girls with migraine symptoms around the start of menstruation cycle for at least 2/3 cycles
What is the differential diagnosis of Migraine?
Tension Headache
Cluster Headache
Paroxysmal Hemicrania
Cough/cold Headache
Trauma/injury to head/neck
Intracerebral Haemorrhage
Central Venous Thrombosis
Giant Cell Arteritis
TIA/Stroke
Idiopathic Intracranial Hypertension
Neoplasm
Substance Withdrawal
Medication Overuse
CO Exposure
Intracranial Infection
Hypoxia
Hypertension
Pre-eclampsia/Eclampsia
Closed Angle Glaucoma
Dental Problem
Otitis Media
Sinusitis
Somatisation Disorder
Management of Migraine in Adults?
Advice/Self Care
Migraine Diary
Avoid Triggers
Lifestyle changes – Stress, sleep hygiene, hydration, regular meals, exercise, weight
Treat co-morbidities – Sleep apnoea, insomnia, depression & anxiety
Medication Overuse Headache (MOH)
- Restrict acute meds use to max. 2 days a week
Inc. risk if using simple analgesics >15 days/month or Triptans/combination analgesics for >10 days/month
Combined Hormonal Contraceptives – CI in women with migraine + aura
Acute treatment of migraine? (3)
When to follow up?
- Simple analgesics ( NSAIDs, Aspirin, Paracetamol)
- Triptans(Sumatriptan, Naratriptan, Rizatriptan, Zolmitriptan)
- Anti-emetics (Prochloperazine, Metoclopramide)
- Acute medication should be started as early as possible at onset of pain or aura
- No ergots or opioids should be used
- Follow up in 2-8 weeks
