29-09-23 - Headache

Question 1

Learning outcomes

Answer 1

• Recognise common forms of headache, including tension headache and migraine
• Recognise the features of more serious causes of headache
• Know how to treat common headaches

Question 2

Describe the pattern for the following headaches (in picture):
1) Migraine
2) Tension
3) Sinus
4) TMJ
5) Cluster
6) Neck

Answer 2

Question 3

Epidemiology of headaches:

Answer 3

• Epidemiology of headaches:
• In top 10 of primary care symptoms (>4% GP consultations)
• Accounts for 30% of neurology referrals
• Estimated to cost >£6bn/year in UK (service costs, loss of employment)
• 70% of headache in primary care not given a diagnostic label.
• 40% of population have tension headache at any time

Question 4

What are 5 common types of headaches?

Answer 4

• 5 common types of headaches:
  1) Migraine
  2) Muscular tension
  3) Analgesia overuse
  4) Systemic illness
  5) Cervicogenic (neck)

Question 5

What are 6 different types of serious headaches?

Answer 5

• 6 different types of serious headaches:
  1) Subarachnoid haemorrhage
  2) Raised Intercranial pressure
  3) Infection – meningitis
  4) Temporal Arteritis
  5) Cerebral Venus sinus thrombosis
  6) Low intercranial pressure

Question 6

What are 11 pieces of information we need regarding headache history?

Answer 6

• 11 pieces of information we need regarding headache history:
  1) How long?
  2) Position on head?
  3) Character (not intensity)? (Pressure?, dislike of light/noise?)
  4) Frequency? When in the day?
  5) Diurnal variation? (Worse in the morning or as day goes on?)
  6) Change in character?
  7) Nausea/vomiting?
  8) Postural? (worse lying down?)
  9) Other neurological symptoms? (double vision for example?)
  10) Previous Medical History, Family History (eg Inflammatory Bowl Syndrome linked to venous sinus thrombosis)
  11) Medicines (how often – more than 15 days/month – analgesic abuse headache)

Question 7

What are 5 symptoms/signs of a tenson headache?

What are 6 parts of the treatment of tension headaches?

Answer 7

• 5 symptoms/signs of a tenson headache:
  1) Weeks, months, years
  2) “tightness”, “pressure” round the head
  3) Constant, or worse towards evening
  4) Often there is frequently used analgesia
  5) Rarely presents with nausea

Question 8

What are 6 parts of the treatment of tension headaches?

Answer 8

• 6 parts of the treatment of tension headaches:
  1) Reassurance around severity and duration
  2) Won’t go away overnight
  3) Explain the muscles around the head
  4) Use relaxation exercises
  5) Reduce analgesia
  6) Low dose amitriptyline (10-20mg) – normally an antidepressant at 150+ mg

Question 9

What are 7 symptoms/signs of a migraine?

Answer 9

• 7 symptoms/signs of a migraine:

1) Classically on one side at a time

2) Most headache with nausea will be migraine

3) Unilateral or bilateral, usually hours-days

4) Photophobia, phonophobia, gut symptoms
* Photophobia is an abnormal sensitivity to light, especially of the eyes
* Phonophobia is persistent, abnormal, and unwarranted fear of sound
* IBS may be a form of gut migraine - responds to amitriptyline)

5) Pulsating, sharp Character

6) More common in women, especially mid-cycle, and newly at menopause (oestrogen)

7) Can be +/- Aura
* Can be visual, weakness or sensory and spreads over minutes.
* Can look similar to hemiplegia from stroke.
* Can have black and white Scotoma (typically associated with migraine) – NB coloured scotoma = danger sign as is associated with epilepsy (in picture)

Question 10

What are the causes of migraines?

What are potential triggers for migraines?

How can migraines potentially start?

What is an important aspect of managing migraines?

Answer 10

• Mechanisms behind migraines unclear - vascular and neural theories
• Triggers for migraines by include: foods, alcohol, beginning or end of working week
• Migraines may be started by physical activity or a bang on the head, with there often being a family history
• An important aspect of managing migraines is keeping a diary to help decide pattern & treatments

Question 11

What is the treatment of migraines related to?

What are 3 potential treatments in the management of acute migraines?

Which is considered the best?

Answer 11

• The treatment of migraines is related to the frequency of the migraines
• 3 potential treatments in the management of acute migraines:

1) Aspirin, paracetamol

2) Anti-nausea (prochlorperazine, metoclopramide)

3) Triptans – agonists at 5HT-1b and 5HT-1d receptors (best treatments)
* Also related family of drugs Sumatriptan, rizatriptan, naratriptan, zolmitriptan etc
* Note - may need a variety of delivery methods to combat nausea and vomiting eg melts, injection or nasal spray
* Available without prescription but expensive

Question 12

When should prophylactic (preventative) treatments be used for migraines?

