Headache Flashcards
(138 cards)
1
Q
Types of headache
A
Primary
Secondary
2
Q
What % of headaches are primary?
A
90%
3
Q
What is a primary headache?
A
A headache that has no underlying medical cause
4
Q
What is a secondary headache?
A
A headache which has an identifiable structural or biochemical cause
5
Q
Types of primary headaches
A
Tension type headache
Migraine
Cluster Headache
6
Q
Causes of secondary headaches
A
Tumour Meningitis Vascular disorders Systemic infection Head injury Drug induced
7
Q
What is the most frequently disabling primary headache?
A
Migraine
8
Q
Which gender gets more migraines?
A
Females
9
Q
What age is the most common for migraines?
A
20 - 50
10
Q
Features of migraine
A
A chronic disorder
Episodic attacks
11
Q
Features of migraine attacks
A
Episodic
Recurrent
Reversible
12
Q
Presentation of migraine
A
Headache Nausea Vomiting Photophobia Phonophobia Functional disability Nasal congestion Muscle pain Osmophobia
13
Q
Effects of in between attacks of migraine
A
Enduring predisposition to future attacks
Anticipatory attacks
14
Q
How long can headache attacks of migraine last for?
A
4 to 72 hours
15
Q
To diagnose migraines by the international headache society, what must be present?
A
Unilateral location Pulsating quality Moderate or severe pain intensity And/or aggravation by or causing avoidance of routine physical activity (e.g. walking, climbing stairs) During the headache phase, 1 of the following symptoms should be present, - nausea and/or vomiting - photophobia - phonophobia
16
Q
Possible physiological changes in the CNS that have been found in migraine suffers are…..
A
Between attacks - deficit of habituation or potentiation, reported for several sensory modalities (visual, auditory, somatosensory, cognitive and painful stimuli)
Interictal allodynia - alteration in thresholds between episodes
17
Q
Triggers for migraine
A
Stress Hunger Sleep disturbance Dehydration Diet Environmental stimuli Changes in oestrogen level in women
18
Q
When do women commonly get migraines due to changes in oestrogen level?
A
Before / during period
19
Q
Features of the headache in migraine
A
Unilateral
Throbbing
20
Q
Pre migraine symptoms
A
Aura Mood changes Fatigue Cognitive changes Muscle pain Food craving
21
Q
Postdrome symptoms of migraine
A
Fatigue
Cognitive changes
Muscle pain
22
Q
What % of migrainerus have aura?
A
33%
23
Q
What is an aura?
A
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve visual, sensory, motor or speech systems
24
Q
Where does an aura start and go?
A
Starts in periphery
Spreads all over brain
Evolution of symptoms - moves from one area to next e.g. vision to sensory to speech
25
Duration of aura
15 - 60 mins
26
Treatment of migraine
```
Abortive treatment
- aspirin
- NSAIDs
- Triptans (if they dont work)
Prophylactic treatment
- propanolol
- candesartan
- antiepileptics (topiramate, valproate, gabapentin)
- Venlafaxine
```
27
What is an issue of migraine treatment in women?
Teratogenic
28
Abortive treatment for migraine is limited to what and why?
10 days per month (approx. 2 days per week) to avoid the development of medication overuse headache
29
In migraine without aura, in what situation in women do they get better?
Pregnancy
30
Does migraine with aura usually get better in any situation in women?
No
31
What migraine can particularly occur for the first time during pregnancy?
Migraine with aura
32
What is contraindicated in active migraine with aura?
OCP
33
Treatment of migraine in pregnancy
Acute attack; paracetamol
| Preventative; Propanolol or amytiptyline
34
Definition of chronic migraine
Headache on over and including 15 days per month, of which over and including 8 days have to be migraine, for more than 3 months
35
What is a transformed migraine?
History of episodic migraine
Increasing frequency of headaches over weeks/months/years
Migranous symptoms become less frequent and less severe
36
Presentation of transformed migraine
Episodes of severe migraine on the background of less severe featureless frequent daily headache
37
Types of transformed migraine
With medication use
| Without medication use
38
Definition of medication overuse headache
Headache present on and over 15 days/month which has developed or worsened whilst taking regular symptomatic medication
39
Who are particular prone to medication overuse headache?
