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Flashcards in Headaches Deck (84):



What are the main types of primary headache?


  • Migraine
  • Tension Headache
  • Autonomic cephalgias




What are main types of secondary headache?


  • Thunderclap headache
  • Postural headaches
  • Associated with CNS infection
  • Asscoiated with Systemic illness




What are features of migranous aura?

  • Visual Aura
    • Positive - Fortification spectra, scintillations, spots
    • Negative - visual field loss
  • Sensory Aura - spreading unilateral numness - Fingers to face
  • Motor - ataxia, dysarthria, opthalmoplegia, hemiparesis
  • Speech - dysphasia/paraphasia
  • Migranous Vertigo
  • Speech Distrubance
  • Neck/limb pain
  • Hemiplegic migraine


What is the following?



Fortification spectra




What type of visual field defects are seen in migraines?


  • Scotoma
  • Hemianopia/tunnel vision




What is hemiplegic migraine?


This rare autosomal dominant disorder causes a hemiparesis and/or coma and headache, with recovery within 24 hours. Some patients have permanent cerebellar signs as it is allelic with episodic ataxia. It is distinct from commoner forms of migraine.




What is the mechanism behind migraine development?


  1. Spreading cortical depression (causing aura) – wave depolarization followed by depressed activity spreading anteriorly across cortex from the occipital region 
  2. Activation of trigeminal pain neurones (causing headache) - Release of CGRP, substance P and other vasoactive peptides by activated trigeminovascular neurones causes painful meningeal inflammation and vasodilation.
  3. Peripheral and central sensitization of trigeminal neurones and brainstem - makes innocuous sensory stimuli (such as CSF pulsation and head movement) painful and light and sound perceived as uncomfortable.




What are partial triggers of migraine?


  • Chocolate
  • Hangovers
  • Orgasms
  • Cheese/caffeine
  • Oral contraceptives
  • Lie-ins
  • Alcohol
  • Travel
  • Exercise




What are negative visual aura symptoms?



Visual field loss




What are the 3 main areas of migraine treatment?


  • Lifestyle
  • Acute treatment
  • Preventative treatment




What are positive visual aura symptoms?


  • Fortification spectra
  • Scintillations
  • Scotoma
  • Hemianopia
  • Chaotic distortion




What are sensory features of migraine aura?



Spreading unilateral numbness - over minutes, spreading fingers to face




What are motor features of a migraine aura?


  • Dysarthria + Ataxia
  • Opthalmoplegia
  • Hemiparesis




What proportion of migraine sufferers have aura preceding an attack?







What are features of the prodromal phase of a migraine?


  • Mood changes
  • Fatigue
  • Cognitive changes
  • Muscle pain
  • Food craving




Which sex is migraines more common in?



Females - 3:1




What are features of a migraine?


  • Severe unilateral headache
  • Nausea
  • Vomiting
  • Photophobia/Phonophobia/Osmophobia
  • Allodynia




What are the diagnostic crtieria for diagnosing migraine?

>/=5 headaches lasting 4-72 hrs + nausea/vomiting (or photo/phonophobia), plus any two of:

  • Pulsating/Throbbing
  • Impairs routine activity




What changes in routine can cause increased migraines?


  • Sleep disturbance
  • Stress
  • Hormonal factors - menstruation, pregnancy, menopause, OCP
  • Eating - skipping meals/alcohol
  • Sensory stimuli




What would be your differential be for a migrainous type headache?


  • Cluster/tension headache
  • Cervical spondylosis
  • Hypertension headache
  • Intracranial pathology
  • Sinusitis/otitis media
  • TIA




What lifestyle advise would you give someone suffering from migraines?


  • Avoid food triggers
  • Sleep
  • Hydration
  • Regular meals
  • Look at meds - overuse headache?




What treatment would you prescribe someone with migraines for acute attacks?

Stop regular opiates/paracetamol

  • 1st line - Combination therapy Oral triptan + NSAID/Paracetamol
  • If monotherapy preferred
    • Triptan
    • NSAID
    • Aspirin - 900 mg every 4–6 hours
    • Paracetamol
  • Consider anti-emetics






What are contraindications of triptan use?


  • IHD
  • Coronary Spasm
  • Uncontrolled HTN
  • Recent Lithium use
  • SSRI use
  • Ergot use




What would you prescribe for prophylactic management of migraines?


  • 1st lines - Propranolol or topiramate
  • Amitryptiline
  • Candesartan
  • Others - valproate, pizotifen, pregabalin, ACEi




What dose of propranalol would you start someone on for prophylactic management of migraines?



40mg daily for 2 weeks, then increase to 80mg daily




What dose of topiramate would you start someone on as prophylactic treatment of migraine?



25mg daily, increase by 25mg every 2 weeks up to 75 mg




What dose would you start amitryptyline on for prophylactic treatment of migraine?



