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Headache Flashcards

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1
Q

What is the most frequent disabling primary headache?

A

Migraine

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2
Q

When is migraine incidence higher?

A

In women during puberty and menopause

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3
Q

What is a migraine

A

Neurological chronic disorder with episodic attacks, characterised by recurrent and reversible attacks of pain and associated symptoms

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4
Q

Symptoms of migraine

A

Headache
Functional disability
Anticipatory anxiety
Associated symptoms

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5
Q

Triggers of migraine

A 
Stress 
Hunger 
Sleep disturbance 
Dehydration 
Diet 
Environmental stimuli 
Changes in oestrogen levels in women
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6
Q

Premonitory features of migraine

A 
Mood changes 
Fatigue 
Cognitive changes 
Muscle pain 
Food craving
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7
Q

Features of migraine

A 
Premonitory features 
Aura 
Early headache 
Advanced headache 
Postdrome features
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8
Q

Features of early headache in migraine

A

Dull headache
Nasal congestion
Muscle pain

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9
Q

Features of advanced headache in migraine

A 
Unilateral 
Throbbing 
Nausea 
Photophobia 
Phonophobia 
Osmophobia
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10
Q

Postdrome features of migraine

A

Fatigue
Cognitive changes
Muscle pain

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11
Q

What percentage of those who experience migraines will experience aura?

A

33%

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12
Q

What is aura?

A

Transient neurological symptom resulting from cortical or brainstem dysfunction which may involve visual, sensory, motor or speech symptoms

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13
Q

Duration of aura

A

15-60 minutes

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14
Q

What might an aura be confused with?

A

Transient ischaemic attack - loss of function, sudden onset, symptoms start at same time, can be localised to particular vascular area

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15
Q

What is a chronic migraine?

A

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

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16
Q

Presenting features of transformed migraine

A

History of episodic migraine
Increasing frequency of headaches over weeks/months/years
Migraine symptoms become less frequent and less severe
Episodes of severe migraine on background of less severe featureless frequent/daily headache

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17
Q

Most common cause of chronic migraine

A

Medication overuse

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18
Q

What is a medication overuse headache?

A

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

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19
Q

Most common primary headache in which medication overuse headache occurs

A

Migraine

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20
Q

What can cause a medication overuse headache?

A 
Use of;
Triptans
Ergots 
Opioids 
Combination analgesics 
for > 10 days/month

or use of simple analgesics for > 15 days/month

or caffeine overuse e.g. coffee

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21
Q

What is the most frequent primary headache?

A

Tension-type headache

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22
Q

Lifetime prevalence of tension-type headache

A

42% in men

49% in women

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23
Q

Features of tension-type headache

A

Mild, bilateral headache which is often pressing or tightening in quality but has no significant associated features and is not aggravated by routine physical activity

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24
Q

What might be felt on manual palpation of a patient with a tension-type headache?

