Headache Flashcards
(123 cards)
1
Q
Most headaches are primary headaches. Name 3 types
A
Tension type
Migraine
Cluster
2
Q
Define secondary headache
A
Identifiable structural or biochemical cause of headache
3
Q
Six examples of seconday headache
A
Tumour Meningitis Vascualr disorders Systemic infection Head injury Drug-induced
4
Q
Most frequent type of primary headache
A
Tension Type Headache
5
Q
What type of headache is the 3rd most disabling condition in women under 50 according to WHO
A
Tension Type headache
6
Q
Why are tension type headaches common to women in their reproductive years?
A
Drop in oestrogen can trigger
7
Q
Describe the severity and spread of tension type headaches
A
Mild
Bilateral
8
Q
Symptoms of tension headache that may be described
A
Pressing
Tightening
No other associated features
Not aggravated by phyical activity
9
Q
3 categories of Tension type headache
A
Infrequent Episodic TTH
Frequent ETTH
Chronic TTH
10
Q
How many days of TTH constitute an infrequent episodic TTH?
A
1 day per month
11
Q
How many days of TTH constitute an frequent episodic TTH?
A
1-14 days per month
12
Q
How many days of TTH constitute chronic TTH?
A
More than 15 days in one month`
13
Q
Two classes of treatment in headache
A
Abortive
Prophylactic
14
Q
Abortive treatment for Tension type headache
A
Aspirin, paracetamol
NSAIDS
15
Q
What is the limit on abortive treatment for TTH to avoid overuse headache?
A
10 days per month
2 days in week
16
Q
Preventative treatment of tension type headache?
A
Tricyclic antidepressants
- Amitriptyline, dothiepine, nortriptyline
17
Q
What is the most frequent disabling type of headache?
A
Migraine
18
Q
What is the typical age range for migraine sufferers?
A
20-50
19
Q
How do migraine attacks present?
A
Episodic 4-72 hours of headache Unilateral location Pulsating Moderate to severe pain Aggravated by/avoidance of physical activity
20
Q
What symptoms may be experienced during a migrainous attack?
A
Headache Nausea Photophobia Phonophobia Functional disability
21
Q
What symptoms may be experienced between migrainous attacks?
A
Enduring predisposition to future attacks
Anticipatory anxiety
22
Q
7 triggers of migraine
A
Dehydration Diet Sleep disturbance Hunger Environmental stimuli Stress Oestrogen level change in women
23
Q
5 phases of migraine
A
Premonitory Aura Early headache Advanced headache Postdrome
24
Q
Describe features of the premonitory phase in migraine
A
Mood changes Fatigue Cognitive change Muscle pain Food craving
25
Describe features of the aura phase of migraine
Mild to moderate headache
Fully reversible, neurological changes, visual somatosensory
Not always followed by headache
26
What word describes an aura that is not followed by headache?
Acephalgic
27
Describe features of the early headache phase in migraine
Dull, mild pain
Nasal congestion
Muscle pain
28
Describe features of the advanced headache pahse in migraine
```
Moderate to severe pain
Unilateral throbbing
Nausea
Photophobia
Phonophobia
Osmophobia (smells)
```
29
Describe features of the postdrome phase of migraine
Fatigue
Cognitive changes
Muscle pain
30
What percentage of migraine sufferers experience AURA?
33%
31
Define aura
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve sensory, visual, motor or speech systems
32
How do symptoms evolve in aura?
Slowly
Vison precedes sensory, then speech
Wave from occipital lobe
33
How long may aura last?
15=60 minutes
34
What condition can aura be mistaken for?
TIA
35
How to differentiate aura from stroke?
Stroke is sudden
Symptoms will start at once in stroke - localised to specific vascular area
Aura follows wave, occipital forward
36
How is chronic migraine defined?
Migraine experience for more than 15 days in one month. Migraine can last longer than 8 days
Longer than 3 month history
37
How else is chronic migraine described?
