Headache Flashcards
Headache is one of the most common presenting complaints seen in clinical practice. The vast majority of these will be caused by common, benign conditions.
Primary headache is headache that is due to the headache condition itself + not due to another cause.
What are examples of primary headache?
- tension (40%)
- migraine (12%)
- cluser (0.1%)
Secondary headaches are those caused by another condiiton.
What are examples of secondary headaches?
- post-trauma
- meningitis
- subarachnoid haemorrhage
- intracranial haemorrhage
- raised ICP
- brain tumour
- temporal/giant cell arteritis
- acute closed angle glaucoma
- sinusitis
What are red flags for headache?
- compromised immunity
- age <20 + history of malignancy
- vomiting without obvious cause
- worsening headache + fever
- sudden-onset headache reaching max intensity <5mins
- new-onset neurological deficit
- new-onset cognitive dysfunction
- change in personality
- impaired level of consciousness
- recent (typically <3months) head trauma
- headache triggered by cough, valsalva, sneeze or exercise
- orthostatic headache
- symptoms suggestive of GCA or acute narrow-angle glaucoma
- a substantial change in characteristics of their headache
Migraine is a chronic, genetically determined, episodic neurological disorder that usually presents in early-to-mid life. 10% of people have it and it is more common in females.
What are the triggers/risk factors for migraine?
- alcohol
- caffeine
- skipped meals
- physical exertion
- bright lights
- excessive noise
- smells
- lack of sleep
- stress
- weather
- menstruation + COCP
What is the pathogenesis of migraine?
- poorly understood
- acute episodes thought to be caused by transient activation of trigeminal sensory neurons that innervate large vessels + meninges of brain
- this causes a change in way that pain is processed by the brain
- sensitises nerve fibres so that previously ignored stimuli such as normal meningeal vessel pulsations are interpreted as painful
- phenomena of aura is thought to be caused by cortical spreading depression - synchronised activity which spread across cortex
What is the clinical presentation of migraine?
- prodrome → fatigue, low/high mood, irritability
- prolonged headache (lasting 4-72hrs untreated)
- throbbing, unilateral, intense
- associated w/ → nausea, vomiting, photophobia, phonophobia, osmophobia, allodynia
-
+/- aura (33%):
- positive → visual sparkles, flashing lights
- negative → visual loss, scotoma
- numbness, tingling
- can precede headache up to an hour + may endure throughout headache
These patients often find relief in lying still in a dark, quiet room
How can migraine be sub-classified?
- episodic migraine vs chronic migraine
- episodic migraine +/- aura
- if aura → typical or atypical?
- typical → visual, auditory, somatosensory
- atypical → motor, brainsteam, retinal, vestibular
Diagnosis of migraine is clinical and based on the ICHD-3 diagnostic criteria.
What are the core features of migraine criteria?
- episodes last 4-72hrs without treatment
- headache → unilateral, pulsatile, mod-severe pain, worse on exertion
- associated symptoms during attack → n/v, photo/phono-phobia
- with or without aura
Further investigation is only required if there is suspicion for an alternative diagnosis - eg raised ICP, meningitis, SOL, GCA, SAH, dissection, venous thrombosis.
Also keep in mind Ddx for transient neurological symptoms eg. TIA, seizure, metabolic (glucose, Na, Ca) + syncope. Psychiatric disorders may also mimic.
What is basilar migraine?
- aura symptoms result from dysfunction in territory of posterior cerebral circulation, which supplies brainstem, cerebellum + most of occipital cortices
- aura consist of bilateral visual symptoms, ataxia, dysarthria, vertigo, limb paraesthesia + weakness
- may be LoC before, during or after onset of headache, which often causes diagnostic confusion
What is hemiplegic migraine?
- rare + involves hemiplegia that can persist for days after headache has settled
- in some cases, there is autosomal dominant transmission + in 50% of these, it is associated w/ defects in a gene that codes for calcium channel
What is the acute treatment during a migraine attack?
- mild-moderate → simple analgesia (NSAIDS, paracetamol) +/- anti-emetic
- moderate-severe → triptan +/- simple analgesia +/- anti-emetic
- for young people aged 12-17, consider a nasal triptan in preferance to an oral triptan
Treatment should be taken as soon as the patient recognises that a typical migraine attack is beginning, and may need to be repeated later in the attack.
Prevention should be considered for people with disabling, frequent attacks, when acute treatments fail or are contraindicated, or when attacks lead to neurological sequelae.
What is the prophylactic treatment for migraine?
- lifestyle measures → keep headache diary, avoid triggers
- for medical therapy: start low, go slow - trials of at least 6-8wks at max dose should be given before declaring failure
- treatment should be tailored to individual’s risk-benefit profile
- 1st line → propranolol (beta-blocker)
- 2nd line → topiramate or valproate (anticonvulsants)
- 10 sessions of acupuncture 5-8wks
- other drugs: gabapentin, riboflavin, amitryptilline
What are the features of a tension headache?
- recurrent non-disabling, bilateral headache
- often described as, dull ‘tight-band’ across forehead
- non-pulsatile
- lasts 30 mins - 7days
- not aggravated by routine ADLs
What are the features of cluster headache?
- rare
- severe, unilateral, orbital/supraorbital/temporal pain
- 15-180 mins duration
- attack frequency - from 1 every other day to 8 daily
- associated w/ conjunctival injection, lacrimation, ptosis, meiosis, eyelid oedema, nasal congestion, rhinorrhoea, forehead + facial sweating/readness, aural fullness + sense of restlessness or agitation during headache
- alcohol = common trigger
- 5x common in males
- acute Rx → high flow O2 + sumatriptan
- other Rx → avoid triggers, corticosteroids (short-term), verapamil (prophylaxis) + lithium (monitor!)
What are the features of a subarachnoid haemorrhagic headache?
- sudden onset, “thunderclap” pain
- associated w/ meningism, collapse, seizures, coma, vomiting
- causes: berry aneurysm rupture (80%), arterio-venous malformations (15%)
- urgent CT
- manage w/ referral to neurosurg, re-examine often, maintain perfusion, nimodipine
