Headache Flashcards
What is the epidemiology of headaches?
In top 10 of primary care symptoms (>4% GP consultations)
Accounts for 30% of neurology referrals
Estimated to cost >£6 billion per year in UK (service costs, loss of employment)
70% of headache in primary care not given a diagnostic label
40% of population have tension headache at any time
How many headaches is there and what are the most common and most serious types?
There are over 200 types of headache
Most common;
- Migrane
- Cervicogenic (neck caused)
- Systemic illness
- Analgesia overuse
- Muscular tension
(these are quite mild and none should kill you)
Serious;
- Subarachnoid haemorrhage
- Low intercranial pressure
- Cerebral Venus sinus thrombosis (drainage block)
- Temporal arteritis
- Infection (meningitis)
- Rased intercranial pressure
What questions should we be asking in a headache history?
SOCRATES
- Position on head?
- How long?
- Character (not intensity)? (pressure?, dislike of light/noise?)
- Radiation
- Nausea/vomiting + Other neurological symptoms (double vision)
- Frequency + Diurnal variation (worse in morning or as day goes on?)
- Postural? (worse lying down?)
Previous Medical history, family history (e.g inflammatory bowel syndrome linked to venous sinus thrombosis)
Medicines (how often - more than 15 days/month - analgesic abuse headache?)
What are the symptoms and treatments of a tension headache?
Tension headache;
- Weeks, months, years
- “tightness”, “pressure” round the head
- Constant, or worse toward evening (Makes sense as tension built up over day)
- Often there is frequently used analgesia (using medication too much)
- Rarely presents with nausea
Treatments;
- reassurance around severity and duration
- Wont go away overnight
- Explain muscles around head
- Use relaxation exercises
- Reduce analgesia
- Low dose amitriptyline (10-20mg) normally anti-depressant at 150+mg
What are the symptoms of Migraine ?
- Classically on one side at a time
- Pulse, sharp character
- Most headache with nausea will be migraine!
- Photophobia, photophobia, gut symptoms (IBS may be a form of gut migraine - responds to amitriptyline)
- More common in women, especially mid-cycle, and newly at menopause (oestrogen)
Can be +/- Aura - What is an aura?
- can be visual, weakness or sensory and spreads over minutes
- Can look similar to hemiplegia from stroke
- Can have black and white Scotoma - NB coloured scotoma = danger sign as is associated with epilepsy
What are the causes of Migraine’s?
Mechanism unclear, vascular and neural theories (Reduced blood flow and overactive neurons)
Look for triggers (e.g foods, alcohol, beginning or end of working week)
Maybe exacerbated by physical activity or a bang on the head
Often there is a family history
Keep a diary to help decide pattern and treatments
What are the treatments for Acute migraine’s?
Actue treatments;
- Aspirin, paracetamol
- Anti-nausea (prochlorperazine, metoclopramide)
Best treatments are;
Triptans - agonists at 5HT-1b and 5HT-1d receptors
- and related family of drugs Suma, Riza, Nara, Zolmi-triptan etc.
Note may need a variety of delivery methods to combat nausea and vomiting (e.g melts, injection or nasal spray) - available without prescription but expensive
What are the treatments for Prophylactic migraines?
Prophylactic migraines if events occur >2 per month -
rotate schedules of different meds as after a while become less effective!
Medications;
- Beta blockers (e.g propranolol) commonest use - unless asthmatic
- Low dose amitriptyline
- Pizotifen (5HT-2a and 2c antagonist, antihistamine, anticholinergic)
- Topiramate - anti epileptic also
- Sodium valproate anti epileptic also
( These 2 are sodium channel blockers, reducing excitatory) - Candesartan - angiotensin receptor action - reduced BP
- Flunarazine - Ca channel blocker - reduced BP
- Lisinopril: ACE inhibitor - reduced BP
- Methysergide (Ergot derivative - with a retroperitoneal fibrosis side effect) - Last resort
What are some other treatments for migraines?