Migraineurs
40
Causes of medication overuse headache
Migraneurs taking triptans, opoids and combination analgesics for other things > 10 days/months
Simple analgesics > 15 days per month
Caffeine overuse; tea, coke, irn bru, coffee
41
Types of trigeminal autonomic cephalalgias
Cluster headache
Paroxysmal hemicrania
SUNT
SUNA
42
What does SUNCT stand for?
Short lasting unilateral neuralgiform headache with conjunctival injection and tearing
43
What does SUNA stand for?
Short lasting unilateral neuralgiform headache with autonomic symptoms
44
Symptoms of trigeminal autonomic cephalalgias
```
Unilateral head pain
- predominately V1
Very severe/excruciating
Cranial autonomic symptoms
- conjunctival injection/lacrimation
- nasal congestion/rhinnorhoea
- eyelid oedema
- forehead and facial swelling
- miosis/ptosis (horners syndrome)
```
45
Features of a cluster headache attack
```
Pain
- orbital
- temporal
Sharp and throbbing
Strictly unilateral
Restless and agitated
- rocking / walking about
Prominent ipsilateral autonomic symptoms
Redness of eye, lacrimation, lid swelling
Nasal stuffiness
Migraneous symptoms often present
- premonitory symptoms; tiredness, vomiting
- Associated symptoms; nausea, vomiting, photophobia, phonophobia
Typical aura
```
46
Onset of the attack of cluster headache
Rapid onset (max within 9 mins in 86%)
47
Duration of cluster headache attack
15 mins to 3 hours
Majority 45 - 90 mins
Rapid cessation of pain
- very quick, very severe and then goes very quickly
48
What % of people with cluster headaches have episodic symptoms?
80 - 90%
49
How many attacks of cluster headaches do people get during a cluster?
1 every other day to 8 per day
| may be continuous background pain between attacks
50
When does alcohol trigger cluster headaches?
During a bout, not attacks
51
What is so peculiar about cluster headaches?
Striking circadian rhythm
- attacks occur at same time each day
- bouts occur at same time each year
52
What % of people with cluster headaches have a chronic cluster?
10 - 20%
53
Features of chronic cluster headaches
Bouts last > 1 yr without remission OR
| Remissions last < 1 month
54
Features of paroxysmal hemicrania headaches
Pain
- orbital
- temporal
Strictly unilateral
Excrutiatingly severe
50% restless and agitated during an attack
Prominent ipsilateral autonomic syndromes
Migraneous symptoms may be present
Background continous pain may be present between the attacks
55
Onset of paroxysmal hemicrania headaches
Rapid onset
56
Duration of paroxysmal hemicrania headaches
2 - 30 mins
57
How quickly does the pain cessede after the attack of a paroxysmal hemicrania headache?
Rapidly
58
10% of paroxysmal hemicarnia attacks are precipitated by what?
Bending
| Rotation of the head
59
What % of patients have chronic and episodic PH?
Chronic - 80%
| Episodic - 20%
60
Frequency of paroxysmal hemicrania headaches/attacks
2 - 40 attacks per day
61
Circadian rhythm of paroxysmal hemicrania
It does not have a circadian rhythm
62
What does paroxysmal hemicrania have an absaloute response to?
Indomethacin
63
Features of SUNCT
Unilateral
Orbital, supraorbital or temporal pain
Stabbing / pulsating pain
Conjunctival injection and lacrimation
64
Duration of SUNCT
10 - 240 seconds
65
What are the triggers of SUNCT?
Cutaneous triggers
- wind
- cold
- touch
- chewing
66
Attack frequency of SUNCT
2 - 200 per day
| No refractory period
67
Presentation of trigeminal neuralgia
Unilateral
Maxillary or mandibular division pain > opthlamic division
Therefore lower face
Stabbing pain
68
Duration of trigeminal neuralgia
5 - 10 seconds
69
Triggers of trigeminal neuralgia
Cutaneous triggers
- wind
- cold
- touch
- chewing
70
Frequency of attacks of trigeminal neuralgia
2 - 200 per day
| Has a refractory period
71
Are autonomic features in trigeminal neuralgia common?
