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Flashcards in Headache Deck (41):

Headaches can be split into Primary and Secondary Types, what would be signs of a secondary headache?

- Trauma
- First or worst ever headache
- Thunderclap onset
- A new daily & persistant headache
- A change in the headaches pattern or type
- Other symptoms such as jaw claudication, fevers, neuro signs/symptoms or worsened by position


List 2 things that could cause a thunderclap style headache?

Sub arachnoid haemorrhage


What causes most subarachnoid haemorrhages?



How would we approach a subarachnoid haemorrhage?

Immediately CT the brain and do an LP after 12 hours from onset

Early coiling or clipping


Define a thunderclap headache?

High intensity peaking instantly or within 1 minute of onset


What would indicate a thunderclap headache to be caused by CNS infection?

If the patients headache comes with fever, rash or:
Meningitis - STiff neck, photo/phonophobia, n&V
Encephalitis - Altered mental state, seizures, focal neuro symptoms/signs


What could raise or lower Intracranial pressure?

Raised ICP:
- Hydrocephalus
- Cerebral Abscess
- Glioblastoma/Meningioma
- Venous sinus infarct

Lowered ICP:
- Dural CSF leak either spontaneously or after LP


What are the specific signs of raised ICP?

Progressively worse headache
Worse in morning/wakes them up
Worse on flat, valsalva (shit/cough/strain) or on exertion
Neurological symptoms
Visual Obscurations and pulsatile (whooshing) tinnitus


What indicates a intracranial hypotension and how do appraoch it?

Headache appearing/worsening on standing and lessening/resolving on lying down

Sagittal MRI of brain and spine will show an empty subarachnoid space

Bed rest, fluids, analgesia, caffeine

Epidural Blood patch (to stimulate healing of a CSF leak)


What is an epidural blood patch?

A treatment for leaking CSF leading to lowered ICP

Put some of the patietns blood in their epidural space which will cause irritation leading to healing of the leak


What is Giant Cell Arteritis and what about a headache would indicate it?

Giant cell granulomatous inflammation of the arteries causing narrowing which can cause an infarction to the brain and/or optic nerve

The headache is diffuse persistant and may be severe


What are the symptoms of giant cell arteritis?

- Diffuse, persistant and maybe severe headache
- Jaw claudication
- Visual Disturbance
- Scalp Tenderness


What investigations and treatment are there for suspected GCA?

ESR/CRP/Platelets all elevated

Treat with high dose prednisolone and confirm with a temporal artery biopsy


What are the main types of Primary Headache?

- Tension-Type
- Migraine
- Medication Overuse Headache
- Trigeminal Neuralgia
And the Trigeminal Autonomic Cephalagias:
!) Cluster HEadache
") Paroxysmal Hemicrania


Define a Tension-Type HEadache?

- Most frequent Primary headache
- Mild, bilateral
- Often pressing or tightening


What are the subtypes of Tension Type HEadache?

Episodic - <15 days a month
Chronic - >15 days a month


How do you treat tension type headache?

Aspirin, paracetamol or NSAIDs

Can prevent with Tricyclic Antidepressants


Define a Migraine?

A chornic disorder of episodic attacks featuring headaches, phono/photophobia, functional disability and nausea.
And in 33%, an aura
The most frequent disabling primary headache


What causes a migraine?

We dont know the cause but it can be triggered by lots including:
- Stress
- Oestrogen changes e.g. menstruation
- Diet
- Sleep Disturbance


What is an "aura"?

A set of transient neurological symptoms lastig 15-60 minutes.
It moves from one area to the next so might appear as vision then sensory then speech problems (can be mistaken for a TIA)


What defines a Chronic Migraine?

Headaches >15 days a month for >3 months
Of which atleast 8 a month must be migraines


How do we treat migraines?

- Aspirin & NSAIDs
- Triptans

- Propanolol
- Anti-epileptics
- Tricyclic Antidepressants
- Vanlafaxin


What should we be aware of in women with migraines?

