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Flashcards in Headache Deck (22):

What are the red flag symptoms for headache?

Abrupt or split second onset

Diurnal variation

Postural variation

Progressively worsening headache

Neurological symptoms and signs

Systemic symptoms and signs

Secondary risk factors-sinusitis, cancer, head injury


What are red flag signs of headache?

Neck stiffness
Focal neurological signs
Tender temporal arteries


Tension type headache:
-is this common?
-describe the nature of the headache?

Most common type of headache, mild to moderate

Tight band quality, generalised, discomfort, pressed tingling quality, feeling of pressure at vertex


Tension type headache:
-uni or bilateral?
-is there systemic upset/photophobia/N+V?
-how often does this occur?
-when does this worsen?


No systemic upset, photophobia or aura (no N&V)

Often daily occurrence

otowards end of the day
oanxiety, noise or glare


Tension type headache:
-what is this assoc. with?
-what is found on physical examination?

losely assoc. with musculoskeletal problems esp. neck muscle tension and neck trauma e.g. whiplash

1/3 pt.s have depressive symptoms

physical examination normal: may be inappropriate muscle contraction over head and neck


What is the treatment for tension type headache

Conservative: explanation, exacerbating factors e.g. ill fitting dentures/glasses/teeth grinding, relaxation exercises

acute treatment: aspirin, paracetamol or an NSAID are first-line

prophylaxis: NICE recommend 'up to 10 sessions of acupuncture over 5-8 weeks'
(low-dose amitriptyline is widely used in the UK for prophylaxis against tension-type headache. The 2012 NICE guidelines do not however support this approach)


Migraine - what is the diagnostic criteria?

Need both:
oFive attacks or more
oPhotophobia, phonophobia or nausea

+ Need two or more:
oModerate to severe headache
oWorse on movement


Describe the nature of a migraine headache?


– lasts 4hr to 3 days



oExacerbated by exertion/movement

oAssociated with systemic upset: nausea, vomiting, phonophobia, photophobia, fatigue, hyperaesthesia, autonomic dysfunction


Does everyone with migraine get an aura?What is the aura assoc. with migraine?

30% have an aure: visual/dysphasic/positive sensory e.g. pins and needles

oFocal cerebral cortical and or brainstem dysfunction

ogradual progression

oresolves over 60 min

(migraine with aura contraindication for OCP)


What are common trigger factors for migraine?

tiredness, stress
combined oral contraceptive pill
lack of food or dehydration
cheese, chocolate, red wines, citrus fruits
bright lights


What is the acute treatment for migraine?

First-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol
for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan

if the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide* or prochlorperazine and consider adding a non-oral NSAID or triptan


What is used for migraine prophylaxis?

-prophylaxis for 2+ a month, review after 12wks

-topiramate or propranolol used (Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives)

-if these measures fail acupuncture or gabapentin
-riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people'

-menstrual migraine either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of 'mini-prophylaxis'


Medication overuse headache:
-how long are these present
-when do these develop
-who is most at risk
-what co-morbidity is possible?

Present for 15 days or more per month
Developed or worsened whilst taking regular symptomatic medication
Patients using opioids and triptans are at most risk
May be psychiatric co-morbidity


medication overuse headache:
-what is the treatment?

Stop analgesia, gradually or overnight

oReplace with amitryptiline and NSAID combo

oWarn patients of transient worsening

oif severe consider hospital admission

oBrief course oral steroid for 5-10days may be useful


Cluster headache:
-what is the nature of this headache?

Rapid onset

* Unilateral, severe pain BEHIND ONE EYE or supraorbital

* Clusters - refer to episodes of onset roughly 2/day lasting 30-180mins for 4-12 weeks duration


What are the assoc. symptoms with cluster headache?

Assoc. autonomic features

* Eye signs: oedema, ptosis/miosis, lacrimation, redness


What is the acute and prophylactic treatment of cluster headache?

Acute: Sumatriptan (tripans are 5-HT agonists)

o Prophylaxis: Verapamil (ACE inhibitor) or Topiramate (anticonvulsant)







A patient has a severe rapid onset headache behind one eye which resolves with the administration of indamethacin - what is the diagnosis?

Paroxysmal hemicrania:
-Similar to cluster headache- Rapid onset, severe pain behind one eye
* Characterised by absolute response to Indomethacin (NSAID)- resolves pain in 100%
* Episodes typically shorter than cluster headache, all other symptoms identical


what is hemicrania continua? what is the treatment?

* Persistent version of paroxysmal hemicranias (hence ‘continua’)

* Absolute response to Indomethacin

* Symptoms
o Headache- stabbing and unilateral
o ANS features- conjunctioval injections, tearing, eyelid oedema, rhinnorhea
o Migraine features- throbbing, photophobia, nausea, phonophobia

* Treatment: Indomethacin (NSAID)


Idiopathic intracranial hypertension:
-F or M?
-describe the headache
-what is assoc with this?

-F>M, obese
-headache with diurnal variation and morning N+V
-visual loss assoc.


Idiopathic intracranial hypertension:

MRI - normal
CSF - high pressure but normal constituents

-weight loss
-ventricular atrial / lumbar peritoneal shunt
-monitor visual fields & CSF pressure


What is the management of migraine in pregnancy?

paracetamol 1g is first-line
aspirin 300mg or ibuprofen 400mg can be used second-line in the first and second trimester