- Botulnum toxin injection (usually every 90 days) approved in the UK
- Anti-CGRP monoclonal antibodies, erenumab, licensed in 2018 for > 4 migraines/month UK, (s/c monthly injection), must have tried at least 3 other prophylactics (expensive so thats why)
- Acupuncture (effects not shown)
- Women with migrane and aura should not use combined OCP due to stroke risk
What are Trigeminal Autonomic Cephalagia (TAC)
Trigeminal Autonomic Cephalagia (TAC)
- Rare condition
Commonest of these is cluster headache;
- Unilateral - often around the eye
- Striking circadian rhythm, same time of day (e.g 4-5pm)
- Clustering in periods usually of a few weeks then goes - until next time
Presents;
- Recurrent pain in trigeminal distribution with
- Autonomic features (eye watering, nasal congestion, redness eye)
- More common in males (3:1)
Paroxysmal hemicrania
- More common in women
- Shorter, more frequent attacks
- Responds to indomethacin (non-steroidal anti-inflammatory) so is a differentiator between cluster headache and paroxysmal hemicrania
What are the treatment options for Trigeminal Autonomic Cephalagia (TAC)?
Triptans
Oxygen - High dose
High dose verapamil (up to 960mg/day) - Ca channel blocker at very high doses (causes vasodilation)
Indomethacin for P Hemicrania
What are the features of a Medication overuse headache ?
Presents as;
- Present for >15 days/month
- Worsened while analgesia has been used
Common where;
- Patient using simple analgesia > 15 days/month, or
- 10 > days for other acute e.g triptans
Uncertain whether abrupt cessation of gradual stopping is better for treatment - patient will suffer headache during withdrawal
What are the features of a Thurderclap headache
Instant or rapidly appearing (<60 seconds), very severe pain
Must consider;
- Sub-arachnoid Haemorrhage, .e stroke commonly from leaking aneurism - similar presentation
Requires urgent investigation
- CT head looking for blood immediate
- Lumbar Puncture after 12 hours, look for blood or bilirubin and oxyhaemaglobin in CSF
Can be exertional (coital cephalgia - during sex)
- type of migraine from vasospasm, quickly reversible and comes back is reassuring (you know its reversible)
What are the 2 types of early morning headaches and their features?
Cervicogenic (arising from the neck)
- poor posture in bed, pillow bends neck. Anatomical position is best
- Over exertion of neck muscles
- Spinal degeneration (spondylosis)
- Usually muscular if not presenting with neurological compromise (reflex loss, weakness etc)
- Break pain/spasm cycle - anti-inflammatory or pain treatment
Sleep apnoea with CO2 retention;
- Obesity
- History snoring (common with alcohol)
- tested by monitoring chest movements
- treated with +ve pressure oxygen
What are the features of Raised Intracranial pressure?
SERIOUS
Presents;
- Headache (usually mild)
- Diurnal variation (worse in morning= Bad sign!, often gone by lunchtime)
- Often mild nausea
These mild symptoms are often dismissed
Neurological features - look for bilateral papilloedema - tumours rare presents as headache only, could be access or CSF blockage
Treatment;
- requires a scan urgently and referral
What are the features of infections (meningitis)?
Presents as;
- fever
- photophobia
- neck stiffness
- altered consciousness (encephalitis)
- petechial rash from meningococcal meningitis (can lead to purpuric area and on to amputation)
Treatments;
- most meningitis is viral, but cannot distinguish clinically so treat with Ceftriaxone/cefotaxime or benzyl penicillin
What are the features of cerebral venous sinus thrombosis ?
Presentation & referral;
- Often female, on oral contraceptive pill
- Headache, often severe
- Raised intracranial pressure
- Often papilloedema and seizures
- Maybe MR bilateral, haemorrhage and
- empty delta sign
- Refer on to neurosurgical centre