No
72
What is trigeminal neuralgia usually caused by?
A blood vessel touching the nerve
73
Treatment of cluster headache
Abortive - headache
- subcutaneous sumatriptan or nasal zolmatriptan
- 100% oxygen 7-12 l/min via a tight fitting non rebreathing mask
Abortive - the bout
- occipital depomedrone injection on the same side as the headache
- tapering course of prednisolone
Preventative
- VERAPAMIL
- lithium
- methysergide
- topiramate
74
How does 100% oxygen treat an attack of a cluster headache?
High flow oxygen dampens down the autonomic pathway
75
How much treatment can be used in cluster headache vs migraine?
Migraine - up to 2 per WEEK
| Cluster headache - up to 2 per DAY
76
Treatment of paroxysmal hemicrania
```
NO abortive treatment
Prophylaxis - indometacin
Also could try
- COX-II inhibitors
- Topiramate
```
77
Treatment of SUNCT/SUNA
```
NO abortive treatment
Prophylaxis
- lamotrigine
- topiramate
- gabapentin
- carbamazepine
```
78
Treatment of trigeminal neuralgia
```
NO abortive treatment
Prophylaxis
- CARBAMAZEPINE
- oxcarbazepine
Glycerol ganglion injection
Stereotactic radiosurgery
Decompressive surgery
```
79
Red flags for secondary headache
```
New onset headache
New or change in a headache if
- > 50 y/o
- immunosuppression or cancer
Change in headache frequency, characteristics or assosiated symptoms
Focal neurological symptoms
Non focal symptoms of
- drowsiness
- depressed
- cortical symptoms
Abnormal neurological examination
Neck stiffness / fever
High pressure
Low pressure
GCA
- jaw claudication or visual disturbance
```
80
What indicates a high pressure headache?
Headache worse when
- lying down
- wakening up the patient
- precipitated by physical exertion
- precipitated by the valsalva manouvre
81
What indicates a low pressure headache?
Precipitated by sitting/standing up
82
What is a high pressure headache a risk factor for?
Cerebral venous sinus thrombosis
83
Headache presentations which are more likely to have a sinister cause
```
Assosiated head trauma
First or worst
Sudden (thunderclap) onset - feels like they have been hit with something
New daily persistent headache
Change in headache pattern or type
Returning patient
```
84
A longstanding episodic headache is unlikely to be caused by what?
A serious intracranial pathology
85
What is the most frequent primary headache?
Tension type headache
86
What % of men and women have tension type headaches?
42% men
| 49% women
87
Presentation of a tension type headache
Mild, bilateral headache which is often pressing or tightening in quality
No significant associated features
Not aggravated by routine physical activity
88
Classification of tension type headaches
Infrequent TTH
Frequent TTH
Chronic TTH
89
How often do you have to have a headache for in a month to have infrequent TTH?
< 1 day / month
90
How often do you have to have a headache for in a month to have frequent TTH?
1 - 14 days / month
91
How often do you have to have a headache for in a month in order to have a chronic TTH?
> 15 days / month
92
Treatment for a tension type headache
```
Abortive
- aspirin or paracetamol
- NSAIDs
Preventative (rarely required)
- tricyclic antidepressants
1. amytriptyline
2. dothiepin
3. nortriptyline
```
93
What is abortive treatment in TTH limited to and why?
10 days per month (approx. 2 days per week)
| To avoid the development of medication overuse headache
94
Definition of a thunderclap headache
A high intensity headache reaching maximum intensity in less than 1 minute
95
Differential diagnosis for thunderclap headache
```
Primary
- migraine
- primary thunderclap headache
- primary exertional headache
- primary headache associated with sexual activity
SAH
Intracerebral haemorrhage
TIA/Stroke
Carotid/vertebral dissection
Cerebral venous sinus thrombosis
Meningitis/encephalitis
Pituitary apoplexy
Spontaneous intracranial hypotension
```
96
What is the most common cause for thunderclap headache?
SAH
97
What does SAH stand for?
Subarachnoid haemorrhage
98
What is SAH usually due to?
