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15 Cards in this Set

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Frontal lobe tumors
-slow growing
-non-specific headache
-subtle personality changes, resulting in tx for depression
-->-non-response to tx prompt further investigation
Red Flags in Headache presentation
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)
Causes of Secondary Headache
-presence of red flags prompts consideration of a wide range of dx's. List some
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
Examination for all initial presentation of headache
Fundoscopy
Visual acuity
BP measurement
H&N: muscle tenderness, stiffness, ROM and crepitation
Examination for positive red flags or other features suggesting secondary headache
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
A useful diagnostic tool for diagnosis of primary headache is
Headache diary
-helps diagnosis of headaches
-identifies any predisposing or precipitating factors
Tension-type headache
-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"
Migraine
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
For visual or other transient focal neurological signs presenting for the first time in older people...
question TIAs
For prolonged aura in all age groups, esp. continuing after resolution of headache and aura which involve muscular weakness...
indicate for specialist investigation to exclude other causes
Cluster headache
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
Management of tension-type headache
-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
Risk in managing headache
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
Strategy for pharmacological prophylactic management for tension-type headache
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
Management of migraine
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