Transformed migraine
38
How may chronic migraine evolve from other episodes
History of episodic migraines, increasing frequency of headaches
Migrainous symptoms become less frequent and less severe
Episodes of sever migraine on background of less severe featureless frequent/daily headache
Can occur with/without escalation in medication use
39
Define medication overuse headache
Headache on more than 15 days in one month
Taking regular symptomatic medication
Can occur from primary headache
40
Which medications are common to causing medication overuse headache?
Triptans
Ergots
Opioids
Combo analgesics for more than 10 dyas in month
Simple analgesics for over 15 days in month
41
What other substance can cause 'medication' overuse headache>
Caffeine
42
Abortive migraine treatment
Aspirin
NSIADs
Triptans (limit 10 days per month)
43
Prophylactic migraine treatment
Propanolol
Candesartan
Antiepileptics ; topiramate, valproate, gabapentin
Tricyclic antidepressants; Amitryptiline, Dothiepin, nortriptyline
Venlafaxine
44
How does migraine change in pregnancy?
Migraine without aura improves in pregnancy
| Migraine with aura will not change
45
What medication is contraindicated in active migraine with aura?
Combined oral contraceptive pill
46
Which medication for treating migraine should be avoided in women of child-bearing age?
Anti-epileptics
47
What treatment can be used in women of child bearing age/pregnant for migraine?
Acute - paracetamol
| Prophylactic - propanolol
48
Four types of headache categorised as Trigeminal Autonomic Cephalgias
Cluster
Paroxysmal hemicrania
SUNCT
SUNA
49
Features of a trigeminal autonomic cephagia
Unilateral head pain V1
Very sever, excruciating
Cranial autonomic symptoms
50
List 6 cranial autonomic syptoms
```
Conjunctival injection/lacrimation
Nasal congestion.rhinorrhoea
Eyelid oedema
Forehead and facial swelling
Misosis/ptosis (Horner's)
```
51
What region of the head is painful in cluster headaches
Orbital and temporal
52
What is the distribution of pain in cluster headaches?
Unilateral
53
How long do cluster headaches tend to last?
15 minutes to 30 minutes
| Rapid cessation
54
What term is given to the severe pain experienced in cluster headaches?
Suicide headache
55
How do autonomic symptoms coincide with a cluster headache?
Ipsilateral autonomic symptoms
56
What migrainous symptoms are experienced in cluster headache?
Premonitory - tiredness, yawning
Assoicated - nausea, vomiting, photophobia, phonophobia
Typical Aura
57
What percentage of patients with cluster headache experience epsiodic attacks?
80-90%
58
In episodic cluster headache, how long do bouts and remission tend to last?
1-3 months
| 1 month remission
59
How often can attacks occur in cluster headache?
Varies 1 every other day up to 8 attacks in a day
| Continuous background of pain may be experienced
60
What substance can trigger an attack during a bout of cluster headache, but typically has no effect in remission?
Alcohol
61
Is there a pattern of timing in cluster headache?
Yes
| Striking circadian rhythmicity - same time each day, same time of year
62
How many people with cluster headache suffer chronically?
10-20%
63
How long does chronic cluster headache last?
Bouts must last longer than 1 year without remission or with remission of less than a month
64
Which region of the head is painful in paroxysmal hemicrania?
Orbital, temporal
65
Distribution of pain in paroxysmal hemicrania
Unilateral
66
Describe severity and time period of headache in paroxxysmal hemicrani
Rapid onset, rapid cessation - 2 to 30 minutes
| Excruciatingly severe - 50% restless, agitated
67
How do autonomic symptoms coincide with pain in paroxysmal hemicrania?
Ipsilateral autonomic symptoms
68
10% of attacks in paroxysmal hemicrania are precipitated by...
bending/rotation of head
69
What percentage of sufferers of paroxysmal hemicrania are chronic and episodic?
80% chronic
| 20% episodic
70
How many attacks can occur daily in paroxysmal hemicrania?
2-40 attacks
71
Paroxysmal hemicrania has an absolute repsonse to what drug?
Indometacin
72
What does SUNCT stand for?
