Session 9 Headache Flashcards
(23 cards)
What are the names of three common primary headache disorders?
- Cluster Headache
- Tension Headache
- Migraine
Four causes for secondary headaches that are ACUTE (plus examples?)
- Vascular: haemorrhage or thrombosis
- Infective/Inflammatory: meningitis, encephalitis, abscess, temporal arteritis
- Opthalmic: glaucoma
- Situational (exacerbating factors): cough, exertion, coitus
Some examples of chronic causes of secondary headache?
Drug side effect: analgesics, caffeine (from withdrawal), vasodilators
Trigeminal neuralgia
Raised ICP (could be from a tumour)
Temporal / giant cell arteritis
Systemic: hypertension, pre-eclampsia, phaemochromocytoma (rare)
What are the red flag features of headaches?
SNOOP
S = Systemic signs and disorders (meningitis = fever / neck stiffness) N = Neurological symptoms (SOL, ICH, glaucoma (visual)) O = onset is new or changed and patient is >50 yo (malignancy or brain mets) O = onset in thunderclap presentation (suggests vascular cause - SAH) P = Papilloedema, pulsating tinnitus, positional provocation, precipitated by exercise (suggests raised ICP)
What is the most common primary headache disorder? (Put them in order)
most common = tension-type headache > migraine > cluster headache
Tension headache: the classic person presenting with it?
More common in females than males
Young people (20-39 yr)
A first onset over 50 yr is unusual - think of another cause if this is the case!
Tension Headache: Clinical features?
SQITARS
Site = bilateral frontal/occipital regions - can radiate to neck
Quality = tight and band-like, non-pulsatile
Intensity = mild-moderate (can still do normal things)
Timing = worse at the end of the day
* chronic = >15 times a month
* episodic = <15 times a month
Aggregating factors = stress, poor posture (think desk job!), lack of sleep
Relieving factors = simple analgesics
Secondary symptoms = mild nausea
Tension headache
Neurological exam would be?
Pathophysiology?
Neurological exam = normal :)
Pathophysiology
- tension in muscles of the head and neck (e.g. occipitofrontalis)
- usually no family history
Medication over-use headache
Epidemiology?
More common in females than males
Headache present on at least 15 days per month (constant)
Occurs in patients with pre-existing headache disorder!
Younger people normally
Medication over-use headaches
Clinical feature?
Present on at least 15 days per month
No improvement with OCT medication (like paracetamol) - key is that headaches re not responding!
Often co-exist with depression or sleep disturbance
These people are often using analgesia for at least 10 days every month
How would you manage someone with a medication over-use headache?
Discontinuation of medication - tell them that it will likely get worse before it gets better but should resolve within 2 months
Pathophysiology of medication over-use headaches?
Related to upregulation of pain receptors in the meninges
Cluster headaches
epidemiology?
More common in males than females
1/1000 people
Usual onset = 20-40 years old
Cluster headaches: Clinical features
Site = unilateral, around or behind eye - no radiation
Quality = sharp, stabbing, penetrating
Intensity = very severe, constantly intense, disabling and agitating
Timing = rapid onset, attacks can last 15 min - 3 hours (1-2 times a day), usually at night, occurs in clusters (2-12 weeks) with periods of remission (3 months to 3 years)
Aggregating factors = head injury, alcohol, smoking, volatile smells, warm temperature, lack of sleep
Relieving factors = simple analgesics not very effective but oxygen and triptans are used
Secondary symptoms = features associated with decreased sympathetic activity:
* red, watery eye
* nasal congestion / runny nose
* ptosis (drooping eye lid)
* constricted pupil
Migraine: epidemiology
More common (twice as common!) in females over males
Common 15/100 people
Presents early-mid life: most have first attack <30 yr
Severity decreases as age increases
migraine: possible pathophysiology?
Unclear but theories suggest vasodilation of meningeal blood vessels
Often a family history present
Migraine: Clinical features
Site = unilateral, often frontal or temporal
Quality = throbbing or pulsating
Intensity = moderate
Timing = onset can be sudden OR gradual - lasts between 4-72 hours, possibly with a cyclical character
Aggravating factors
* triggers: certain foods (cheese, chocolate), lack of sleep, stress, menstrual cycle
* photophobia and phonophobia
Relieving factors = sleep, triptans
Secondary symptoms
* aura: neurological signs that often come before an attack (but can have aura alone)
* nausea, vomiting, photophobia
Space occupying lesion: Clinical Features
- Gradual onset and progressive = KEY
Quality = dull (but can be variably described)
Intensity = may be mild in severity but gets worse over time
Timing = early morning, on waking (rare that the headache wakes them up though!)
Aggravating = worsened with posture (leaning forward), coughing and bending
Relieving = simple analgesics may help early on
Secondary symptoms = nausea, vomiting, focal neurological or visual symptoms
Neurological exam - may have behavioural or personality changes, seizures / unilateral signs, papilloedema and signs of increased ICP
Trigeminal neuralgia: epidemiology
More common in females than males
25/100,000 (UK)
Age: 50-60 years (increasing incidence with age)
Trigeminal neuralgia: Clinical features
Would the clinical examination be normal?
Site = unilateral, often over one eye, pain felt in 1 or more divisions of CN V (CNVa involved = headache described!), can radiate to eyes, lips, nose and scalp
Quality = sharp, stabbing, shooting, ‘electric shock’ feeling, sometimes burning pain
Intensity = severe and lasts a few seconds to minutes
Timing = sudden onset and lasts a few seconds to minutes
Aggravating factors = light touch to face, eating, cold winds and vibrations, combing hair
Relieving factors = simple analgesics not effective so difficult to treat
Secondary symptoms = tingling, numbness before attack
Clinical examination = NORMAL
Trigeminal neuralgia: pathophysiology
Most cases are caused by COMPRESSION of the trigeminal nerve by a vascular malformation
A few cases: caused by tumours, MS or skull base abnormalities
More common in those with a history of chronic pain
Temporal Arteritis
What is it?
Common in who?
Symptoms?
Which artery is commonly involved?
Risk?
It is vasculitis involving small and medium sized arteries of the head
More common in females and presentation >50 yr (most common = >75 yr)
Symptoms: abrupt onset of headache, visual disturbance or jaw claudication, scalp tenderness, abnormalities of the temporal artery (pain, nodules, absence of pulse)
Symptoms due to involvement of great vessels: claudication of extremities (especially arm!)
Symptoms due to systemic inflammation: fever, night sweats, weight loss
Artery most commonly involved is the superficial temporal artery
Risk of irreversible loss of vision due to ischemia of CN I
Referral criteria for headaches?
- suspicion of a tumour
- suspicion of raised ICP
- recent onset seizures
- previous cancer
- unexplained focal deficits
- unexplained cognitive/personality changes