10mg nightly, increase by 10 mg weekly up to 75 mg




What are women with migraines at risk of if on OCP?



Increased stroke risk




What would you give as oral contraception in women with migraines?


  1. POP
  2. Non-hormonal contraception




What are tension type headaches?


In contrast to migraine, pain is usually mild to moderate severity, bilateral and relatively featureless, with tight band sensations, pressure behind the eyes, and bursting sensations being described.





How would you manage tension type headaches?


  • Simple analgesia - don't encourage overuse




What is a cluster headache?


Recurrent bouts (clusters) of excruciating unilateral retro-orbital pain with parasympathetic autonomic activation in the same eye causing redness or tearing of the eye, nasal congestion or even a transient Horner’s syndrome


Describe the following features of SUNCT headaches:

  • Duration
  • Onset
  • Frequency


  • Duration - 2-250s
  • Onset - Rapid
  • Frequency - 1/day - 30/hr


Describe the following features of a cluster headache:

  • Duration
  • Onset
  • Frequency


  • Duration - 15 mins - 3 hrs
  • Onset - Rapid
  • Frequency - 1 every other - 8/day




What are features of a cluster headache?

Suicide headache

  • Rapid onset excruciating pain around one eye
    • Restless patient
  • Prominent ipsilateral autonomic symptoms
    • Conjunctival injection / lacrimation
    • Nasal congestion / rhinorrhoea
    • Eyelid oedema
    • Forehead & facial sweating
    • Miosis / ptosis (Horner’s syndrome)




In terms of yearly time course, what are the distinct features of cluster headaches?



Clusters last 4-12 weeks, then have headache free periods of months to 1-2 years





How would you manage cluster headaches acutely?


  • Give high flow oxygen - non re-breath mask
  • Triptan injection




How would you manage cluster headaches prophylactically?


  • Verapamil
  • Topiramate




What is SUNCT?

Short-lasting Unilateral Neuralgiform headaches with Conjunctival injection and Tearing


A rare headache disorder that belongs to the trigeminal autonomic cephalalgias (TACs). Symptoms include excruciating burning, stabbing, or electrical headaches mainly near the eye and typically these sensations are only on one side of the body. The headache attacks are typically accompanied by cranial autonomic signs that are unique to SUNCT. Each attack can last from five seconds to six minutes and may occur up to 200 times daily.




What are features of SUNCT?


  • Severe unilateral headache - stabs, sawtooth
    • Restless patient
  • Prominent ipsilateral autonomic symptoms
    • Conjunctival injection / lacrimation
    • Nasal congestion / rhinorrhoea
    • Eyelid oedema
    • Forehead & facial sweating
    • Miosis / ptosis (Horner’s syndrome)





In terms of daily time course, what are features of cluster headaches?


  • Attacks occur at the same time each day
  • Bouts occur at the same time each year




How would you manage someone with SUNCT?


  • Lamotragine
  • Topiramate
  • Gabapentin




What can trigger SUNCT?



Cutaneous contact




What percentage of those with SUNCT have chronic SUNCT?





Desribe the following features of paroxysmal hemicrania:

  • Duration
  • Onset
  • Frequency



  • Duration - 2- 45mins
  • Onset - rapid
  • Frequency - 1-40/day




What are features of paroxysmal hemicrania?


  • Excruciatingly severe headache - unilateral
    • Restless patient
  • Prominent ipsilateral autonomic symptoms
    • ​​​Conjunctival injection / lacrimation
    • Nasal congestion / rhinorrhoea
    • Eyelid oedema
    • Forehead & facial sweating
    • Miosis / ptosis (Horner’s syndrome)





How do you distinguish between cluster headaches and paroxysmal hemicrania?



Duration and Frequency - PH is shorter duration (2-30 mins) and higher frequency per day (2-40 per day)




What can paroxysmal hemicrania attack be precipitated by?



Bending or rotating head




How would you manage someone with paroxysmal hemicrania?


  • Indomethicin




What are the autonomic cephalgias?


  • Cluster headaches
  • Paroxysmal hemicrania




What is a cervicogenic headache?


A chronic headache arising from the atlanto-occipital and upper cervical joints and perceived in one or more regions of the head and/or face. These occur due to a neck disorder or lesion and feature the converging of trigeminal and cervical afferents in the trigeminocervical nucleus within the upper cervical spinal cord.




What are features of a cervicogenic headache?


  • Unilateral dominant headache - Exacerbated by neck movement or posture
  • Tenderness of the upper cervical spine joints
  • Weakness - deep neck flexors






How would you manage cervicogenic headache?


  • Amitryptilline
  • Physiotherapy




What clinical examinations would you perform in someone presenting with headache?


