1 Gp - Headache

Front 1

Frontal lobe tumors

Back 1

-slow growing
-non-specific headache
-subtle personality changes, resulting in tx for depression
-->-non-response to tx prompt further investigation

Front 2

Red Flags in Headache presentation

Back 2

Age:
-age50+ at onset of new headache
-age<10 at onset

Characteristics:
-first/worst/different from usual headache
-progressive headache (over weeks)
-persistent headache ppt by
Valsalva maneuver (cough, sneeze, bending, or exertion)
-Thunderclap headache (explosive onset)

Additional features:
-atypical or prolonged aura (>1hr)
-aura occurs for the 1st time in women on COC
-new onset headache in pat with a history of cancer/HIV
-concurrent systemic illness
-neurological signs
-seizures
-symptoms/signs of GCA (e.g. jaw claudication)

Front 3

Causes of Secondary Headache
-presence of red flags prompts consideration of a wide range of dx's. List some

Back 3

Vascular
-subdural hematoma
-epidural hematoma
-subarachnoid hemorrhage
-venous sinus thrombosis

Tumor

Toxins e.g. CO

Infectious causes:
-meningitis
-encephalitis
-abscess

GCA

Hydrocephalus:
-obstructive
-acute

Metabolic disorders

Front 4

Examination for all initial presentation of headache

Back 4

Fundoscopy
Visual acuity
BP measurement
H&N: muscle tenderness, stiffness, ROM and crepitation

Front 5

Examination for positive red flags or other features suggesting secondary headache

Back 5

Neurological examination
-Qu of whether to perform, or in how much detail is problematic when there are no suspicious features & hx is more primary headache
-in -ve red flags, a brief neurological exam is a strong source of reassurance to pat's, although unlikely to be +ve

Front 6

A useful diagnostic tool for diagnosis of primary headache is

Back 6

Headache diary
-helps diagnosis of headaches
-identifies any predisposing or precipitating factors

Front 7

Tension-type headache

Back 7

-commonest form of primary headache

Character: tightness/pressure, band-like, non-disabling, non-progressive

Site: around the head, often radiate to/seems to arise from the neck, bilateral>>unilateral

Time: episodic, low frequency, short duration
BUT chronic tension=type can occur on more days than it is absent

Other features:
-photophobia or exacerbation with movement, but less prominent than in migraine

Association/Cause:
-stress
-functional/muscloskeletal problems of neck
--often these goes together
-H&N muscles are often tight & tender

Useful to Explain to patient:
-pain is related to muscle tensions in H&N, often made worse by stress
-this explores stressors w/o giving the idea - "it's all in the head"

Front 8

Migraine

Back 8

Character:
-unilateral>>bilateral
-and/or pulsating
-moderate/severe intensity

Features:
-preceding aura (1/3 pat's)
---5~60min before migraine onset, settle as headache begins
---commonly reported: flickering/jagged lines or blind spots
---other neurological symptoms: unilateral paraesthesia of hand/arm/face; and dysphasia can occur as aura
---cf. visual blur or spots before the eyes are non-specific and are not aura
-aggravated by routine physical activity (walking/stairs)
-avoidance of light & noise
-recurrent episodes
-free from symptoms between attacks
-FmHx of migraine

Time: several hrs ~ 3d: 4~72hrs

Association:
-GI symptoms -due vestibular hypersensitivity
-limitation of activity
-hypersensitivty: photophobia & phonophobia;
--other: allodynia, osmophobia, movement and pulsation of the artieres


Features common in migraine, not usually in headache
-aura
-unilateral headache
-hypersensitivity to light & noise (other: touch, smell)
-GI symptoms e.g. n&v
---Tension-type headache: mild nausea & anorexia can occur , but usually not major feature

Front 9

For visual or other transient focal neurological signs presenting for the first time in older people...

Back 9

question TIAs

Front 10

For prolonged aura in all age groups, esp. continuing after resolution of headache and aura which involve muscular weakness...

Back 10

indicate for specialist investigation to exclude other causes

Front 11

Cluster headache

Back 11

Character:
-unilateral
-severe & disabling

Time:
-occurs in bouts for 6~12 wks, or 1-2 times/yr
-during bouts, headache usually occurs daily at a similar time each day

Autonomic features: Eyes&Nose
-ipsilat conjunctival injection
-lacrimation
-ptosis
-rhiorrhea
-nasal congestion
---these may not always occur; but presence of 1 or 2 with a typical cluster headache pattern clinch the diagnosis

Features:
-young men
-male>>female 6:1

Front 12

Management of tension-type headache

Back 12

-general exercise
-stress reduction
-tx of any underlying MSK problems
-analgesia: episodic use of aspirin or ibuprofen
---cf. paracetamol less effective
-complementary tx: yoga, meditation, acupunctrure may help some people

Front 13

Risk in managing headache

Back 13

Physiotx & counselling may be unaffordable and associated stressors are often not amenable to change.
---This may lead to over-reliance on medication.

-Chronic use of medication for analgesia carries high risk of medication overuse headache.
---Hence, analgesia use should be limited to no more than 2d/week
---opiates e.g. codeine, carry high risk of medication overuse headache

Front 14

Strategy for pharmacological prophylactic management for tension-type headache

Back 14

NSAID (e.g. naproxen)
may break the cycle of continuing pain & cover the early management of predisposing & precipitating factors, e.g. MSK problems & stress.

if NSAID fails, prophylactic medication of choice is amitriptyline (TCA):
-start v. low (5-10mg at night), increase slowly every 3wks until symptoms are controlled, up to 75-150mg
---as in other chronic pain $'s, amitriptyline efficacy doesn't depend on its antidepressant activity
-Nortriptyline - if amitriptyline is not well tolerated, this has fewer side effects & may be an effective alternative

Front 15

Management of migraine

Back 15

Frequency, duration & severity can be reduced with many medicine including:
-Beta-blockers: propranolol, atenolol, metoprolol
-Ca ch blocker: amlodipine, verapamil
-Anti-convulsant: Na valproate, gabapentin
-TCA: amitriptyline, nortriptyline

TCA has been long established as an efficacious prophylactic
-but carries undesirable side effects including sedation, insomnia, or sexual dysfunction
-nortriptyline more tolerated than amitriptyline

NB: for migraine, it is important to take the medication before the onset of migraine