Headache

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  • Created by: z
  • Created on: 15-03-16 19:19

Migraine

  • aura phase (evolves over 30-60mins so can diff w/ TIA)
    • visual- flahing lights, zigzag lines, fortification spectra, paracentral scotoma
    • hemianopia
    • sensory- paraesthesiae, numbness
    • hemiparesis
    • ophthmaloparesis
  • headache phase
    • severe, throbbing, unilateral, photo/phonophobia, N&V, worse w/ activity
  • NB common to have no aura, can be bilateral, can last 2-5 days
  • Mx
    • avoid trigger factors
      • dietary: cheese, chocolate, alcohol, coffee, dieting, dehydration
      • non-dietary: stress, menstruation, OCP, exercise, relaxation, travelling, altered sleep 
    • acute Tx: analgesic (not codeine), anti-emetic, triptan if severe
    • prophylaxis: B antagonist (propanolol) or AED (topiramate) or amytriptyline or acupuncture, botox for chronic migraine
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Tension type headache

  • band around head
    • "pressure", "going to explode"
  • may have other features of anxiety
    • acute hyperventilation (panic attacks)
    • chronic hyperventilation 
      • distal and perioral paresthesiae, dizzy spells, palipitations
  • Mx
    • reassurance
    • lifestyle changes
    • analgesics (aspirin, paracetamol, ibuprofen, never codeine)
    • prophylaxis (amitryptaline, ?SSRIs)
    • possible psych referral
  • NB medication overuse headache
    • any analgesic, esp codeine, also ergotamine, triptans
    • no set dose triggers it
    • Dx confirmed 3 months post-w/drawal
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Cluster headache

  • one of the trigeminal autonomic cephalgias (TACs)
  • clinical features:
    • unilateral
    • several occular/frontal pain
    • eye injected/watering
    • unilateral nasal discharge
    • agitation
    • often at night
    • 30-60 mins, may have multiple attacks
    • occur in clusters
  • Ix
    • MRI- can be due to pituitary lesions (e.g. pituitary adenoma)
  • Mx
    • acute: sumatriptan, oxygen
    • prophylaxis: verapamil, methysergide, lithium, prednisolone
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Temporal arteritis

  • clinicla features
    • headache
    • scalp tenderness
    • jaw claudication (rare)
    • fever, weight loss, anaemia
    • raised ALP
    • polymyalgia rheumatica
  • Ix
    • ESR
    • temporal artery biopsy
  • Cx
    • TIA, stroke, blindness
  • Tx
    • prednisolone 60mg daily for 1 month then reduce (by 5mg every 2 weeks until 10mg then by 1mg per month to 5mg then by 1mg every 2 months)
    • continues for 2-3 years (even though sympt pos only for days)
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Benign/idiopathic intracranial hypertension

  • clinical features
    • headache
    • visual disturbances
    • tinnitus
    • blindness
    • papilloedema
    • CNVI palsies
  • precipitants: obesity, OCP, pregnancy, steroid therapy, tetracyclines, nitrofuraantoin
  • Ix
    • CT/MRI - cerebral venous sinus thrombosis
    • LP
  • Mx
    • monitor visual fields
    • remover precipitant- weight loss
    • acetazolamide or other diuretic
    • lumpo-peritoneal shunt
    • optic nerve sheath fenestration
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When GPs should refer

  • ?tumour
    • focal symptoms, headache wakes pt, epilepsy
    • physical signs e.g. hemiparesis
  • ?SAH
  • ?temporal arteritis
  • ?cluster headache or other TAC
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