13. Headache Flashcards
(88 cards)
1
Q
how can headaches be divided?
A
- Primary (due to a headache disorder) or
- Secondary to another condition
- Non- Life threatening
- life (or sight)- threatening
2
Q
are primary headache disorders, usually life threatening? are they usually acute or chronic?
A
Non- ‘life or sight’ threatening
Many chronic (i.e. recurrent)
3
Q
are secondary headache disorders, usually life threatening? are they usually acute or chronic?
A
Some are life or sight threatening
Many ‘acute’
4
Q
What are 3 primary headache disorders (most common first)?
A
- Tension headache
- Migraine
- Cluster headache
5
Q
What are secondary acute causes of headaches?
A
- vascular
- infective/inflammatory
- ophthalmic
- situational
6
Q
what are vascular causes of secondary headaches?
A
• Haemorrhage o Subarachnoid haemorrhage A&E o Subdural haemorrhage A&E o Extradural haemorrhage A&E • Thrombosis o Venous sinus thrombosis A&E
7
Q
what are infective/inflammatory causes of secondary headaches?
A
- Meningitis A&E
- Encephalitis A&E
- Abscess A&E
- Temporal arteritis A&E
8
Q
what are ophthalmic causes of secondary headaches?
A
glaucoma
9
Q
what are situational causes of secondary headaches?
A
- Cough
- Exertion
- Coitus
10
Q
What are secondary chronic causes of headaches?
A
- drug side effects (analgesics, caffeine, vasodilators)
- trigeminal neuralgia
- raised intracranial pressure (e.g. tumours)
- giant cell arteritis
- systemic (hypertension, pre-eclampsia)
11
Q
of the causes of secondary headache disorders, which ones are life threatening?
A
• intracranial lesion:
- tumour
- haemorrhage
• meningitis
12
Q
of the causes of secondary headache disorders, which ones are sight threatening?
A
giant cell (temporal) arteritis acute glaucoma
13
Q
of the causes of secondary headache disorders, which ones are non life or sight threatening?
A
sinusitis
medication overuse headache
trigeminal neuralgia
14
Q
WHat is the difference between clinical examination in primary vs secondary causes of headaches?
A
Primary: typically normal
Secondary: may have clinical findings
15
Q
What is important in taking history of headaches?
A
- HPC - SQITARS/SOCRATES
- PMH - prev. headaches, conditions causing secondary headache?
- DH - Analgesic use (medication over-use)? Causative of headache?
- FH - Migraines with aura?
- SH - Stress? Sleep? Alcohol and caffeine consumption, diet (triggers)?
16
Q
What are the red flags of headaches?
A
SNOOP:
- systemic signs and disorders
- neurological symptoms
- Onset new or changed and patient >50 yo
- Onset in thunderclap presentation
- papilloedema, positional provocation, precipitated by exercise
17
Q
what are some systemic signs or disorders that can be red flags for headaches?
A
Meningitis (fever, neck stiffness) hypertension Immunosuppressed (e.g. HIV) Pregnant ? Underlying Cancer ?
18
Q
what can neurological symptoms as a red flag for headache indicate?
A
SOL, ICH, glaucoma (visual)
19
Q
what can Onset new or changed and patient >50 yo as a red flag for headache indicate?
A
Malignancy, GCA
20
Q
what can a thunderclap presentation as a red flag for headaches indicate?
A
Vascular (haemorrhage) such as SAH
21
Q
what can papilloedema, positional provocation, precipitated by exercise as a red flag for headache indicate?
A
Indicators of raised ICP
22
Q
What is important in clinical examination of headache presentation?
A
- Vital signs e.g. BP, PR, temp
- Neurological examination (cranial and peripheral nerve examination)
- Other relevant systems, guidance by history
23
Q
what will the vital signs be like in raised ICP?
A
raised ICP can cause bradycardia / hypotension.
24
Q
what are 4 common causes of headache with most common at top and least at bottom?
A
- Tension-type headache (primary headache disorder)
- Migraine (primary headache disorder)
- Medication over-use (secondary headache)
- Cluster headache (primary headache disorder)
25
WHat is the epidemiology of tension-type headaches?
