14 Headaches

Question 1

How do we categorise headaches? (ie what are the 2 categories)

Answer 1

1. Primary headache disorder
2. Secondary to another condition

Question 2

Give some different types of primary headache disorders. List in order of the most common. (3)

Answer 2

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

Question 3

Give some secondary causes of a headache.

Answer 3

Life threatening:

• Space occupying lesion
• Infections
• Haemorrhage

Sight threatening:

• Temporal giant cell arteritis
• Acute (closed angle) glaucoma

Systemic:

• Hypertension
• Pre-eclampsia

Other:

• Medication related
• Medication overuse

Question 4

What should we consider when taking the history of a patient who presents with a headache?

Answer 4

Question 5

What red flag symptoms should we be checking for if a patient presents with a headache? (SNOOP)

Answer 5

Question 6

In what age group is a tension type headache (first onset) most common?

Answer 6

F>M

20-39yrs

(First onset >50yrs= unusual)

Question 7

A tension-type headache is thought ot do due to tension in muscles of the head and neck. How does a tension type headache present in terms of SQUITARS?

Answer 7

Question 8

When do migraines usually present in patients (what age)? How common are migraines in the population?

Answer 8

F>M

Presents: early to mid-life - most have first attack by 30yrs

Prevalence: common = 15 in every 100

Question 9

How do migraines present in terms of SQITARS?

Answer 9

Question 10

Who is susceptible to medication over use headaches? How should you approach prescribing analgesics to a patient with a headache?

Answer 10

Patients susceptible= patients with pre-existing headache disorder (eg tension-type/migraines) who is taking medication for it

Medication over-use headache present >15days/month

MANAGEMENT:

• Discontinue medication
• Headache worsens before it improves - typically resolve in 2 months
• When prescribing medication for headaches- tell patients they should not be using it on more than 2days in a week

Question 11

Cluster headaches are more common in men and usually present at around 30-40 yrs. How do they present in terms of SQUITARS?

Answer 11

Question 12

Headaches caused by space occupying lesions rarely happen in the absence of suspicious historical or examination findings. How do headaches due to space occupying lesions present in terms of SQITARS?

Answer 12

Question 13

Trigeminal neuralgia affects more women than men and usually presents from the age of 50-60yrs. How is it caused and how does it present (using SQITARS)?

Answer 13

Cause:

• Most: compression of CN V due to loop of blood vessel
• 5% due to tumours/skull base abnormlaities

Question 14

Explain why temporal arteritis carries a risk of causing loss of vision.

Answer 14

Temporal arteritis= vasculitis involving superficial temporal artery

–> can affect CN II

(Affects >50yrs - most common in >70yrs)

(Consider in any >50yr old with abrupt onset of headache + visual disturbance or jaw claudication)

Question 15

How should temporal arteritis be treated?

Answer 15

With steroids

Don’t delay treatment

Question 16

What are the symptoms of temporal arteritis?

Answer 16

Headache

Jaw claudication (pain on chewing)

Loss of vision

Scalp tenderness

Abnormalities of temporal artery (pain, nodules, absence of pulse)

Question 17

What is the most likely diagnosis?

Answer 17

Tension headache

Question 18

What is the most likely diagnosis?

Answer 18

Space occupying lesion

Question 19

Useful diagram showing site of pain for 4 types of headaches:

Answer 19