1
Q
What is a headache?
A
- A symptom
- 1/2 to 3/4 of adults aged 18-65 years in the world have had headache in the last year and among them, >30% have reported migraines
2
Q
What is the diagnostic criteria for headaches?
A
- Primary: migraines, tension type, trigeminal autonomic cephalalgias (cluster headaches)
- Secondary: headache is precipitated by another condition/disorder- local or systemic. Serious causes of secondary headaches are uncommon.
3
Q
What are the red flags suggesting secondary headache?
A
- Age: new onset or different headaches in a person (>50yrs)
- Onset: sudden, abrupt onset of a severe headache (thunderclap headache)
- Systemic symptoms: fever, neck stiffness, rash, weight loss
- Neurological signs: confusion, impaired consciousness, focal neurology, swollen optic discs
Therefore, the history is key to the diagnosis of primary vs secondary headaches
4
Q
What are the red flags for headaches in general?
A
- Onset: thunderclap, acute, subacute
- Meningism
- Systemic symptoms
- Neurological symptoms or focal signs
- Orthostatic: headache is better when lying down
- Strictly unilateral
5
Q
What are red flag neurological symptoms or focal signs of headache?
A
- Visual loss
- Double vision
- Confusion
- Seizures
- Hemiparesis: weakness/inability to move one side of body
- Papilloedema: optic disc swelling secondary to elevated intracranial pressure
- 3rd nerve (oculomotor palsy)
- Horner syndrome
6
Q
What are the symptoms of an irritated meninges?
A
- Photophobia
- Phonophobia
- Stiff neck
- Vomiting
7
Q
What is oculomotor palsy?
A
- If posterior communicating artery aneurysm happens, it can rupture and haemorrhage which is very close to third nerve
- 3rd nerve innervates levator muscle so palsy would cause droopy eyelid
- 3rd nerve causes pupil constriction, so palsy causes dilated pupil
- 3rd nerve also controls all eye muscles except lateral rectus and superior oblique- palsy causes eye to point outwards
8
Q
What is Horner syndrome?
A
- When sympathetic supply to eye is affected
- Eye looks a bit droopy
- Eye looks pushed in bit
- Pupil is smaller on the affected side than the other
9
Q
What is the basis for generation of headaches?
A
- Some structural
- Some perhaps pharmacological e.g. GTN for angina dilates vessels around heart to relax them but also does it around brain causing banging headache
- Some psychological
10
Q
What is a migraine?
A
- A disorder of a tendency of repeated attacks of headaches
- These headaches are triggered
- Tends to be hemicranial- affecting half of head
11
Q
What are the common symptoms of a migraine?
A
- Visual vertigo
- Motion sickness
- Easily hung over
12
Q
What are the 3 forms a migraine can come in?
A
- Pain
- Focal symptoms- aphasia/ pins and needles/ tingling/ weakness
- Pain and focal symptoms
13
Q
What are the phases of a migraine?
A
- Prodrome
- Aura
- Headache
- Resolution
- Recovery
14
Q
What symptoms are in prodrome?
A
- Changes in mood
- Urination
- Fluid retention
- Food craving
- Yawning
15
Q
What is aura?
A
Positive and negative visual and sensory phenomena
- Numbness/paraesthesia
- Weakness
- Speech arrest
16
Q
What does the headache actually encompass?
A
- Head and body pain
- Nausea
- Photophobia
17
Q
What is the resolution stage?
A
Rest and sleep
18
Q
What small issues are involved in recovery of migraines?
A
- Mood disturbed
- Food intolerance
- Feeling hungover
19
Q
Over what time period do the stages of a migraine happen?
A
48 hours or so, but a lot of individual variability (from 1 day to 5/6)
20
Q
What are the symptoms of an aura?
A
- Positive and negative symptoms together
- Positive- flashes of light, zigzags, scintillations
- Negative- blind spot
21
Q
What kind of shapes do people with aura see?
A
- Expanding C’s
- Elemental visual disturbance: little patch that grows in their vision and moves towards periphery of vision and disappears- why does this happen?
Migraine is caused by spreading electrical depression across the cerebral cortex and as it goes across the visual cortex you get the expansion and movement of the migraine aura image
22
Q
What is the treatment for an acute attack of migraine?
A
- Painkillers
- Metoclopramide (anti-emetic to stop the sickness)
- Triptans- painkillers we use just for migraines
- Opiates
- A short nap
- TMS (transcranial magnetic stimulation)
23
Q
What painkillers can be taken for an acute attack of migraine?