- F>M
- Young (teenagers and young adults [20-39 yr])
- Young > old
- First onset >50yr unusual
26
What are tension headaches thought to be due to?
Pathophysiology thought due to tension in muscles of head and neck
- Usually no family history
27
site of tension headaches?
* Generalised- predilection for Bilateral frontal and occipital regions
* Can radiate to neck
28
quality of tension headaches?
Squeezing / Tight band like constriction, +/- radiating into neck
Non-pulsatile
29
Intensity of tension headaches?
Mild-moderate
30
Timing of tension headaches?
* Worse at end of day (as stress builds up)
* Chronic if > 15 times per month
* Episodic if <15 times per month
31
Aggravating factors for tension headaches?
* Stress
* Poor posture (e.g at a computer)
* Lack of sleep
32
Relieving factors for tension headaches?
Simple analgesics can help
33
How long do tension headaches last?
30 mins to 1 Hr
34
What symptoms may be associated with tension headaches?
• Sometimes mild nausea
35
what is found on clinical examination of tension headaches?
Clinical examination is normal
36
What is the epidemiology of migraines?
- F>M (1 in every 5 F) Common (15 in every 100)
- Presents early to mid-life
- Most have first attack by 30
- Severity decreases as age increases
37
site of migraine?
Unilateral, temporal or often frontal
38
quality of migraine?
Onset can be sudden or gradual. Throbbing / pulsating
39
intensity of migraine?
Moderate
40
How long do migraines typically last?
prolonged headache - Lasts between 4 and 72 hours, possibly with cyclical character
41
What can trigger migraines?
Certain food(cheese, chocolate), menstrual cycle, stress, lack of sleep aggravates, often is a FH
42
Aggravating factors of migraine?
Photophobia / phonophobia (dislike of loud noise)
43
Relieving factors of migraines?
Can respond to simple analgesics (may need triptans); tend to want to lie down
44
What symptoms are associated with migraines?
- nausea, vomiting, sweating
- aura - peculiar sensory signs e.g visual - zigzag lines, shimmery lights etc
- neurological features - e.g. speech disturbance
- photophobia
- phonophobia
45
Pathophysiology of migraines?
* Pathophysiology unclear
* Possible theories proposed e.g.
* neurogenic inflammation of trigeminal sensory neurons innervating large vessels and meninges
* Alters way pain processed by brain; sensitized to otherwise ignored stimuli
46
What is the epidemiology of medication overuse headaches?
- 3rd most common type of headache
- 1-2% of UK population
- 20% of headaches are due to medication overuse
- 30-40 years old
- Females > males
47
What causes medication overuse headaches?
Often using regular analgesics (at least 10 days/month) - Headache not responding
-Related to upregulation of pain receptors in meninges
48
to diagnose medication overuse headaches how long should they have the headache for?
• Headache present on at least 15 days/month (constant)
49
in which patients do medication overuse headaches normally occur in?
• Occurs in patients with pre-existing headache disorder
• Using regular analgesics (for headache)(at least 10 days/month)
– Headache not responding
50
How are medication overuse headaches treated?
Discontinue medication
| - headaches will get worse before they improve
51
quality of medication overuse headaches?
Variable character- can be dull, tension-type or migraine-like
52
What is the epidemiology of cluster headaches?
M >F
1 in 1000
Usual onset 20-40 years old
53
site of cluster headaches
* unilateral
* Around / behind one eye
* No radiation
54
quality of cluster headaches?
Sharp, stabbing, penetrating, often at night
55
intensity of cluster headaches?
* Very severe
* Constant intensity
* often disabling, agitated
56
How long do cluster headaches last, and how often do they occur?
* Rapid onset
* Attacks last 15 min – 3hrs and occur 1-2 times per day
* Usually at night
* Clusters of attacks last 2-12 weeks
* Remissions between clusters can last 3 months – 3 years
57
Aggravating factors for cluster headaches?
* Head injury
* Alcohol
* Smoking
58
Relieving factors for cluster headaches?
