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Flashcards in Headache Deck (54):
1

what is a primary headache?

Most common headache
No underlying medical cause

2

name a few primary headaches

Tension Type Headache
Migraine
Cluster Headache

3

what is a secondary headache?

has an identifiable structural or biochemical cause

4

give some causes of secondary headaches

Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced

5

what is a tension-type headache?

Most frequent primary headache, but is NOT disabling and rarely presents to doctors
Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity

6

how often are infrequent ETTH?

< 1 day / month

7

how often are frequent ETTH?

1-14 days / month

8

how often are CTTH?

≥15 days/ month

9

what is the treatment for tension-type headache?

Abortive treatment
Aspirin or paracetamol
NSAIDs
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache

10

what is a migraine?

most frequent disabling primary headache
Most sufferers aged 20 to 50
A chronic disorder with episodic attacks
Complex changes in the brain

11

what are the symptoms during the attacks?

Headache
Nausea, photophobia, phonophobia
Functional disability

12

what are the symptoms in-between attacks?

Enduring predisposition to future attacks
Anticipatory anxiety

13

name some migraine triggers

stress
sleep disturbance
changes in oestrogen level in women
hunger
dehydration
environmental stimuli
diet

14

what are the 5 phases of a migraine attack?

Premonitory Phase
Aura Phase
Early headache
Advanced headache
Postdrome

15

how long do migraine attacks last?

4 to 72 hours

16

what is the Premonitory Phase?

predictors of the headache attack
Mood changes, muscle pain, food cravings, cognitive changes, fatigue

17

what is aura?

Affects 33% of migraineurs
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve visual, sensory, motor or speech systems
15-60 minutes

18

what are the symptoms of early headache?

Dull headache
Nasal congestion
Muscle pain

19

what are the symptoms of advanced headache?

Unilateral
Throbbing
Nausea
Photophobia
Phonophobia
Osmophobia

20

what is the Postdrome phase?

migraine-associated symptoms beyond the resolution of the headache
can last 1-2 days

21

what is a chronic migraine?

Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months

22

what is the treatment for medication overuse headaches?

discontinuing the overused medication often (but not always) dramatically improves headache frequency

23

what is a transformed migraine?

History of episodic migraine
Increasing frequency of headaches
Migrainous symptoms become less frequent and less severe

24

what is medication overuse headache?

Headache present on ≥15 days / month which has developed or worsened whilst taking regular symptomatic medication

25

when does medication overuse headache occur?

Migraineurs are particularly prone
Migraineurs taking pain medication for another reason can develop chronic headache

26

what causes medication overuse headache?

triptans, ergots, opiods and combination analgesics >10 days / month
simple analgesics > 15 days per month
Caffeine overuse: coffee, tea, cola, irn brew

27

what is abortive migraine treatment?

Aspirin or NSAIDs
Triptans
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache

28

what is prophylactic migraine treatment?

Propranolol, Candesartan
Anti-epileptics
Tricyclic antidepressants
Venlafaxine

29

how does pregnancy affect migraine frequency?

Migraine without aura gets better in pregnancy
Migraine with aura usually does not change

30

what is Trigeminal Autonomic Cephalalgias?

type of primary headache that occurs with unilateral head pain in the trigeminal nerve area

31

describe a cluster headache attack

Pain: mainly orbital and temporal
Attacks unilateral
Rapid onset
15 mins to 3 hours
Rapid cessation of pain
Excruciatingly severe (“suicide headache”)
Prominent ipsilateral autonomic symptoms Migrainous symptoms often present

32

describe the cluster headache bout

Episodic in 80-90%
Attacks “cluster” into bouts typically lasting 1-3 months with periods of remission lasting at least 1 month
Attack frequency: 1 every other day to 8 per day
Striking circadian rhythmicity-same time every day
10-20% have chronic cluster

33

what is chronic cluster?

