Headaches Flashcards
Managament of migraine in pregnancy
Avoid aspirin and ibuprofen in 3rd trimester - fetal ductal arteriosus
1st line: paracetamol
2nd line: NSAID in 1st and 2nd trimester
Avoid aspirin and opiods
Management of migraine and menstruation
1) mefanamic acid
2) or combination of aspirin, paracetamol, caffeine
3) triptans -
NICE:
- prophylaxis with frovatriptan 2.5mg BD or zolmatriptan 2.5mg BD - TDS
SIGN
1) Mefanamic acid
2) Combination of aspirin, paracetamol, caffine
3) Triptans
Idiopathic intracranial hypertension
RFs:
- young
- overweight
- female
- pregnancy
- COCP
- steroids
- tetracyclines
- retinoids, vitamin A
- lithium
Features:
- headache
- blurred vision
- papiloedema (usually present)
- enlarged blind spot
- 6th nerve palsy - abducens - cannot abduct eye, double vision
Management:
- weight loss - may consider topiramate, semaglitide
- carbonic anhydrase inhibitors - acetozolamide, topiramate
- lumbar puncture as temporary measure
- sugrgery - optic sheath decompression to prevent damage to optic nerve or a lumboperitoneal/ventriculoperitoneal shunt
Cluster headache
RF: men, smokers, alcohol
Features:
- intense stabbing pain around one eye
- episodes 1-2x/day lasting 15m-2h
- restless, agiated during an attack
- eye redness, lacrimation, lid sweeling, nasal stuffiness, miosis, ptosis
- clusters last 4-12w
Invesitgations:
- neurimaging - MRI with gadolinium r/o brain lesion
Management:
- 1st episode - neurology advice to consider imaging
- acute : 100% oxygen (80% respond in 15m), subcutaneous triptan (75% response in 15m)
- prophylaxis - 1st line is verapamil, could consider tapering prednisolone dose
Medication overuse headache
1/50 affected
Features:
- >=15 days /month
- developed or worsened whilst taking regular analgesia
- opiods and triptans most risky
Management:
- abruptly stop triptans and simple analgesics
- gradually withdraw opiods
- headaches should improve within a few days
Advice on taking sumatriptan for migraines
Take at onset of headache (not aura)
1st line: take with NSAIDs or paracetamol
Migraine management
1) Prophylaxis if > 1/week and impact on QoL:
- propranolol, topiramate (not in childbearing age)m amitriptyline
- 10 sessions of acupuncture over 5-8 weeks/CBT if propranolol and topiramate not working after 2 months/CI
- riboflavin 400mg OD
2) Treatment options under neurology: candesartan, monoclonal antibodies, erenumab
Acute migraine:
1) triptan + paracetamol/NSAID
2) if not effective/tolerated - non oral metoclopramide or prochlorperazine + non-oral NSAID or triptan
Difference between adult and child migraine
Children more often have bilateral symptoms, GI disturbance and shorter headaches
Consider nasal triptan instead of oral 12-17y
International Headache Society migraine diagnostic criteria
At least 5 attacks with these criteria:
1) Headaches 4-72h
2) >= 2 of:
- unilateral
- pulsating
- moderate-severe
- aggravated by walking/climbing stairs
3) Nausea/vomiting or photophobia + phonophobia
4) Not attributed to another disorder
Aura’s in migraine
Affects 25%
5-60 minutes long, fully reversible
Atypical aura: motor weakness, double vision, visual symptoms affecting one eye only, poor balance, reduced GCS
Lhermittes sign
Sharp pain radiating down spine on flexion of neck - associated most commonly wth MS, but can also be seen in DCM
Trigeminal neuralgia
RF: women > 50y
Severe unilateral pain - brief shock like pains
Trigger - brushing teeth, light touch, washing , shaving, smoking, talking
Red flags suggesting serious cause:
- sensory changes
- deafness/ear problems
- history of skin or oral lesions
- pain in opthalmic division only (eye socket/forehead, nose) or bilateral
- optic neuritis
- FH of MS
- Onset < 40y
Management:
1) carbamazepine
2) if not responding or < 50y - refer