  • General/systemic
  • Cranial nerve - mainly eyes
  • Limb Examination - weakness, coordination, reflexes




What CNS infections can present with headache?


  • Meningitis
  • Viral encephalitis




If someone had chronic headache which was worse on lying flat, and improved on sitting up, what might this indicate?



Riased ICP




What are features of raised pressure headaches?


  • Worse on lying flat, improved on sitting / standing up
  • Worse in the morning
  • Worse on valsalva 
  • Worse with physical exertion
  • Vomiting without nausea
  • Transient visual obscurations with change in posture





If someone had a headache which was worse on lying down, whilst doing any valsalva maneuvre, and was worse in the mornings, what might you expect to find on examination?


  • Optic disc swelling – papilloedema
  • Restricted visual fields / enlarged blind spot
  • VIth nerve palsy - false localising sign
  • Focal neurological signs




What are mass effect causes of raised ICP?


  • Tumour
  • Infarction with oedema
  • Subdural/extradural/intracerebral haematoma
  • Abscess




What venous problems can cause raised ICP?


  • Cerebral venous sinus thrombosis
  • Obstruction of jugular venous system




What CSF problems can cause raised ICP?


  • Hydrocephalus
  • Meningitis




What idiopathic processes can cause raised ICP?



Idiopathic intracranial hypertension




What are features of low-pressure headaches?


Orthostatic headaches - Headache worse on sitting / standing up and relieved by lying down




What are causes of low-pressure headaches?


  • Post LP
  • Spontaneous intracranial hypotension - following dural tear




What investigations would you consider in someone with features of raise ICP?


  • CT head
  • CT/MR Venogram - rule out venous sinus thrombosis
  • Consider LP - after imaging!!!! risk of coning




If someone had features of a SOL, and they're imaging showed no features of mass lesion, venous sinus thrombosis or hydrocephalus, what would you consider as the diagnosis?



Idiopathic intracranial hypertension




If someone presented with a headache and a red, painful eye +/- reduced vision, what diagnosis would you want to rule out?



Acute angle glaucoma




If someone presented with a temporal headache and jaw claudication, what diagnosis would you want to rule out?



Giant cell arteritis




If someone presented with a headache which felt like a tight band around their head, what might you suspect to be the cause?



Tension headache




What are causes of medication overuse headaches?


  • Mixed analgesia - Paracetamol + opiates
  • Ergotamines
  • Triptans
  • Caffeine

For medications, more at risk if using analgesia for > 10 days




In terms of management of migraines, what medications should you avoid using when they are of childbearing age?



Anti-epileptics - valproate




What are migraneurs more at risk of if they are pregnant?







What is idiopathic intracranial hypertension?



Increased intracranial pressure caused by reduced CSF resorption




Who does Idiopathic Intracranial Hypertension occur most commonly in?



Younger overweight female patients, many of whom have polycystic ovaries




How does Idiopathic intracranial hypertension present?

Raised ICP headache features

  • Positional Headaches - worse on lying, bending over
  • Transient visual obscurations - florid papilloedema
  • VIth nerve palsy - false localizing sign




What investigations might you do in someone with suspected intracranial hypertension?


  • Imaging - Exclude SOL
  • Consider LP - Opening pressure
    • If Safe to do so




How would you try to minimise medication overuse headache in someone using simple analgesia for tension type headache?


Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache




What is medication overuse headache?


Headache present on ≥15 days / month which has developed or worsened whilst taking regular symptomatic medication




Which of the Autonomic cephalgias are there no abortive treatments for?


  • Paroxysmal Hemicrania




How would you manage low-pressure headaches?

Significant number resolve spontaneously

  • Bed rest
  • Fluids
  • Analgesia
  • Oral/IV caffeine
  • Epidural blood patch




How would you manage someone with Idiopathic intracranial hypertension?

Usually self-limiting

  • Regular monitoring of visual fields with perimetry
  • Reduce CSF
    • Repeated LP
    • Acetazolamide
    • Thiazide diuretics 
  • Consider surgery
    • Ventriculoperitoneal shunt
    • Optic nerve sheath fenestration




What are secondary causes of intracranial hypertension?


  • Drugs (tetracycline, Vit A)
  • Sleep apnea
  • Chronic renal failure
  • Addisons disease,
  • Cushings disease, 
  • Hypoparathyroidism




What are red flags to ask about when someone is presenting with a headache?


  • Intracranial bleed - thunderclap, recent trauma
  • Raised ICP - increases with posture change
  • SOL - immunosuppression, malignancy, focal neurology, onset > 50
  • Meningitis - neck stiffness, phtophobia, fever, rash
  • Glaucoma - red eye, visual disturbance, halos




What antiemetics are good for using in migraines?


  • Metoclopramide hydrochloride
  • Domperidone
  • Phenothiazine
  • Antihistamine antiemetics - cyclizine