Dont give antiepileptics to those of child-bearing age as they're teratogenic

Treat pregnant women with paracetamol or propanolol/Amitriptyline prophylactically


Define a medication overuse headache?

HEadache >15days a month developed or worsened on regular symptomatic medications


What causes a medication overuse headache?

- Triptans
- Erots
- Opiods
More than 10 days a month

Or simple analgesics more than 15 days a month

Also caffeine overuse


Where do Trigeminal Autonomic Cephalagias present with pain?

In the orbital, supraorbital and temporal regions


What do SUNA/SUNCT stand for?

Short Lasting Unilateral Neuralgiform headache

With either Autonomic symptoms
or Conjunctival injection and Tearing


Describe a cluster headache?

- Unilateral sharp/throbbing pain
- Rapid onset and 15-180 minutes duration
- Incredibly severe (nicknamed "suicide Headache")
- Often comes with migranous symptoms such as nausea, aura and photo/phonophobia

Also remember Autonomic symptoms with all TACs


Why are cluster headaches called cluster headaches?

They are episodic, occuring in clusters typically lasting 1-3 months wiht anything from 1-8 a day during a bout.

The bouts may be triggered by alcohol and may feature continuous background level pain

They may show circadian rythmicity with bouts coming the same time every year and attacks the same time each day


How do you treat a cluster headache?

100% O2 ro SC sumatriptan for the attack

Occipital Depomedrone injection for the bout

Verapamil for prevention


Describe a paroxysmal hemicrania?

Unilateral sharp/throbbing pain
Rapid onset, duration 2-30 minutes
Very severe
Possible Continuous bacground pain
2-40 attacks per day without circadian rythm


How do we treat Paroxysmal Hemicrania?

Prophylactic Indometacin (An NSAID)


Describe SUNCT?

Unilateral Stabbing/pulsing pain
Short 10-240 second duration
Triggered by wind/cold/touch/chewing
3-200 attacks a day
Comes with conjunctival injection (red eye) and tears


How do we treat SUNCT?

Lamotrigine prophylactically (an anti-epileptic, same for SUNA)


Describe Trigeminal Neuralgia

Unilateral stabbing pain, unlike TACs its to the maxillary/mandibular regions.
5-10 second duration
Also triggered by wind/cold/touch/chew
3-200 a day
unlikely to have autonomic symptoms


How do we treat Trigeminal Neuralgia?

Carbamazepine prophylactic
Surgical intervention


What kind of autonomic symptoms come with the Trigeminal Autonomic Cephalagias?

- NAsal Congestion/rhinorrhoea
- Eyelid Oedema
- Facial Sweating
- Miosis (Constricted Pupil) /Ptosis (Drooping eyelid)
[Horner's Syndrome]


Name a tricyclic antidepressant and what headaches its used for?



Name a tricyclic antidepressant and what headaches its used for?


- Prophylaxis of Tension Type Headaches
- Prophylaxis of Migraines


How do you differentiate the types of TACs?

CH = 1-8 PH = 1-40 SUNCT = 3-200

CH = 15-180 mins PH=2-30mins SUNCT = 5-240 seconds

I.e. frequency and duration are inversely proportional

Pain is sharp and throbbing in CHs & PHs but stabbing/pulsing or burning in SUNCT

All have a very severe pain

CH most likely to show circadian rythmicity


Summary of Treatments for Headache Types:

Thunderclap - Probably SAH - Coiling/clipping

Tension Type Headache - Aspirin/NSAID/Paracetamol + Amitryptiline

Migraine - Aspirin/NSAID/Triptan + Propanalol/Anti-epileptic/Amitryptiline

Medication Overuse Headache - Use less meds

Trigeminal Neuralgia - Carbamazepine

Cluster Headache - 100% O2/SC Sumatriptan + Verapamil

Paroxysmal Hemicrania - Prophylactic Indometacin NSAID

SUNA/SUNCT - Anti-epileptic Lamotrigine