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Year 3 Clinical > Headaches > Flashcards

Headaches Flashcards

1
Q

Types of headache based on onset / peak?

A

Acute VS sub-acute VS gradual

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2
Q

Potential relieving factors of a headache?

A

Posture, headache behaviour

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3
Q

Potential exacerbating factors of a headache?

A

Posture

Valsalva (sneezing, coughing, straining, etc)

Diural variation

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4
Q

Assoc. features with headache?

A

Autonomic features, e.g: N&V

Photophobia

Phonophobia (aversion to loud sounds)

+ve visual symptoms

Ptosis, miosis

Nasal stuffiness

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5
Q

Other features that help to identify the type of headache?

A

Demographic, e.g: migraine tends to occur in young females

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6
Q

Red flags in headache history?

A
  1. New onset headache >55 years of age
  2. Known / previous malignancy
  3. Immunosuppression
  4. Early morning headache
  5. Exacerbation by valsalva (coughing, sneezing, raised ICP)
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7
Q

Significant Hx features in headache?

A

PMH - previous CA, predisposition to thrombosis

DH - use of a headache diary allows accurate account of OTC medication ingestion

FH - particularly of migraines

SH - caffeine intake

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8
Q

Occurrence of migraines?

A

More common in women; most patients have 1 attack per month

Types:
• Migraine WITH aura (20%)
• Migraine WITHOUT aura (80%)

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9
Q

Requirements for the diagnosis of a migraine without aura?

A

At least 5 attacks in the Hx, with a duration of 4-72 hours each

2 of the following:
• Moderate / severe 
• Unilateral
• Throbbing pain
• Worst with movement (they prefer to lie still)

AND

1 of the following:
• Autonomic features
• Photophobia / phonophobia

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10
Q

Pathophysiology of migraines?

A

Vascular and neural influences can trigger migraines in SUSCEPTIBLE individuals; stress triggers brain changes and release of serotonin

Blood vessels constrict and dilate

Chemicals, inc. substance P, irritate nerves and blood vessels, causing pain

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11
Q

Neurophysiological basis of a migraine with aura?

A
  1. Cortical spreading depolarisation stimulates the migraine centre of the brain
  2. Activation of the trigeminal vascular system occurs, resulting in dilatation of cranial blood vessels
  3. Substance P, neurokinin A, etc are released
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12
Q

Constituents of the migraine centre of the brain?

A

Dorsal raphe nucleus

Locus coeruleus

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13
Q

What is an aura?

A

Collective name given to the many types of neurological symptoms that may occur just before or during a migraine

These include fully reversible visual, sensory, motor or language symptoms

NOTE - visual aura is most common (usually monochromatic)

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14
Q

Development of a migraine with aura?

A

Aura typically lasts for 20-60 minutes; headache follows <1 hour later

NOTE - the aura can occur simultaneously

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15
Q

Types of visual aura?

A

Scotoma (reduction / loss of central vision in specific regions of the visual field, e.g: central)

Fortification (bright, shimmering, jagged lines that can spread across the visual field, e.g: central)

Hemianopic loss

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16
Q

Triggers of a migraine?

A
  • Sleep
  • Dietary
  • Stress
  • Hormonal (consider in young females in early teens and in females in their 40s)
  • Physical exertion

NOTE - a headache diary is helpful in identify triggers; often, a trigger is not found but knowledge of one can help in treatment of the headache

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17
Q

Non-pharmacological treatment of migraine?

A

Set realistic goals and request headache diary

Avoid triggers

Relaxation / stress management

Acupuncture, relaxation exercises

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18
Q

Pharmacological treatment of migraine?

A

Acute:
• NSAIDs, e.g: aspirin, naproxen, ibuprofen, +/- anti-emetic
• Triptans (5-HT agonist), e.g: Rizatriptan, eletriptan, sumatriptan, frovatriptan

Prophylactic

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19
Q

Use of NSAIDs in acute management of a migraine?

A

TAKE AS EARLY AS POSSIBLE (at onset)

Most patients experience a significant reduction in their headache at 2 hours; some experience complete pain relief

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20
Q

Cautions with NSAID use?

A

If gastroparesis, consider an anti-emetic

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21
Q

Administration routes for triptans?

A

Oral, sub-lingual or subcutaneous

Choose based on whether patient has N&V

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22
Q

Use of triptans in acute management of a migraine?

A

TREAT AT ONSET OF HEADACHE

Stimulate vasoconstriction

Frovatriptan is used for sustained relief of migraine

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23
Q

Comparison of NSAIDs and triptans?

A

Similar efficacy

NSAIDs are cheaper

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24
Q

When should prophylaxis of migraines be considered?

