headaches Flashcards
headache red flags
new onset headache >55
known/previous malignancy
immunosupressed
early morning headache
exacerbation by valsava - coughing, sneezing -> raised ICP
first investigation for headache
fundoscopy - pailloedema -> raised ICP
(headache diary)
migraine with aura (20%) criteria
aura fully reversible
aura duration 20-60mins
headache follows <1hr later but aura can occur simultaneously
(trigeminal vascular problem with vasoddilation of crainial blood vessels)
migraine without aura criteria
at least 5 attacks
duration 4-72hrs
2of: moderate/severe, unilateral, throbbing pain, worse movement
1of: autonomic features, photphobia
migraine triggers
sleep
dietary
stress
hormonal
physical exertion
(keep headache diary to identify)
migraine
recurrent, severe headahce which is usually unillateral + throbbing in nature
- assoc aura, nausea + photosensitivity, menstruation
usual trigger
tension headache
recurrent, bilaterl headache, often described as “tight band”
not aggravated by routine activities
temporal arteritis
> 60yrs old
usually rapid onset (<1month) unilateral headache
jaw claudication
tender, palpable temporal artery
raised ESR
sudden vision loss
cluster headache
episodes over weeks - 2 a day, lasting 15-120mins
intense pain around eye - always same side
assoc redness, lacrimation + lid swelling
more common in men + smokers
migraine pathophysio
vascular + neural influence cause migraines in susceptible individuals
increased sensitivity, in both cases, the chemicals result in the sensitization of trigeminal neurons + brainstem pain pathways
o this makes otherwise innocuous sensory stimuli (such as CSF pulsation + head movement) painful, and light and sound are perceived as uncomfortable
- Stress triggers changes in brain, these changes cause serotonin to be release
- Blood vessels constrict + dilate
- Chemical including substance P irritate nerves + blood vessels causing pain
acute management of migraines
NSAIDs - take as early as poss, 60% reduction in headache at 2hrs
Triptans - treat at strt of headache, too many can induce headache
-> rizatriptan, eletriptan, frovatriptan
criteria + management for migraine prophylaxis
> 3 attacks a month or very severe
must trial for min of 3months
- amitriptiline - SE: dry mouth, postural hypotension, sedation
- propranolol - avoid in asthma, PVD, heart failure
- topiramate - not 1st, lots of SE start slow (weight loss, paraesthesia, impaired concentration)
acupuncture if fails
autonomic cephalgia
group of headache disorders characterised by unilateral trigeminal distribution pain that occurs in assoc with prominent ipsilateral autonomic features
cluster headaches - males
hemicrania - females
autonomic features that can occur in autonomic cephalgia
ptosis
miosis
nasal stuffiness
N+V
tearing
eye lid oedema
autonomic cephalgia investigations
MRI brain
MR angiogram
trend in cluster headache episodes
striking circadian (around sleeo) + seasonal variation - more common in spring
triggers of cluster headaches
alcohol
strong smells
exercise
treatment of cluster headaches
high flow oxygen 100% for 20mins
subcutaneous sumatriptan 6mg
prophylaxis
- verapamil
- steroid - reducing course over 2 wks
hemicrania
elderly (50s-60s)
women
paroxysmal unilateral autonomic features
duration - 10-30mins
frequency - 1-40 a day
usually in orbital, supraorbital or temporal region
hemicrania treatment
indomethacin
–> ABSOLUTE response, if no response probs something else
tension headache treatment
reassurance, basic analgesia, relaxation techniques, hot towel
pharmological = antidepressants
- dothiepin or amitriptyline
- give for 3months
idiopathic intracranial hypertension features
F>M
obese, young
worse in morning, N+V
worse lying down
vision loss
papilloedema, blurred vision
enlarged blind spot
idiopathic intracranial hypertension risk factors
obesity, female
pregnancy
combined oral contraceptive pill
tetracyclines
idiopathic intracranial hypertension investigations
MRI brain with MRV sequence - normal, empty sella
cerebrospinal fluid - elevated pressure, normal constituents
visual fields
Fx = empty sella, flattened optic disc
idiopathic intracranial hypertension management
weight loss
acetazolamide (diuretic)
ventricular atrial/lumbar shunt
monitor visual fields + CSF pressure
trigeminal neuralgia
pain syndrome characterised by severe unilateral pain
-> brief elctric shock like pain, abrupt in oset + terminations
(triggered by touch)
most idiopathic, compression of trigeminal roots by tumours/vascular problems may occur
trigeminal neuralgia features
elderly >60
W>M
severe stabbing unilateral pain
duration = 1sec-90sec
frequency = 10-100 aday
bouts of pain may last from a few weeks to months before remission
trigeminal neuralgia investigations
MRI
- FLAIR sequence
- Ciss sequence
trigeminal neuralgia management
pharmacological
- carbamazepine = 1st line
- gabapentin
- phenytoin
surgical
- ablation
- decompression
giant cell arteritis investigation + management
elevation CRP + plasma viscosity
US temporal artery biopsy
steriods
