Headaches CA

Question 1

Examples of primary headaches

Answer 1

1. Migraine
2. Tension-type
3. Cluster headache

Note: primary headaches constitute 90% of diagnosed headaches

Question 2

Examples of secondary headaches (caused by an underlying condition)

Answer 2

1. Meningitis
2. Fasting
   - hypoglycemia, cause metabolic changes
3. Nose/Sinus
   - Inflammation or infection, increased pressure in the nasal cavities, pain
4. Non-vascular intracranial disease including tumours
   - abscesses or structural abnormalities increase ICP or compress surrounding structures
5. Others
   - caused by trauma (like a concussion), infections, or drug use

Question 3

What is the mechanism of a migraine?

Answer 3

Neurally induced dilatation and inflammation of intracranial and extracranial vessels

Question 4

What is the mechanism of a tension-type headache?

Answer 4

Unknown

May be increased sensitivity of pain-mediating systems in brain

Question 5

What is the mechanism of cluster headaches?

Answer 5

Neurally induced inflammation and edema of internal carotid artery

Question 6

What is the mechanism of a headache caused by an Intracranial Mass Lesion? (e.g. brain tumor, hydrocephalus)

Answer 6

Displacement (traction) of pain-sensitive vessels

“Mass causes pressure → Stretches vessels → Pain signals fire” = Headache from mass lesion.

Question 7

What is the mechanism of a headache caused by Low Intracranial Pressure state?(e.g. post LP)

Answer 7

Traction through brain sagging on dural attachments ;intracranial vasodilatation

“Brain sag → Stretches dura → Causes pain and vessel dilation” = Low ICP headache.

Question 8

What is the mechanism of a headache caused by Meningitis/Subarachnoid haemorrhage?

Answer 8

Inflammation of vessels in meninges and of perivascular dura

“Inflamed meninges → Irritated vessels and dura → Pain signals” = Headache from meningitis/SAH.

Question 9

What is the mechanism of a headache caused by temporal arteritis and intracranial vasculitis?

Answer 9

Inflammation of scalp and intracranial vessels

“Vessels inflamed, blood flow restricted → Pain-sensitive → Headache” = Headache from temporal arteritis or vasculitis.

Question 10

Investigations to be ordered for headaches

Answer 10

1. Blood test
   - FBC
   - ESR
   - CRP
   - Biochemistry profile
   - Hormonal profile
2. Imaging
   - SXR (Skull X-ray)
   - C-spine X-ray
   - X-ray of sinuses/para-nasal sinuses
   - CT head, base of skull or sinuses
   - MRI brain
3. Lumbar puncture
   - Exclusion of SAH
   - Diagnosis of CNS infection
   - Confirmation of raised ICP in BIH (manometer used to measure the opening pressure of CSF)
4. Biopsy
   - Temporal artery (test for temporal arteritis)
   - Meningeal (test for meningitis)

Question 11

Common triggers for migraine

Answer 11

1. Hormonal
   - menstruation
   - oral contraceptives
   - anything hormone related
2. Dietary
   - alcohol
   - nitrite laden meat
   - MSG
   - aspartame
   - chocolate
   - aged cheese
   - missing a mea
3. Psychological
   - stress
   - post-stress (weekend or vacation)
   - anxiety
   - worry/depression
4. Physical environment
   - glare
   - flashing lights
   - visual stimulation
   - fluorescent lighting
   - odours
   - weather changes
   - high altitude
5. Sleep related
   - lack of /excessive sleep
   - excessive
6. Drugs
   - nitroglycerine
   - histamine
   - reserpine
   - hydralazine
   - ranitidine
   - estrogen
7. Others
   - head trauma
   - physical exertion
   - fatigue

Question 12

Treatment for migraine

Answer 12

Abortive and symptomatic treatment
1. NSAIDS
e.g. naproxen

2. Mixed barbiturate analgesic
   e.g. aspirin, acetaminophen, codeine-containing compound
3. Triptans
   e.g. sumatriptan, aolmitriptan, eletriptan
4. Anti-emetics
   e.g. promethazine, procholorperazine, metoclopramide

Question 13

What is migraine prophylaxis?

Answer 13

refers to preventive treatment aimed at reducing the frequency, severity, and duration of migraine attacks

Question 14

When to start prophylaxis?

Answer 14

1. 2 or more attacks each month with significant disability that lasts 3 or more days
2. Contraindication to or ineffectiveness of symptomatic medications
3. Use of abortive medications more than twice a week
4. Migraine variants such as hemiplegic migraine or rare attacks that suggest risk of permanent neuro injury

Question 15

Nursing care for headaches

Answer 15

1. comfort measures
2. patient education
   - type of headache
   - headache diary
   - identify triggers of migraine headache
   - lifestyle modification
   - stress reduction and relaxation
   - medication