A

If patient has >3 attacks per months

OR

Very severe migraines

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25
Aim of prophylactic treatment of migraines?
Titrate drug as tolerated to achieve efficacy at the lowest dose possible (i.e: go slow and keep low) Must trial each for a minimum of 4 months
26
Options for prophylaxis of migraines?
1. Propranolol (β-blocker) | 2. Topiramate (carbonic anhydrase inhibitor)
27
Use of propranolol as prophylaxis of migraines?
Reduces migraine frequency in majority of patients Daily dose of 80-240mg
28
Contraindications to propranolol use?
Avoid in patients with: • Asthma • Peripheral Vascular Disease (PVD) • Heart failure
29
Use of topiramate as prophylaxis of migraines?
Daily dose of 25-100mg; start slowly, as it has a poor side effect profile
30
Adverse effects of topiramate?
* Weight loss * Paraesthesia * Impaired conc. * Enzyme inducer
31
Other medications used for migraine prophylaxis?
Amitriptyline (generally 25mg with a max of 150mg) - unclear mechanism of action for migraine prophylaxis Gabapentin Pizotifen Sodium valproate
32
Adverse effects of amitriptyline?
Dry mouth Postural hypotension Sedation
33
Lifestyle changes that can be made to improve migraines?
Diet - ensure regular intake and a healthy, balanced diet; avoid dietary triggers Hydration - drink at least 2 litres every day and decrease caffeine Decrease stress Regular exercise
34
General description of a migraine?
Common unilateral headache of the young
35
Ix for migraines?
For a typical migraine, no Ix required Consider imaging if: • Late onset (>55 years of age) • Known malignancy • Acephalgic (no headache) migraine
36
Types of 'fancy' migraine?
Acephalgic - migraine without headache Basilar - start in the brainstem; cause symptoms of dizziness, diplopia and lack of coordination Retinal (AKA ocular / ophthalmic migraine) - retinal disease often accompanied by a migraine headache; typically affects 1 eye and causes vision loss / BLINDNESS, lasting <1 hour Hemiplegic - temporary weakness on one side of the body as part of a migraine attack; there are 2 types Abdominal - episodes of abdominal pain without an accompanying headache; mainly occurs in children
37
Cause of retinal migraine?
Ischaemic or vascular spasm in / behind the affected eye
38
2 types of hemiplegic migraine?
1. Familial | 2. Sporadic
39
What is autonomic cephalgia?
Trigeminal autonomic cephalgias (TACs) are a group of primary headache disorders characterised by: • Unilateral TRIGEMINAL DISTRIBUTION PAIN that occurs in associated with • Prominent ipsilateral cranial AUTONOMIC features
40
Ipsilateral cranial autonomic features that occur in the TACs?
* Ptosis * Miosis * Nasal stuffiness * N&V * Tearing * Eye lid oedema
41
4 main types of TCA?
1. Cluster 2. Paroxysmal hemicrania 3. Hemicrania continua 4. SUNCT
42
Occurrence of cluster headache?
Young patients (30-40s) and more common in men Tend to occur around sleep and there is seasonal variation
43
Features of cluster headache
SEVERE unilateral headache that lasts 45-90 minutes (more severe than migraines) Occur 1-8 times a day Cluster bout (period of time during which individual cluster headache attacks occur) may last from a few weeks to months
44
Treatment of cluster headaches?
High flow O2 100% for 20 minutes Subcutaneous sumatriptan 6mg (oral does not act fast enough) Steroids (reducing course over 2 weeks)
45
Prophylaxis of cluster headaches?
Verapamil
46
Occurrence of paroxysmal hemicrania?
Older individuals (50-60s) and more common in women
47
Features of paroxysmal hemicrania?
Severe unilateral headache with unilateral autonomic features Lasts for 10-30 minutes and occur 1-40 times a day, i.e: comes and goes NOTE - these are SHORTER AND MORE FREQUENT THAN CLUSTER HEADACHE
48
Treatment of paroxysmal hemicrania?
Absolute response to indomethicin
49
SUNCT headache?
``` Short-lived (15-120 seconds) Unilateral Neuralgioform headache Conjunctival injections Tearing ```
50
Treatment of SUNCT headache?
Lamotrigine Gabapentin
51
Ix for TACs?
Patient with new onset unilateral cranial autonomic features require imaging: • MRI brain • MR angiogram
52
Occurrence of trigeminal neuralgia?
Elderly patients (>60 years of age) and more common in women It is triggered by touch, usually in the sensory territories of V2 and V3
53
Features of trigeminal neuralgia?
Severe stabbing unilateral pain that last for 1-90 seconds and occurs 10-100 times a day Bouts pain may last from a few weeks to months before remission occurs
54
Treatment of trigeminal neuralgia?
``` Pharmacological: • Carbamezapine • Gabapentin • Phenytoin • Baclofen ``` Surgical treatment - ablation vs decompression
55
Ix for trigeminal neuralgia?
``` MRI brain if: • Any signs on examination • Atypical features • Poor response to medical treatment • Considering surgical treatment ```
56
How to differential between the different types of TACs and trigeminal neuralgia?
ADD TABLE
57
Other considerations with headache?
``` Consider non-neurological structures, e.g: • Eyes (strain) • Ears • Sinuses • Teeth (grinding) - give mouth guard • TMJ ```
58
Classifications of headache?
``` Primary: • Migraines • Tension-type headache • TACs • Trigeminal neuralgia ``` Secondary: • Medication overuse headache • Meningitis, etc
59
Features of tension-type headaches?
Less severe than migraines and usually have mild-moderate BILATERAL pain Absence of photophobia, phonophobia and N&V These can be episodic or chronic
60
Occurrence of Idiopathic Intracranial Hypertension?
More common in females; occurs in OBESE patients, i.e: BMI reflects IIH
61
Symptoms of IIH?
Headache with diurnal variation Other features: • Visual loss • Morning N&V Absence of venous pulsations on fundoscopy (if these cannot be seen, it does not mean they are absent; but, in IIH, there is a true absence of them)
62
Ix for IIH?
MRI brain is normal ``` Lumbar puncture (normal constituents but pressure is higher) NOTE - papilloedema is an absolute contraindication for LP; IIH patients are the only ones with papilloedema who can have a LP ```
63
Treatment of IIH?
WEIGHT LOSS (makes all issues go away but not often achievable) Acetazolamide Ventrical atrial / lumbar peritoneal shunt NOTE - visual fields and CSF pressure must be monitored

Year 3 Clinical (100 decks)

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