Headaches Flashcards
(38 cards)
What is the most common neurological outpatient referral?
Headaches
- 25% of new referrals
What is a primary headache?
The headache itself is the disorder (no underlying cause)
- e.g. migraine tension-type headache and cluster headache
What is a secondary headache?
Secondary to an underlying cause - e.g. Subarachnoid haemorrhage, space occupying lesion, meningitis, temporal arteries, high/low intracranial pressure, drug induced…
What is the most important question when assessing a patient?
Could this be a secondary headache?
When taking history of a headache, what are the most important features?
Onset (time to maximal symptoms and circumstances at onset)
Severity and quality of pain
Location/radiation of pain
Presence of an aura/prodrome
Periodicity
Associated features - photophobia, phonophobia, osmophobia, nausea, movement sensitivity and periorbital autonomic disturbance (common in cluster headaches)
Age at onset (migraine more common in childhood/early adulthood, whereas a secondary cause is more common in the over 50s)
Triggers/exacerbating/relieving factors
Family history
Social/employment history
Medication history
Co-morbid depression and sleep disturbance
What are the ‘red flag’ symptoms of a headache? (indicate a secondary cause)
Age >50
Thunderclap headache
Focal/non-focal neurological deficit
Worsening of symptoms with posture (high/low CSF pressure), valsalva (coughing, straining) or physical exertion
Early morning headaches
Systemic symptoms
Seizures
Temporal artery tenderness/jaw claudication
Specific situations
- cancer, pregnancy, post-partum, HIV/immunosupression
What acronym is used to remember red flag symptoms?
S - systemic symptoms
N - neurological signs or symptoms
O - older age at onset
O - acute onset (less than 5 minutes)
P - previous headache history is different
T - triggered headache (valsala or postural)
What clinical signs might you find on examination to suggest a secondary cause?
General/systemic - reduced consciousness - BP/pulse - pyrexia - meningism - skin rash - temporal artery tenderness Cranial nerve - pupillary responses - visual fields may have a blind spot - eye movements - fundoscopy
What abnormal findings might indicate a secondary cause on fundoscopy?
Papilloedema - raised ICP
Subhyaloid haemorrhage - raised ICP/SAH
What abnormal findings may indicate a secondary cause when assessing the cranial nerves of the eye?
3rd nerve palsy - eye droops down and out
6th nerve palsy - eye can’t move laterally
Horner’s syndrome
Which upper motor neurone signs may indicate a secondary cause?
Pronator drift
Increased tone
Brisk reflexes
Extensor plantar response
What cerebellar signs may indicate a secondary cause of the headache?
D - dysdiadochokinesis
A - ataxia
N - nystagmus
I - intention tremor (worse during voluntary movement)
S - scanning dysarthria (jerky, explosive, slurred speech)
H - heel-shin test positive
Describe the aetiology of a migraine.
More common in women than men
12-16% of population
25-55 years has highest prevalence
Positive family history is common
Give some examples of triggers of migraines.
Hormonal Weather Stress Hunger Sleep disturbance Exertion Alcohol excess Foods
What is the pathophysiology of a migraine?
Neurovascular hypothesis
- disorder of the endogenous pain modulating systems, particularly in subcortical structures (e.g. brainstem and diencephalic nuecli)
What are the phases of migraine?
Prodrome - sensation that a migraine is coming for 24/48 hours
Aura - 30% of migraine patients
Headache - persists from 4-48 hours
Postdrome - mild, non-specific headache lasting for 24/48 hours
What are the symptoms of a prodrome?
Mood disturbance Restlessness Hyperosmia Photophobia Diarrhoea
What is an aura?
Recurrent reversible focal neurological symptoms
- visual, sensory or motor (visual most common)
Develops over 5-20 minutes and lasts less than an hour
Describe visual and sensory auras.
Visual
- negative scotoma (blind spot)
- positive scotoma (dark spot)
- flashing lights
- fortification syndrome (halo effect around objects)
- visual field loss
Sensory - tingling starting in the thumb and fingers and spreading up the arm
Describe a normal headache.
Throbbing or pulsatile pain in the head of moderate to severe intensity
Gradual onset, lasting 4-72 hours
60% are unilateral
Aggravated by routine physical activity
Name some symptoms associated with a headache.
Nausea and vomiting Photophobia Phonophobia Osmophobia Mood disturbance Diarrhoea Autonomic disturbance - e.g. lacrimal, conjunctival, nasal stiffness
What investigations can you do if someone presents with a migraine?
Good history and normal clinical examination does not require further investigation
Cranial imaging advised if they have red flag symptoms or an aura lasting more than 24 hours
What is the most common complication associated with migraine management?
Medication overuse headache
- patient has a headache for at least 15 days of the month associated with frequent use of pain medication
- e.g. NSAIDs, paracetamol, opiods and triptans
- to avoid this, patients can’t take medication more than 2-3 times a week
What is a chronic migraine?
Headache on 15 or more days of a month