Short-lasting Unilateral Neuralgiform headache with Conjunctival Injection and Tearing
73
Describe the regions headache is present in SUNCT
Unilateral
| Orbital, supraorbital, temporal
74
Describe the character of the headache in SUNCT
Stabbing, pulsating at V1
75
Name cutaneous triggers of SUNCT
Wind
Touch
Cold
Chewing
76
How many headache attacks can be experienced daily with SUNCT
3-200, no refractory period
77
Describe the region of pain in trigeminal neurallgia
Unilateral
| MAXILLARY OR MANDIBULAR -moreso than opthalmic
78
Describe the character of pain in trigeminal neuralgia
Stabbing pain - 5-10 seconds
| Electric SHock
79
What can trigger trigeminal neuralgia?
Cutaneous triggers - wind, cold, touch, chewing
80
What is the attack frequency of Trigeminal neuralgia?
Similar to SUNCT 3-200
81
How does trigeminal neuralgia differ from SUNCT?
Pain in maxillary, mandible region
| Refractory period between attacks
82
Autonomic features in trigeminal neuralgia
UNCOMMON
83
Abortive treatment of cluster headache?
Subcutaneous sumatriptan 6mg
or
nasal zolmatriptan
100% oxygen
84
Abortive treatment of bout of cluster headache?
Occipital injection
| Oral prednisolone
85
Prophylactic treatment of cluster headache
Verapimil
Lithium
Methysergide (ERGOMETRINE TARTRATE)
Topiramate
86
Abortive treatment of paroxysmal hemicrania>
NO ABORTIVE TREATMENT
87
Prophylactic treatment of paroxysmal hemicrania
Indometacin
88
Alternatives to indometacin
COX II inhibitors
| Topiramate
89
Abortive treatment for SUNCT
NO ABORTIVE
90
Prophylactic treatment for SUNCT
Lamotrigine
Topiramate
Gabapentin
Carbamazepine/Oxcarbazepine
91
Abortive treatment of trigeminal neuralgia
NO ABORTIVE
92
Prophylactic treatment of trigeminal neuralgia
Carbamazepine
| Oxcarbazepine
93
Surgical intervention for trigeminal neuralgia
Glycerol ganglion injection
Steriotactic radiosurgery
Decompressive surgery
94
Likely presentations of secondary headache
```
Assoicated head trauma
Sudden onset
New daily persistent headache
Change in pattern/type of headaches
Returning patient from primary
```
95
Red Flag Headache symptoms
New onset
New/change in headache - over 50, immunosupressed, cancer
Focal neurological symptoms
Non-focal symptoms
Abnormal neurological examination
Neck stiffness
Fever
High pressure ; worsens lying down, on wakening, on exertion, valsalva (RF for cerebral venous sinus thrombosis)
Low pressure - headache precipitated by sitting/standing up
Giant cell arteritis - jaw claudication, visual disturbance, prominent/headed temporal arteries
96
Describe onset of thunderclap headache
High intensity headache reaches max intensity in less than 1 minute.
Majority peak instantaneously
SUDDEN, SEVERE, INSTANTANEOUS
97
Diferrentials for thunderclap headache
```
Primary - migraine, exertional, sexual activity
Subarachnoid haemorrhage
Intracerebral haemorrhage
TIA/Stroke
Catorid/vertebral dissection
Cerebral venous sinus thrombosis
Meningitis/encephalitis
Pituitary apoplexy
Spontaneous intracranial hypotension
```
98
How many people with thunderclap headache are diagnosed with subarachnoid haemorrhage?
1 in 10
99
What percentage of SAH cases are aneurysmal?