Why should prophylactic medications be rotated? What are the 9 prophylactic treatments/medications for migraines?

Answer 12

• Prophylactic (preventative) treatments should be used for migraines if there are events more than 2 times a month
• Prophylactic medications schedule used should be rotated, as eventually the dugs will stop working
• 9 prophylactic treatments/medications for migraines:

1) Beta blockers (e.g. propranolol) commonest use - unless asthmatic

2) Low dose amitriptyline

3) Pizotifen (5HT-2a and 2c antagonist, antihistamine, anticholinergic)

4) Topiramate – anti epileptic also

5) Sodium valproate anti epileptic also

6) Candesartan: angiotensin receptor action - reduced BP

7) Flunarazine: Ca Channel Blocker – reduced BP

8) Lisinopril: ACE inhibitor – reduced BP

9) Methysergide (Ergot derivative-with a retroperitoneal fibrosis side effect)

Question 13

What are 4 other migraines treatments?

When should women not use the combine Oral contraceptive pill (OCP)?

Answer 13

• 4 other migraines treatments:

1) Botulinum toxin injection
* Usually, every 90 days
* Approved in UK

2) Rimegepant
* An oral calcitonin gene-related peptide (CGRP) receptor blocker
* Works by preventing vasodilatation must have tried 3 other drugs

3) Anti-CGRP monoclonal antibodies
* Erenumab,
* Licensed in 2018 for >4 migraines/month UK, (s/c monthly injection)
* Must have tried at least 3 other prophylactics.

4) Acupuncture

• Women with migraine and aura should not use combined OCP (Oral contraceptive pill) due to stroke risk

Question 14

How common is Trigeminal Autonomic Cephalagia (TAC)?

What are the 2 forms of TAC?

How do they each present?

Which sexes are they most common in?

How can we distinguish between each?

Answer 14

• Trigeminal Autonomic Cephalagia (TAC) is a rare condition
• 2 forms of TAC:

1) Cluster headache (most common form)
* Unilateral – often round the eye
* Striking circadian rhythm, same time of day,
* Clustering in periods usually of a few weeks then goes – until the next time.
* – Presents as:
* Recurrent pain in trigeminal distribution with
* Autonomic features (eye watering, nasal congestion, redness
in the eye)
* More common in males (3:1)

2) Paroxysmal hemicrania
* More common in women
* Shorter, more frequent attacks,
* Responds to indomethacin (non-steroidal anti-inflammatory) so is a differentiator between cluster headache and paroxysmal hemicrania

• Cluster headaches don’t response to indomethacin (non-steroidal anti-inflammatory), while Paroxysmal hemicrania does, which can be used as a differentiator

Question 15

What are 4 treatments for Trigeminal Autonomic Cephalagia (TACs)?

Answer 15

• 4 treatments for Trigeminal Autonomic Cephalagia (TACs):

1) Triptans

2) Oxygen – High dose

3) High dose verapamil (up to 960mg/day)
* Calcium channel blocker at very high doses

4) Indomethacin for Paroxysmal Hemicrania

Question 16

What are 2 presentations of medication overuse headaches?

In what 2 scenarios are medication overuse headaches common?

Is abrupt or gradual cessation from medication better for patients?

Answer 16

• 2 presentations of medication overuse headaches:
  1) Present for >15 days/month
  2) Worsened while analgesia has been used.
• 2 scenarios are medication overuse headaches common:
  1) Patient using simple analgesia >15days/month, or
  2) >10 days for other acute e.g. triptans
• Uncertain whether abrupt cessation of gradual stopping is better for treatment. – patient will suffer headache during withdrawal

Question 17

How do thunderclap headaches present?

What do we need to distinguish from thunderclap headaches?

What 2 urgent investigations are required to distinguish sub-arachnoid haemorrhages from thunderclap headaches?

What is a potential cause of thunderclap headaches?

Answer 17

• Thunderclap headaches present Instantly or rapidly (<60 seconds) with very severe pain
• We need to distinguish thunderclap headaches from Sub-Arachnoid Haemorrhage, ie stroke commonly from leaking aneurism – as they have a similar presentation
• 2 urgent investigations are required to distinguish sub-arachnoid haemorrhages from thunderclap headaches:

1) CT head looking for blood

2) Lumbar Puncture after 12 hours, look for blood or bilirubin and oxyhaemaglobin in CSF

• Thunderclap headaches can be exertional e.g coital cephalgia - a headache related to sexual activity usually at or near orgasm
• Coital cephalgia is a type of migraine by vasospasm - quickly reversible and comes back is reassuring

Question 18

What are 2 forms of early morning headaches?

What are potential causes?