Bouts last >1 year without remission or
Remissions last <1 month

34

describe a Paroxysmal Hemicrania attack

Pain: mainly orbital and temporal
Attacks unilateral
Rapid onset
2-30 mins
Rapid cessation of pain
Excruciatingly severe
Prominent ipsilateral autonomic symptoms
Migrainous symptoms may be present
Background continuous pain can be present
Absolute response to indometacin

35

describe the Paroxysmal Hemicrania frequency

80% have chronic PH, 20% have episodic PH
Frequency: 2-40 attacks per day (no circadian rhythm)
Absolute response to indometacin

36

describe a SUNCT attack

Unilateral orbital, supraorbital or temporal pain
Stabbing or pulsating pain
10-240 seconds duration
Cutaneous triggers eg Wind
Pain is accompanied by conjunctival injection and lacrimation

37

describe SUNCT frequency

3-200/day, no refractory period

38

describe Trigeminal Neuralgia attack

Unilateral maxillary or mandibular division pain > ophthalmic division
Stabbing pain
5 - 10 seconds duration
Cutaneous triggers eg cold
Autonomic features are uncommon

39

describe Trigeminal Neuralgia frequency

3-200/day-similar to SUNCT, has a refractory period

40

What features predict sinister headache?

Serious intracranial pathology is very unlikely in longstanding episodic headache
Presentations more likely to have a sinister cause
Associated head trauma
First or worst
Sudden (thunderclap) onset
New daily persistent headache
Change in headache pattern or type

41

what are red flags of a sinister headache?

new onset headache
new or change in headache
aged over 50
abnormal neurological examination
neck stiffness / fever
high/low pressure
GCA

42

what indicates high pressure headache

headache worse lying down
headache wakening the patient up
headache precipitated by physical exertion
headache precipitated by valsalva manoeuvre
risk factors for cerebral venous sinus thrombosis

43

what indicates low pressure headache

headache precipitated by sitting / standing up

44

what indicates Giant Cell Arteritis headache

Headache is usually diffuse, persistent and may be severe
systemically unwell
scalp tenderness
jaw claudication
visual disturbance
beaded temporal arteries

45

what is a thunderclap headache?

A high intensity headache reaching maximum intensity in less than 1 minute
Majority peak instantaneously

46

what must be tested for in patients with a thunderclap headache?

Subarachnoid Haemorrhage
1 in 10 patients with thunderclap headache will have a SAH
85% aneurysmal
50% mortality, 20% of survivors remain dependant
Early coiling (or clipping) of the aneurysm saves lives

47

how is thunderclap headache investigated?

SAME DAY hospital assessment
Does the patient have SAH or another secondary cause
CT brain (3% negative at 12 hrs, 7% negative at 24 hrs)
LP (must be done >12hrs after headache onset)
CT +/- LP is unreliable beyond 2 weeks and angiography is required beyond this time

48

what should be considered in any patient presenting with headache and fever?

CNS infection
Meningitis and Encephalitis
Look for a rash!

49

what are the symptoms of Meningitis?

nausea +/- vomiting, photo/phono phobia, stiff neck

50

what are the symptoms of Encephalitis?

altered mental state / consciousness, focal symptoms / signs, seizures

51

what features suggest a space occupying lesion and/or raised intracranial pressure?

Progressive headache with associated symptoms and signs
Headache worse in morning/lying flat or brought on by valsalva
Focal symptoms or signs
Non-focal symptoms e.g. cognitive or personality change, drowsiness
Seizures- due to underlying structural causes
Visual obscurations and pulsatile tinnitus

52

what causes Intracranial hypotension?

Dural CSF leak
Spontaneous or iatrogenic (post lumbar puncture)

53

what features suggest Intracranial hypotension?

headache precipitated by sitting / standing up
Once the headache becomes chronic it often loses its postural component

54

what supports the diagnosis of Giant cell arteritis?

An elevated ESR (usually >50, often much higher, rarely normal)
Raised CRP and platelet count are other useful markers