3+ Primary Headaches

Question 1

What are some causes of headaches?

Answer 1

1. Traction or dilation of intracranial or extracranial arteries
2. Traction or distension of large extra-cranial veins, dural venous sinuses
3. Compression, traction or inflammation of cranial and spinal nerves
4. Spasm and trauma to cranial and cervical muscles
5. Meningeal irritation and raised ICP
6. Disturbance of intra-cerebral serotonergic projections

Question 2

What are primary headaches vs secondary headaches?

Answer 2

Primary:
- Symptom based
- No organic causes

Secondary:
- Aetiology based

Question 3

What are the primary headaches?

Answer 3

1. Migraine:
   - Migraine with aura
   - Migraine without aura
   - Hemiplegic migraine
   - Basilar migraine
2. Tension type headache
3. Trigeminal autonomic cephalgias TACs:
   - Cluster headache `

Question 4

What are some secondary causes of headache?

Answer 4

Head/neck trauma
Cervical or cranial vascular disorders
Substance misuse or withdrawal
Psychiatric disorder related
Arterial HTN related

Question 5

What does a headache worse with standing up and relieved by lying down indicate?

Answer 5

Intracranial hypotension

Question 6

What does a headache worse with coughing, straining or valsalva indicate?

Answer 6

Raised ICP

Question 7

What associated symptoms should you ask about?

Answer 7

N/V
Photophobia
Phonophobia
Fever
Blurred vision/loss of vision
Visual scintillation
Double vision

Question 8

What are the headache red flags?

Answer 8

S2NOOP5/SNOOP

• Systemic symptoms: fever, weight loss
• Secondary risk factors: cancer, HIV, immunocompromised
• Neurological symptoms
• Onset: new onset, worst ever, abrupt
• Older patient: new over 50 (GCA)
• Previous headache different
• Position component (e.g. increases when upright)
• Pulsatile tinnitus (diplopia, transient visual changes)
• Provocative factors (coughing, exercise, sex)
• Pregnancy

Question 9

When would you do neuro-imaging in a headache presentation?

Answer 9

• Thunderclap or sudden, severe headaches
• New onset of headache
• New pattern of headache
• Headache >50
• Focal signs or symptoms occurring with the headache
• Headache worse with valsalva
• Postural headache
• Headaches associated with fever, vomiting, meningism
• Headache associated with another systemic disease (HIC, vasculitis)