How can they be treated?

Answer 18

• 2 forms of early morning headaches:

1) Cervicogenic (arising from the neck)
* Can be caused by:
1) Poor posture in bed, pillow bends neck - Anatomical position is best.
2) Over exertion
3) Spinal degeneration – spondylosis

• Usually muscular if not presenting with neurological compromise (reflex loss, weakness etc)
• Break pain/spasm cycle with anti-inflammatory or pain treatment

2) Sleep apnoea with CO2 retention
* Can present in obese patients
* History of snoring – common with alcohol
* Tested by monitoring chest movements
* Treated with positive (+ve) pressure Oxygen – more oxygen per intake of breath so more oxygen in their blood

Question 19

What are 6 different types of serious headaches?

Answer 19

• 6 different types of serious headaches:
  1) Subarachnoid haemorrhage
  2) Raised Intercranial pressure
  3) Infection – meningitis
  4) Temporal Arteritis
  5) Cerebral Venus sinus thrombosis
  6) Low intercranial pressure

Question 20

What are 3 parts of the presentation of increased intracranial pressure (ICP)?

How often are these symptoms dismissed?

What are neurological features of ICP?

What is the treatment of ICP?

Answer 20

• 3 parts of the presentation of increased intracranial pressure (ICP):
  1) Headache - usually mild
  2) Diurnal variation – worse in morning, often gone by lunchtime
  3) Often mild nausea
• These mild symptoms are often dismissed
• Neurological features of ICP - Look for bilateral papilloedema – tumours rare to present as headache only, could be abscess or CSF blockage
• ICP requires a scan urgently and referral

Question 21

Infections – meningitis. What are 5 parts of the presentation of meningitis?

What are the treatment options for meningitis?

Answer 21

• 5 parts of the presentation of meningitis:
  1) Fever
  2) Photophobia
  3) Neck stiffness
  4) Altered consciousness (encephalitis)
  5) Petechial rash from meningococcal meningitis
• Can lead to purpuric areas and on to amputation
• Most meningitis is viral, but cannot distinguish clinically, so treat with Ceftriaxone/cefotaxime or benzyl penicillin

Question 22

How rare is temporal arteritis?

What age group does it occur in?

What are 3 parts of the presentation of temporal arteritis?

What are 3 tests for temporal arteritis?

Describe the management of temporal arteritis?

Why can this be potentially problematic?

Answer 22

• Temporal arteritis’ is a relatively rare condition
• It never occurs below 50 years of age
• 3 parts of the presentation of temporal arteritis:

1) Jaw claudication (jaw pain on chewing)

2) Maybe features of polymyalgia (tired, stiff in morning), then temporal headache.

3) Can cause blindness through embolism into the eye if not treated

• 3 tests for temporal arteritis:

1) Palpate temporal arteries for tenderness.
* If you feel pulsations and its not tender, - unlikely to be temporal arteritis but still

2) Check for Raised Erythrocyte Sedimentation Rate (ESR>50)

3) Can use ultrasound or temporal artery biopsy (sample error) for inflammation

• Management of temporal arteritis:
• Use high dose steroids early (osteoporosis, hypertension, muscle wasting, truncal obesity) – problems getting off them

Question 23

What age/sex does Cerebral venous sinus thrombosis occur in?

What causes it?

What are 3 parts of the presentation of Cerebral venous sinus thrombosis?

How can Cerebral venous sinus thrombosis present on an MRI?

Answer 23

• Cerebral venous sinus thrombosis often presents in females on the OCP
• This condition is caused by either the sinus vein (main drainage of blood tissue from the brain) or cerebral veins that drain into the sinus vein becoming occluded
• 3 parts of the presentation of Cerebral venous sinus thrombosis:

1) Headache, often severe

2) Raised intercranial pressure due to build up of haem and blood

3) Often with papilloedema and seizures

• Papilledema refers to the swelling of both optic discs in your eyes due to increased intracranial pressure (intracranial hypertension)
• On an MRI, Cerebral venous sinus thrombosis can appear with an empty delta sign and haem seen bilaterally

Question 24

When can low intracranial pressure occur (ICP)?

Why is this?

How can this be reduced?

What are 3 parts of the presentation of Low ICP?

How is Low ICP treated?

Answer 24

• Low intracranial pressure (Low ICP) can occur following a venous puncture (not immediate)
• This is thought to be due to CSF leakage through hole left in dura
• Low ICP from lumbar puncture can be reduced by using atraumatic needles or angle of needle bevel
• 3 parts of the presentation of Low ICP:
  1) Headache on standing, eased with lying
  2) Can develop into fits as the brain is supported less
  3) If left can cause death.
• Low ICP is treated using a blood patch for post-LP headache – stops leaking