A
Aspirin/ibuprofen (non-steroidal) and paracetamol
24
Q
How does metoclopramide work?
A
It’s a prokinetic agent and it stimulates peristalsis
Migraine causes gastric paresis which causes gut to slow down and causes nausea- would also mean ingested tablets would just sit there and not be digested
25
What forms do triptans come in and what effect do they have on the vessels?
Vasoconstriction
- tablets
- Melts
- Nasal sprays
- Injections
26
What do triptans synergise with?
- NSAIDs
- This means that if you take an NSAID and a triptan you get more than the effect you'd expect of 2 tablets
27
Why do we want to hit the headache hard and fast?
Once migraine is established, nothing will help it, so we need to hit it quickly and properly before the headache sets in
28
Why should we be careful with opiates?
Analgesic abuse potential
29
What does TMS do?
Interrupts complex networks that trigger and perpetuate migraine which is caused by spreading electrical decompression across the cerebral cortex
30
What lifestyle issues do migraine sufferers have?
- Migraineurs have sensitive heads even between attacks
- They overreact to any sort of stimulation
- They can't ignore the world around them, it overstimulates their brain
31
In which ways can migraineurs look for triggers and avoid them?
- Dietary, environmental, hormonal, weather, dehydration, stress triggers
- Drink 2 litres of water a day
- Avoid caffeine
- Don't skip meals- eat fresh food and avoid ready meals and takeaways
- Don't oversleep or have late nights
- Analgesic abuse
32
What are tension type headaches?
Tight muscles around head and neck bilaterally, as though the head is in a vice
Most common type of headache
33
How are tension type headaches treated?
- NSAIDs painkillers are preferred:
- ibuprofen, naproxen, diclofenac
- Paracetamol
34
What treatment is given to a patient who is very prone to tension type headaches?
Tricyclic antidepressants- amitriptyline
35
Which treatment is less effective for migraines?
SSRIs
36
Can biofeedback and relaxation help with tension type headaches?
Unproven but may help e.g. hot baths/showers/hot water bottles
37
What is a cluster headache?
Severe unilateral pain lasting 15-180 mins untreated
38
What are cluster headaches classified as?
Trigeminal autonomic cephalgia
Pain is mostly in area of first trigeminal nerve
39
Which autonomic (affecting symp/parasymp NS) symptoms do you see in cluster headaches? IPSILATERAL
- Conjunctival redness and/or lacrimation
- Nasal congestion and/or rhinorrhoea (runny nose)
- Eyelid oedema
- Forehead and facial sweating
- Miosis (small pupil on one side) and/or ptosis (eyelid drooping)
40
What else do cluster headaches cause people?
Restless or agitation
41
What is the frequency of cluster headaches?
Between one on alternate days to 8 per day
Tends to have a diurnal pattern
42
What are cluster headaches not associated with?
It's a primary headache so is not associated with brain lesion on MRI
43
How do we treat acute cluster headaches?
- Inhaled 100% oxygen- O2 inhibits neuronal activation in the **trigeminocervical complex**
- subcutaneous injection or **nasal sumatriptan**
44
What drugs do we give for prevention of cluster headaches?
- Verapamil
- Prednisolone (short course of these steroids- they help a lot with headache but have terrible side effects so need to be used carefully)
- Lithium
- Valproate
- Gabapentin
- Topiramate
- Pizotifen
45
What is the distribution for migraine vs cluster?
- Migraine- 33% men, 67% women
- Cluster- 90% men, 10% women
46
What is the duration for migraine vs cluster?
- Migraine- 3 to 12 hours
- Cluster- 45 mins to 3 hours
47
What is the frequency for migraine vs cluster?
- Migraine- 1 to 8 attacks monthly
- Cluster- 1 to 3 attacks daily (often at night)
48
What is remission for migraine vs cluster?
- Migraine- Long remissions are unusual (people have a periodicity of pattern)
- Cluster- long remissions are common (can have bad bout for 2/3 weeks or months and then it goes away for a long time)
49
What is nausea like for cluster vs migraine?
- Migraine- nausea and vomiting is frequent
- Cluster- nausea is rare
50
What is pain like for migraine vs cluster?
- Migraine- pulsating hemicranial pain
- Cluster- steady, exceptionally severe, well localised pain, unilateral in each cluster
51
What are the symptoms for migraine vs cluster?
- Migraine- visual or sensory auras seen
- Cluster- autonomic symptoms- eye waters, nose blocked, ptosis etc
52
What is the activity of patients for migraine vs cluster?
- Migraine- patients lie in dark and try to sleep it off
- Cluster- patients pace about