An aneurysm that bursts
99
What parts of the head does the subarachnoid space cover? Therefore what does this mean for the presentation of a SAH?
Goes around the whole brain
| Therefore the headache is over the whole head
100
How many patients who have a thunderclap headache will have a SAH?
1 in 10
101
Mortality of SAH
50%
102
Examination findings of SAH
Often NORMAL
103
Investigations for SAH
CT brain
LP (> 12 hours after headache onset)
CT +/- LP unreliable after 2 weeks and angiography is required after this time
104
If think the cause of the thunderclap headache is meningitis, what must be done?
DO not wait for results to do treatment - start immediately
105
When should CNS infection be considered in a patient with a headache? When the patient has all of....
Headache and fever
Meningism
Encephalitis
106
What does encephalitis consist of?
Altered mental state / consciousness
Focal symptoms / signs
Seizures
107
What does ICP stand for?
Intracranial pressure
108
What does papilloedema present with?
Headache
109
What is papilloedema?
BILATERAL swollen optic discs
110
What does papilloedema indicate?
Raised ICP
111
What is glioblastoma multiforme? What does it present with?
A tumour
| Presents with a seizure
112
Features that are suggestive of a space occupying lesion and/or raised ICP
Progressive headache with assosiated symptoms/signs
Warning features
- headache worse in morning
- headache wakens patient from sleep
- headache worse by lying flat or brought on by valsalva
- focal symptoms/signs
- non focal symptoms (cognitive or personality change, drowsiness)
- Seizures
- visual obscurations and pulsatile tinnitus
113
Examples of the valsalva manouvre
Cough
Stooping
Straining
114
Examples of visual obscurations seen due to high CSF pressure
Clouding/dulling on vision when stand up / move
115
Pathology of intracranial hypotension
Dural CSF leak
116
Causes of intracranial hypotension
Spontaneous
| Iatrogenic (post LP)
117
Features of intracranial hypotension headache
Better when lie flat
| Worsens soon after assuming upright posture and lessens or resolves shortly after lying down
118
When an intracranial hypotension headache becomes chronic, what feature does it often lose?
Its postural component
119
Investigations of intracranial hypotension
MRI brain and spine
120
What would be seen on MRI in intracranial hypotension?
CSF leaking out a hole in the meningeal sac
Brain sags down
Pulls down meninges/nerves
121
Treatment of intracranial hypotension
```
Bed rest
Fluids
Analgesia
Caffeine (e.g. 1 can red bull qds)
IV caffeine
Epidual blood patch
```
122
What does epidural mean?
In epidual space
123
How does an epidural blood patch work?
Put patients blood in the epidural space and the blood will tract up and down, causing irritation which will seal the hole
124
What is GCA on spectrum with?
Polymyalgia rheumatica
125
What does GCA stand for?
Giant cell arteritis
126
Pathology of GCA
Arteritis of the large arteries
Big blood vessels to eye/brain
Narrowing of blood vessels due to inflammation - risk of infarction to the optic nerve and brain
127
Who should GCA always be considered in?
Any patient > 50 y/o presenting with new headache
128
Presentation of GCA
```
Headache
- diffuse
- persistent
- may be severe
Systemically unwell
Scalp tenderness
Jaw claudication
Visual disturbance
Prominent, beaded or enlarged temporal arteries
Elevated ESR (usually > 50)
Raised CRP
Raised platelet count
```
129
Definition of claudication
Exercise induced pain
130
Definition of jaw claudication
Pain when eat which stops when stop eating
131
Investigations of GCA
History and exam
ESR and CRP
Temporal artery biopsy
132
Treatment for GCA
Prednisolone
133
What is the 1st choice for prophylaxis of tension type headache?
Acupuncture
134
What anti emetic has strong extra pyramidal side effects common in children and young adults?
Metoclopramide
135
What group of symptoms are common in children with migraine?
Gastrointestinal
136
Prophylaxis of primary sexual headache
Indomethacin
| Propanolol
137
What is a contraindication to triptan use?
CVS disease
138
Examples of higher cognitive impairments
```
Disinhibition (aggression)
Change in impulse control e.g. gambling
Inflexible thinking
Poor problem solving
Worsening decision making
```