Simple analgesics often ineffective; oxygen and triptans used
59
What are triggers for cluster headaches?
```
Alcohol
Histamine (hayfever) GTN
Heat
Exercise
Solvent inhalation
Lack of sleep
```
60
What are associated symptoms with cluster headaches?
• Features associated with decreased sympathetic activity - Ipsilateral autonomic symptoms
o Red, watery eye
o Nasal congestion
o Ptosis
61
What are the findings on clinical examination of cluster headaches?
evidence of autonomic features (during attack)
62
What are the findings on clinical examination of migraine headaches?
Clinical examination is normal
63
pathophysiology of cluster headaches?
Pathophysiology unknown ?hypothalamic activation with secondary trigeminal and autonomic involvement
64
how is the response of individuals different in migraine and cluster headaches?
migraine - tend to lie down
| cluster - agitated
65
what are 4 common causes of secondary headache?
* Intracranial haemorrhage*- some can cause signs/symptoms of meningism e.g. subarachnoid haemorrhage
* Raised ICP due to a space occupying lesions e.g. a tumour)
* Trigeminal neuralgia
* Temporal (giant cell) arteritis
66
How are SOL headaches described?
- Gradual, progressive
- Dull, but often variably described; key is progressiveness of severity
- May be mild in severity, worse in mornings
67
When are SOL headaches worse?
Early-morning, on waking (rarely: headache wakes them)
68
aggravating factors of SOL headaches?
Worsened with posture (leaning forward), cough, Valsalva manoeuvre, straining
69
relieving factors of SOL headaches?
Simple analgesics may be effective in early stages
70
What are associated symptoms with SOL headaches?
Nausea, vomiting, focal neurological or visual symptoms (other neurological signs could include behavior/ personality change, seizures)
71
What are the findings on clinical examination on a SOL headache?
- focal (unilateral) neurological signs, papilloedema
72
what are Additional features of raised ICP
Early morning headache
Nausea and vomiting
Worse on coughing and bending
73
What is the epidemiology of trigeminal neuralgia and what causes it?
F>M
25/100,000 UK popn
50 -60 years
Most caused by compression of CN V due to loop of a blood vessel.
A few cases can be found to be caused by tumours, MS or skull base anomalies
74
site of trigeminal neuralgia headache?
• Unilateral pain felt in ≥1 divisions of CN V, often over one eye
• Radiates to eyes, lips, nose and scalp (think distribution
of CN V)
75
quality of trigeminal neuralgia headache?
Sharp, stabbing, ‘electric’ shock (sometimes burning)
76
intensity of trigeminal neuralgia headache?
Severe
77
How long do attacks of trigeminal neuralgia last?
Seconds to 2 mins
| - sudden onset
78
What can trigger attacks of trigeminal neuralgia?
* Light touch to face
* Eating
* Cold wind
* Vibrations
* combing hair
79
how is trigeminal neuralgia treated?
Simple analgesics not effective; can be difficult to treat
80
What associated symptoms are there with trigeminal neuralgia?
Maybe preceding symptoms: tingling, numbness; pain can radiate to areas within CNV distribution
81
what can be found on clinical examination of trigeminal neuralgia headaches?
Clinical examination –normal
82
What is temporal arteritis and epidemiology?
Vasculitis involving small and medium sized arteries of head
• F>M
• >50 years (most common in>75)
83
When might temporal arteritis be considered as a diagnosis?
Any >50 year old with abrupt onset of headache + visual disturbance or jaw claudication
84
Which artery is commonly involved in temporal ateritis?
Superficial temporal artery
85
What risk is associated with temporal arteritis?
Irreversible loss of vision due to ischemia of CN I
86
How is temporal arteritis treated?
Steroids
87
Investigation of headaches?
o Clearly, dependent on cause (e.g. if subarachnoid haemorrhage then investigate accordingly
o Headache diary can be useful for chronic headaches
o Imaging may be indicated if red flags
88
Treatment of headaches?
o Dependent on underlying cause
o Simple analgesia
o Triptans for migraine
o Cluster headaches may respond to high flow oxygen