85%
100
Mortality of SAH
50%
101
Risk of rebleed in SAH
4-6% in first 48 hours
| 40% in first month
102
Treatment of SAH
Coiling
| Clipping
103
How does SAH present
Sudden headache, peaks within minutes, lasts at least 1 hour
| Examination normal
104
Investigations for SAH
CT brain
Lumbar puncture
Beyond 2 weeks - angiography
105
In what time frame must a lumbar puncture be carried out in SAH?
within 12 hours of onset
106
Symptoms of meningitis
```
Nausea with or without vomiting
Photophobia
Phonophobia
Neck stiffness
RASH
```
107
Symptoms of encephalitis
Altered mental state or consciousness
Focal symptoms and signs
Seizures
108
Causes of raised intracranial pressure
```
Glioblastoma multiforme
Cerebral abscess
Venous infarct with focal area of haemorrhage
Meningioma
Hydrocephalus
Papilloedema
```
109
Symptom of gliobastoma multiforme
Weeks to months of high pressure headache
110
Features suggesting space occupying lesion
Progressive headache with associated signs and symptoms
Warning - headache worse in morning/wakes patient from sleep
Worse lying flat or valsalva
Focal signs and symptoms
Seizures
Non-focal ; cognitive, personality change, drowsiness
Visual obscurations
Pulsatile tinnitus
111
What causes intracranial hypotension?
Dural CSF leak - spontaneous or iatrogenic (post LP)
112
What features of headache indicate intracranial hypotension?
Clear postural component - upright; lessens/resolves when lying down
When headache becomes chronic loses postural component
113
Investigation of intracranial hypotension
MRI brain and spine
114
Treatment for intracranial hypotension
```
Bed rest
Fluid
Analgesia
Caffeine - IV
Epidural blood patch - injects blood into widened epidural space, seal to make space tighter
```
115
Purpose of IV caffeine in treatment of intracranial hypotension?
Raise CSF pressure
116
Describe the onset and character of the headache in Giant Cell Arteritis
```
NEW
Diffuse
Persistent
May be severe
PATIENT MAY BE SYSTEMICALLY UNWELL
```
117
Symptoms of giant cell arteritis
Scalp tenderness
Jaw claudication
Visual disturbance
Prominent, headed, enlarged temporal arteries
118
Signs of giant cell arteritis
Prominent, headed, enlarged temporal arteries
Elevated ESR (>50 - much higher)
Raised CRP
Raised platelets
119
Treatment of Giant Cell arteritis
High dose prednisolone
| Temporal artery biopsy - behind eye, stroke, constricted RV
120
Risk factors trigeminal neuralgia
```
Multiple Sclerosis
Age - 50-60
Female
Family history
Stroke and hypertension
```
121
Complications of trigeminal neuralgia
Impact on daily living
Depression/isolation
Weight loss - inability to eat; cutaneous triggers
122
Red flag symptoms in trigeminal neuralgia - may suggest underlying cause
Sensory changes.
Deafness or other ear problems.
History of skin or oral lesions that could spread perineurally.
Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally.
Optic neuritis.
Family history of multiple sclerosis.
Age of onset before 40 years.
123
TTH differentials
Headache not associated with an underlying condition – primary headache:
Migraine.
Trigeminal autonomic cephalgias for example cluster headache and paroxysmal hemicranias.
Other primary headache disorders such as primary cough headache and cold-stimulus headache.
Secondary headaches — headache attributed to an underlying condition including:
Trauma or injury to the head and/or neck.
Cranial or cervical vascular disorders for example intracerebral haemorrhage, central venous thrombosis or giant cell arteritis.
Non-vascular intracranial disorders for example idiopathic intracranial hypertension or neoplasm.
Exposure to, or withdrawal from, a substance such as carbon monoxide, cocaine or alcohol — medication over use headache (which can be due to ergotamines, triptans, simple analgesics and opioids) is included in this category.
Infection for example intracranial infection (including meningitis, encephalitis and cerebral abscess) or systemic infection.
Disorders of homeostasis for example hypoxia or hypertension including pre-eclampsia and eclampsia.
Disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structure such as angle closure glaucoma, temporomandibular disorder, dental problems, otitis media or sinusitis.
Psychiatric disorders such as somatization disorder.
Painful cranial neuropathies and other facial pains such as trigeminal neuralgia, post-herpetic neuralgia and optic neuritis.
