12) Headaches

Question 1

What is a Primary Headache ? Give examples

Answer 1

Due to the headache not another cause e.g. Migraine, Tension, Cluster

Question 2

What is a Secondary Headache ?

Give Examples

Answer 2

Headache due to another condition e.g. Meningitis, Sinusitis, Medication Overuse

Question 3

List some differentials for an Acute onset of an Headache

Answer 3

Vascular: SAH, Intracranial Bleed, Sinus Venous Thrombosis

Infection/Inflammation: Meningitis, Encephalitis, Abscess

Ophthalmic: Acute Glaucoma

Situational: Cough, Exertion, Coitus

Question 4

List some differentials for an Chronic onset of an Headache

Answer 4

> Migraine 
> Cluster Headache 
> Drugs 
> Tension Headaches 
> Neuralgia 
> ICP 
> Giant Cell Arteritis 
> Systemic : HTN

Question 5

What Red Flags symptoms of headache ?

Answer 5

S- Systemic Signs and Disorders
N- Neurological Symptoms
O- Onset New or changes > 50 Years Old 
O- Onset in Thunderclap presentation 
P- Papilledema, Pulsatile Tinnitus, Positional Provocation, Precipitated by exercise

Question 6

Outline the presentations of a Tension Type Headache

SQITARS

Answer 6

S => Bilateral Frontal and Ocipital Regions
Q => Squeezing / Tight Band Like radiating to neck
I => Mild Moderate Intensity
T => Worse at the end of the day
A => Stress, Poor Posture, Lack of Sleep
R => Simple Analgesics
S => Mild Nausea

NO FHx
F > M
Young tenners and Young adults
First onset > 50

Question 7

Outline the presentation of a Migraine

Answer 7

S => Unilateral often frontal
Q => Sudden / Gradual Onset, Throbbing and Pulsating
I => Moderate, often disabling
T => 4 - 72 hours Prolonged
A => Foods, Menstrual Cycle, Stress, Lack of Sleep
R => Better Sleep
S => Aura N+V

FHx 
Tx - Triptans if bad 
F > M 
Common 
Presents in early to mid life before 30

Question 8

Outline the Presentation of Medication Overuse Headache

Answer 8

Defined as headache present at least 15 days / month
> Regular Analgesics 10 / month for 3 months
> OTC does not help
> Resolves completely after 3 months following discontinuation
> Often co exists with depression / Sleep disturbance
> F > M

Question 9

Outline the presentation of a Cluster Headache

Answer 9

S => Around / Behind the eye 
Q => Sharp Penetrating 
I => Very severe and constant intensity 
T => Rapid Onset, lasts 15 - 3 hours 
A => Head Injury, Alcohol, Smoking, GTN, Heat, Exercise, Lack of sleep
R => Simple analgesics ineffective 
S => Red, Watery Eye, Nasal Congestion, 

Ptosis on affecte side
Tx - High flow oxygen
20 - 40 YOs

Question 10

Outline the presentation of Trigeminal Neuralgia

Answer 10

Compression of CN V due to loop of a blood vessel

S => Unilateral often over the eye
Q => Sharp Stabbing Pain
I => Severe
T => Sudden Onset last few seconds 2 minutes
A => Light touch to Face, Cold Wind, Vibrations
S => Radiates to CN V distribution, Tingling, Numbness

Peak incidence 50 - 60
F > M

Question 11

What is Giant Cell Arteritis

Answer 11

Vasculitis Involving small and medium sized arteries of head
F > M
Typically Superficial Temporal Artery

Question 12

When is Giant Cell Arteritis considered ?

Answer 12

> 50 YOs with abrupt onset of headache + Visual Disturbance / Jaw Claudication

Question 13

What is at risk with GCA

Answer 13

Irreversible vision loss due to ischaemia of CN I

Question 14

Outline the presentation of Space Occupying Lesion

Answer 14

S => Top of head
Q => Dull variable
I => Mild in severity, worse in the mornings, progressive in severity
T => Early morning
A => Worsened Posture (Leaning Forward), Cough, Valsalva Manoeuvre
R => Simple analgesics work in early stages
S => N+v, Neurological, Visual Symptoms

Signs => Papilloedema , Neurological Signs