Lecture 15- Headaches Flashcards
1
Q
Headaches
A
- Common presenting complain
- Majority are benign (non life threatening and due to primary headache disorder
2
Q
Causes of headache
A
- Primary (due to headache disorder)
- Secondary to another condition
- Non-life threatening
- Life or sight threatening
3
Q
A
4
Q
(1) Primary headache disorders
A
Non-life or sight threatening- many chronic
- Tension headache
- Migraine
- Cluster headache
5
Q
(2) Secondary due to another condition
A
Some are life or sight threatening- many acute
Life threatening
- Intracranial lesion
- Tumour (benign/malignant or metastasis)
- Haemorrhage (trauma or aneurysm)
- Meningitis
Site threatening
- Giant cell (temporal) arteritis)
- Acute glaucoma
Non-life or sight threatening
- Sinusitis
- Medication-overuse headache
- Trigeminal neuralgia
- Drug side effect e.g. CCB and statins
6
Q
Life threatening- secondary
A
- Intracranial lesion
- Tumour (benign/malignant or metastasis)
- Haemorrhage (trauma or aneurysm)
- Meningitis
7
Q
Site threatening- secondary
A
- Giant cell (temporal) arteritis)
- Acute glaucoma
8
Q
A
9
Q
Non-life or sight threatening- secondary
A
- Sinusitis
- Medication-overuse headache
- Trigeminal neuralgia
- Drug side effect e.g. CCB and statins
10
Q
Diagnosing cause of headache: Patients history is key
A
History taking
- History of presenting complaint (HPC)
- SQITARS/SOCRATES
- Site
- Onset
- Character
- Radiate?
- Associated symptoms
- Timing (day/night)
- Exacerbating factors
- Severity
- SQITARS/SOCRATES
- Past medical history (PMH)
- Prev. headaches, conditions causing secondary headache
- Drug history (DH)
- Analgesic use (medication over use)
- Other drugs causative or headache?
- Family history (FH)
- Migraines?
- Social history (SH)
- Sleep? Stress?
- Alcohol and caffeine consumptions, diet (triggers)
Red flags
Clinical examination
- Vital signs
- BP
- PR
- Temp
- Neurological examination (cranial and peripheral nerve exam, Glasgow-coma scale)
- Other relevant systems, guidance by history
11
Q
red FLAGS of headaches
A
12
Q
A
- vital signs
- BP
- PR
13
Q
headache types from common to least common
A
14
Q
tension headaches
A
primary headaches
- F>M
- Common
- Young (teenagers) and young adults (20-39yrs)
- First onset >50 yrs unusual
15
Q
pathophysiology of tension heafaches
A
- Due to tension in muscles of the head and neck
16
Q
features of a tension type headache
A
17
Q
migraine
A
primary headache
- F>M (1 in every 5F_
- Common
- Present early to midlife
- Most have first attack by 30
18
Q
pathophysiology of migraine
A
- Pathophysiology
- Unclear
- Possible theories
- Neurogenic inflammation of trigeminal sensory neurones innervating large vessels and meninges
- Alters way pain processed by brain, sensitised to otherwise ignored stimuli
19
Q
features of migraines
A
20
Q
Associated symptoms of migraines
A
- Photophobia
- Nausea
- Aura- peculiar sensory signs
21
Q
Medication over-use headache
A
secondary headache
- Medication used to treat headaches
- F>M
- 30-40 yrs
- Headache present on at least 15 days/month (constant)
- Using regular analgesics (at least 10 days/month)
- Headache not responding
- Occurs in pts with pre-existing headache disorder
22
Q
Pathophysiology of medication overuse heaches
A
Regular use of analgesics leads to upregulation of pain receptors in the meninges e.g. codeine
23
Q
featues of medication over-use headaches
A
- Variable character can be dull, tension-type or migraine-like
- Co-exists with depression and sleep disturbance
- Treatment: discontinue medication (headache worsens before improves)- resolves completely by 2 months
24
Q
Cluster headaches
A
primary headache disorder
- M>F
- Smoking history= risk factor
- 1 in 1000
- Usually begins 30-40 years
25
Pathophysiology of cluster headaches
* Unknown
* Hypothalamic activation with secondary trigeminal and autonomic involvement
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features of cluster headaches
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**Secondary headaches**
* Intracranial haemorrhage- meningism
* Raised ICP (e.g. space occupying lesion)
* Trigeminal neuralgia
* Temporal (giant cell) arteritis
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**Raised intracranial pressure- space occupying lesion**
Rarely occurs in absence of other suspicious historical or exam findings
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**Trigeminal neuralgia** aetiology
* F\>M
* 50-60 years
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trigeminal neuralgia pathophysiology
* Most caused by compression of CN V due to loop of blood vessels
* 5% due to tumours/skull base abnormalities or AV malformations
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trigeminal neuralgia features
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**Temporal arteritis**
* Vasculitis of large and medium sized arteries of head
* **Superficial temporal artery commonly involved.**
* F\>M
* \>50 years (most common \>75 yrs)
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major risk associated with temporal arteritis
Risk of irreversible loss of vision due to involvement of blood vessels supplying CN II (optic)
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**General approach to headache**
* History and examination
* Identify if red flag present
* Build illness script for clinical features that would indicate to particular primary headache disorder or secondary causes
* Treatment and management will depend on underlying cause
* Simple analgesics, triptans, high flow oxygen (cluster) vs urgent referral for further investigation
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example scenario- most likely diagnosis
* Recurrent
* Tight band
* Can carry on activities
* Coughing doesn’t make it worse
* No family history of note
* No medication
* Clinical exam normal
* Recent stress
Diagnosis? Tension headache most likely
37
example scenario- most likely diagnosis
* Unilateral
* Morning headache
* Certain positions make headache worse
* Hypertension
* Upper motor neurone signs
Diagnosis?
* Sign of ICP
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