Headache: a clinical approach Flashcards Preview

Yr 3 - December lectures 2018 > Headache: a clinical approach > Flashcards

Flashcards in Headache: a clinical approach Deck (24)
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What are primary headaches?

sometimes referred to as tension headaches or migraines


What is trigeminal neuralgia?

primary headache syndrome = agony and disabling
trigeminal nerve becomes demyelinated


What are tension type headaches?

usually last weeks-months
tight band there all the time but you can continue to do your normal things

they tend to be associated with stiffness in the neck but it is important to check they don't have papilloedema


What factors need to be considered for tension type headaches and what are the treatments?

1) medication overuse? - detox
2) cervicogenic headache (wear and tear in the cervical neck) - physiotherapy
3) need glasses
4) consider migraine - tricyclic antidepressants and SSRIs


What are the rules for migraines?

better when lying down
associated features


What are the 4 stages of acute migraine?

1) prodrome - hours
2) aura (20%)- minutes to hours
3) headache + associated features = hours to days
4) postdrome - usually 1-2 days


What are the common non-headache manifestations of chronic migraine?

chronic fatigue, autonomic symptoms, myokymia, neck pain, back pain, sensory disturbances, restless legs, reflex syncope, stimulus sensitivity, migraine related dysequilibrium, stuttering


How are migraines managed?

1) lifestyle - detox, no caffeine, look for triggers
2) rescue treatment - NSAIDs and antiemetica
3) triptans
4) prophylaxis - beta blockers, topiramate, candesartan (teratogenic), TCAs, SNRIs
6) referral - flunarizine, methysergide, dihydroergotamine, pizotifen, valporate
7) erenumab, fremanexuumab = very very expensive


What are cluster headaches?

comes and goes, period of 3-4 weeks everyday and then period of nothing, there is a kind of hormonal element to them
they can wake you up and there is a diurnal pattern to them
hemicranial and it is always on the same side of the head and they do switch over they don't switch back
droopy eye, miosis, conjunctivial reddeing, and tears on the same side of head
tend to last about 30 mins to several hours


What is the severity of primary headache syndromes?

worst = SUNCT
paroxysmal hemicrania
cluster headache
hemicrania continus


What are the rules for trigeminal autonomic cephalalgias?

1) strictly side-locked
2) autonomic activation
3) agitiation


What are the treatments for trigeminal autonomic cephalalgias?

1) rescue - fast acting triptan e.g. sub cut sumitriptan, nasal zolmitripta
2) break the cluster - oral prednisolone 60mg OD reduce by 10mg every 3 days
3) prophylaxis - depends on duration
4) indometacin
5) needs MRI


What prophylactic treatments are used for:
- Paroxysmal hemicrania
- cluster headaches
- hemicrania continua

SUNCT= lamotrigine (rash)
paroxysmal hemicrania = indometacin (kidney injury, ulcer)
cluster headache = verapamil (heart block - can be delayed)
hemicrania continua = indometacin


What are the rules for trigeminal neuralgia?

demyelinated axon - steady flow of sodium into the cell - can be caused in MS

1) one branch of trigeminal nerve
2) stabbing pain
3) triggered (cold wind, eating/drinking, touch sensitive)
4) need to detox to get clear picture


What are the treatments for trigeminal neuralgia?

1) carbamazepine
2) maximum carbamazepine - refer to neurosurgery
3) oxycarbamazepine
4) another AED
need an MRI


What are examples of secondary headaches?

raised ICP
thunderclap headache
vascular problems


How can raised intracranial pressure arise?

increased arterial blood pressure = malignant hypertension, pre-eclampsia, hypercapnia

increased CSF pressure = obstruction to flow(mass, meningitis), failure of re-absorption, overproduction

increased brain pressure - space occupying lesion (blood, cancer, infection)

increased venous blood pressure - cerebral venous sinus thrombosis

meningeal inflammation - infection, autoimmune, cancer


What red flags are there for secondary headaches?

1) papilloedema
2) seizures, focal neurological signs, cancer of HIV
3) visual disturbances
4) postural change (worse on lying down)
5) pregnancy
6) nausea and vomiting
7) previous history of vasculitis
8) diabetes - old man with temp and new onset hearing loss
9) getting progressively worse
10) morning headache or waking from sleep


What are thunderclap headaches?

first presentation of thunderclap headaches = hospital = very sudden onset, gets as bad as its going to be in minutes
- rarely subarachnoid haemorrhage
- sometimes meningitis, CVST or pituitary apoplexy
- sometimes CSF leak
- mostly migraine


What happens in hospital if you have a thunderclap headache?

need a CT within first 6 hours - sensitivity is almost 100%
if CT is negative do a lumbar puncture


What are the symptoms of a carotid artery dissection?

neck pain, facial pain and horner's syndrome - risk of anterior circulation stroke


What are the symptoms of a vertebral artery dissection?

neck pain, sudden onset, vertigo or ataxia= risk of posterior circulation stroke


What are the rules for temporal arteritis?

1) extremely rare below 60
2) ESR and/or CRP raised


How is temporal arteritis managed?

1) refer immediately to rheumatology
2) steroids
3) US of temporal artery and biopsy within a week