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Headaches TCD Case 4 > General Headaches Notes > Flashcards

General Headaches Notes Flashcards

1
Q

What are the classifications of headaches?

A

Primary headache - NO secondary underlying pathology

Secondary headache - there IS underlying cause

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2
Q

What are examples of primary headaches?

A

Tension headache
Migraine
Cluster headache

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3
Q

What are examples of secondary headaches?

A

Space occupying lesion
Intracranial hypertension
Vasculitis/arteritis (inflammation of blood vessels)

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4
Q

Signs not to miss on examination?

A

Papilloedema - raised ICP (need emergency imaging)
Peripheral field loss or enlarged blind spot - raised ICP
6th (abducens) nerve palsy
- Due to raised ICP (CN VI is stretched)
- Giant cell arteritis causing infarction of nerve
Extensor plantar - toes goes UP (not normal)
Ataxia - loss of controlled movement (potential lesion in posterior fossa affecting the cerebellum)
Oral hairy leukoplakia
Purpuric rash - Non-blanching/Meningococcal sepsis
Livedo reticularis - at risk of venous clot in sinuses of brain - leading to headaches

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5
Q

Investigations that can be done for a headache?

A

Typically done on patients who we know will likely have an abnormality

CT
MRI
CSF manometry - looking at pressure
Lumbar puncture - subarachnoid haemorrhage has xanthochromia in CSF
- CSF should NOT contain any polymorphs-nuclear cells e.g. neutrophils - evidence of bacterial infection e.g. meningitis

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6
Q

What are RED FLAGS for headaches?

A

Sudden ‘thunderclap’ onset = subarachnoid haemorrhage
Sudden neurological deficit
Seizure
Jaw claudication + tender temporal region + over 50 = Giant Cell Arteritis
Photophobia + neck stiffness + fever (+ petechial rash) = Meningitis
Loss of/reduced conscousness
History of trauma
Sudden red, painful eye
Suspected malignancy (SoL)
Worse on coughing or straining (raised intracranial pressure)

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7
Q

How does a tension-type headache present?

A

Bilateral
Pressing/tightening (non-pulsating) - pain
Mild or moderate

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8
Q

How long does tension-type headache last and how does it effect activities?

A

30 mins -> continuous
Not aggravated by routine activities of daily living (ADL)
NO - other symptoms

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9
Q

What is the difference between episodic and chronic tension-type headache?

A

Episodic - LESS than 15 days per month

Chronic - MORE than 15 days per month for more than 3 months

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10
Q

What is the treatment of tension-type headaches?

A

Acute treatment
- Aspirin, paracetamol, NSAIDs but NOT opioids

Prophylactic treatment
- 10 series of acupuncture over 5-8 weeks for chronic tension-type headache

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11
Q

How does migraine present?

A

Unilateral or bilateral
Pulsating/throbbing/banging
Moderate or severe

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12
Q

How long does migraine headache last and how does it effect activities?

A

4-72 hours in adults
1-72 hours in young people (12-17 years)
Aggravated by or causes avoidance of routine ADLs

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13
Q

What other symptoms can be caused due to migraine?

A

Unusual sensitivity to light and/or sound or nausea and/or vomiting

• Aura - symptoms can occur with/without headache and:
◦ Are fully reversible
◦ Develop over at least 5 minutes
◦ Last 5-60 minutes
• Typical aura symptoms include:
◦ Visual symptoms - flickering lights, spots or line and/or partial loss of vision
◦ Sensory symptoms - numbness and/or pins and needles
◦ Speech disturbances

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14
Q

What is the difference between episodic and chronic migraine (with/without aura) headache?

A

Episodic - LESS than 15 days per month

Chronic - MORE than 15 days per month for more than 3 months

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15
Q

What is the acute treatment of migraines?

A

Combination therapy: oral triptan (e.g. 50 mg sumatriptan) + NSAID/paracetamol

If ineffective/not-tolerated:

  • Offer non-oral metoclopramide (anti-emetic) or prochlorperazine
  • Consider non-oral triptan or NSAID

DO NOT GIVE opioids or ergots

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16
Q

What is the prophylactic treatment of migraines?

A

First line :
- Beta-blockers - propranolol (if unsuitable offer 10 acupuncture sessions)
- Low-dose amitriptyline
Second line: Topiramate (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant)

Riboflavin (vitamin B2) may reduce frequency and severity

17
Q

What can trigger migraines?

A 
Jet lag
Cheese
Menstruation
Relaxing after stress
Contraceptive pills
Flickering lights on a TV screen
18
Q

What time frame does menstrual-related migraine occur around?

A

2 days before and 3 days after start of menstruation - in at least 2 or 3 consecutive menstrual cycles

19
Q

How is menstrual-related migraine treated?

A

Frovatriptan/zolmitriptan (2.5 mg twice daily) on days migraine is expected

20
Q

How does a triptan work?

A

Triptans are used to abort migraines when they start to develop. They are 5HT receptors agonists (serotonin receptor agonists). They act on:

  • Smooth muscle in arteries to cause vasoconstriction
  • Peripheral pain receptors to inhibit activation of pain receptors
  • Reduce neuronal activity in the central nervous system
21
Q

How does a cluster headache present?

A

Unilateral (around eye, above eye and along side of head/face)
Quality - can be sharp, boring, burning, throbbing, tightening
Intensity - severe or very severe

22
Q

How long does cluster headache last and how does it effect activities?

A

15-180 minutes

Effects on activities - restless or agitation

23
Q

What other symptoms can be caused due to cluster headache?

A

On same side as headache:

  • Red and/or watery eye
  • Nasal congestion and/or runny nose
  • Swollen eyelid
  • Forehead and facial sweating
  • Constricted pupil and/or drooping eyelid
24
Q

What is the difference between episodic and cluster headache?

A

Episodic - 1 every other day to 8 per day, with remission more than 1 month
Chronic - 1 every other day to 8 per day with a continuous remission less than 1 month in a 12 month period

25
Q

What is the acute treatment of cluster headache?

A

Triptans (e.g. sumatriptan 5mg injected subcutaneously)
High flow 100% oxygen for 15-20 minutes (can be given at home) - at least 12L/min via non-rebreathe mask

DO NOT give paracetamol, NSAID, opioids, or oral triptans

26
Q

What is prophylactic treatment of cluster headache?

A 
Verapamil 360mg (CCB)
Corticosteroids - prednisolone (a short course for 2-3 weeks to break the cycle during clusters)
Lithium
27
Q

What may be the cause of rapid onset headaches?

A

Need to rule out: subarachnoid haemorrhage (SAH, sudden-onset, ‘worst ever’ headache

Other differentials: meningitis, encephalitis

28
Q

What may cause gradual onset headaches?

A

Venous sinus thrombosis
Sinusitis
Intracranial hypotension

Headaches TCD Case 4 (3 decks)

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