A

Peri-cranial tenderness

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25
What is a new daily persistent headache?
Daily and unremitting headache from soon after onset (3 or less days)
26
Diagnostic criteria for primary new daily persistent headache
Must have the headache for > 3 months and exclude secondary causes
27
What are the forms of primary new daily persistent headache?
Self-limiting | Unremitting
28
Cause of primary new daily persistent headache
40-60% no precipitating event | Can be associated with viral illness, trauma, surgery, stressful life event
29
Examples of secondary causes of heterogenous headache disorder
``` Subarachnoid haemorrhage Cerebral venous sinus thrombosis Subdural haematoma Giant cell arteritis Infective/malignant meningitis ```
30
What is hemicrania continua?
Strictly unilateral continuous headache that has an absolute response to indomethacin
31
Features of hemicrania continua
Continuous moderately severe headache that waxes and wanes in intensity Episodic or chronic Strictly hemicranial Superimposed exacerbations of more severe pain
32
Associated symptoms of hemicrania continua
Occur with exacerbations of pain Ipsilateral cranial autonomic features e.g. rhinorrhoea, eyelid oedema Idiopathic stabbing headache Migrainous features
33
Examples of trigeminal autonomic cephalalgias
Cluster headache Paroxysmal hemicranias Short-lasting unilateral neuralgiform headache with conjunctival injection (SUNCT) Short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA)
34
Features of trigeminal autonomic cephalalgias
Unilateral head pain Very severe/excruciating Varied attack frequency, duration and response to treatment
35
Cranial autonomic symptoms
``` Conjuctival injection/lacrimation Nasal congestion/rhinorrhoea Eyelid oedema Forehead and facial sweating Miosis/ptosis ```
36
Features of cluster headache
``` Mainly orbital and temporal pain Attacks strictly unilateral Rapid onset Rapid cessation of pain Excruciatingly severe pain ```
37
Duration of cluster headache
15mins - 3 hours
38
Onset of cluster headache
9 mins max
39
Associated symptoms of cluster headache
``` Restlessness Agitated Prominent ipsilateral autonomic symptoms Migrainous symptoms Premonitory symptoms e.g. tiredness Nausea Vomiting Photophobia Phonophobia Aura ```
40
In what percentage of people are cluster headaches episodic?
80-90%
41
How long do bouts of cluster headache attacks typically last?
1-3 months with periods of remission lasting at least 1 month
42
Attack frequency of cluster headaches
1 every second day - 8 per day
43
When does alcohol trigger a cluster headache attack?
During a bout, but not during remission
44
What percentage of people have chronic cluster headaches?
10-20%
45
Frequency of chronic cluster headaches
Bouts last > 1 year without remission | or remissions last < 1 month
46
Features of paroxysmal hemicrania
``` Pain mainly orbital and temporal Attacks strictly unilateral Rapid onset Rapid cessation of pain Excruciatingly severe Prominent ipsilateral ANS symptoms Restless and agitated (50%) ```
47
Duration of paroxysmal hemicrania
2-30 mins
48
Features of SUNCT
Unilateral orbital, supraorbital or temporal pain Stabbing/pulsating pain Pain accompanied by conjunctival injection and lacrimation
49
Duration of SUNCT
10-240 seconds
50
Cutaneous triggers of SUNCT
Wind Cold Tough Chewing
51
Attack frequency of SUNCT
3-200 per day, no refractory period
52
Features of Trigemial Neuralgia
Unilateral or mandibular division pain Stabbing pain Autonomic features uncommon
53
Duration of trigeminal neuralgia
5-10 seconds
54
Cutaneous triggers of trigeminal neuralgia
wind cold touch chewing
55
Abortive migraine treatments
Aspirin or NSAIDs Triptans Limit to 10 days per month to avoid medication overuse headaches
56
Prophylactic migraine treatments
Propranolol, candesartan Anti-epileptics e.g. topiramate, valproate, gabapentin Tricyclic antidepressants e.g. amitriptyline, dothiepin, nortriptyline Venlafaxine
57
Lifestyle changes to make for treatment of migraine
``` Don't miss meals Stay hydrated Avoid changes in sleep patterns Regular exercise Trigger avoidance ```
58
Tension-type headache abortive treatment
Aspirin or paracetamol NSAIDs Limit to 10 days per month
59
Tension-type headache prophylactic treatment
Tricyclic antidepressants e.g. amitriptyline, dothiepin, nortriptyline Venlafaxine Mirtazapine
60
Cluster headache abortive treatment
Subcutaneous sumatriptan 6mg or nasal zolmatriptan 5mg | 100% oxygen, 7-12 l/min via tight-fitting non-rebreathing mask
61
Headache bout abortive treatment
Occipital depomedrone injection on same side as headache | Tapering course of oral prednisone
62
Preventative treatment of headache bout
Verapamil Lithium Methysergide Topiramate
63
Paroxysmal hemicrania treatment
No abortive treatment Prophylaxis with indomethacin COX-II inhibitors or topiramate
64
SUNCT/SUNA treatment
``` No abortive treatment Prophylaxis; lamotrigine topiramate gabapentin carbamazepine/oxcarbazepine ```
65
Trigeminal neuralgia treatment
No abortive treatment Prophylaxis - carbamazepine, oxcarbazepine Surgical intervention - glycerol ganglion injection, stereotactic radiosurgery, decompressive surgery
66
Presentations of headaches associated with more severe causes
``` Associated head trauma First or worst headache Sudden onset (thunderclap) New daily persistent headache Change in headache pattern or type Returning patient ```
67
Red flag headache presentations
New onset headache New/change in headache if over 50, immunosuppression or cancer Change in headache frequency, characteristics, associated symptoms Focal neurological symptoms Abnormal neurological examination Neck stiffness/fever
68
High-pressure headache presentations
Headache worse lying down Headache waking patient up at night Headache precipitated by physical exertion Headache precipitated by Valsalva manoeuvre Risk factors for cerebral venous sinus thrombosis present
69
Low-pressure headache presentation
Headache precipitated by sitting/standing up
70
Giant cell arteritis presentation
Jaw claudication Visual disturbance Prominent/beaded temporal arteries
71
What is a thunderclap headache?
High intensity headache reaching maximum intensity in less than one minute Majority will peak instantaneously May be primary or secondary
72
Differential diagnoses for thunderclap headache
``` Primary headache Subarachnoid haemorrhage Intracerebral haemorrhage TIA/stroke Carotid/vertebral dissection Cerebral venous sinus thrombosis Meningitis/encephalitis Pituitary apoplexy Spontaneous intracranial hypotension ```
73
What number of patients presenting with thunderclap headache will have a subarachnoid haemorrhage?
1 in 10
74
Mortality of subarachnoid haemorrhage
50%
75
Risk of re-bleed in subarachnoid haemorrhage
4-6% in first 24-48 hours | 40% in first month
76
Immediate treatment of subarachnoid haemorrhage
Coiling or clipping of aneurysm
77
Immediate investigations in suspected subarachnoid haemorrhage
CT brain Lumbar puncture Angiography (if after two weeks)
78
Presentation of meningitis
``` Nausea +/- vomiting Photophobia Phonophobia Stiff neck Rash ```
79
Encephalitis presentation
Altered mental state/consciousness Focal symptoms/signs Seizures
80
Warning features of headache, suggestive of space-occupying lesion/raised ICP
Headache Headache worse in morning or waking patient from sleep Headache worse when lying flat Headache brought on by Valsalva manoeuvre Seizures Focal symptoms/signs Non-focal symptoms/signs e.g. cognitive change Visual obscuration Pulsatile tinnitus
81
When might the cause of intracranial hypotension be iatrogenic?
Post-lumbar punture
82
Intracranial hypotension features
Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down
83
Investigation of intracranial hypotension
MRI brain and spine
84
Treatment of intracranial hypotension
``` Bed rest Fluids Analgesia Caffeine (IV) Epidural blood patch ```
85
When should giant cell arteritis be considered?
In any patient over the age of 50 presenting with new headache
86
Presentation of giant cell arteritis
``` Diffuse, persistent, severe headache Systemically unwell Scalp tenderness Jaw claudication Visual disturbance Prominent/beaded temporal arteries ```
87
Test results which would confirm giant cell arteritis diagnosis
Elevated ESR | Raised CRP and platelet count
88
Treatment of giant cell arteritis
High dose prednisolone | Temporal artery biopsy

Nervous System (44 decks)

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