9. Headache

Question 1

what are the two types of presenting complaint of headaches in broad catergories?

Answer 1

primary - due to a headache disorder - usually non life threatening
secondary - due to another condition - some are life or sight threatening

Question 2

what are acute, emergency causes of headache?

Answer 2

haemorrhage, thombosis, meningitis, encephalitis, abscess, temporal arteritis, glaucoma,

Question 3

what are acute possible causes of headache?

Answer 3

cough, exertion, coitus

Question 4

what are the chronic causes of headache non emergency?

Answer 4

migraine, cluster headaches, tension headaches, drug side effects (analgesics, caffeine, vasodilators), trigeminal neuralgia

Question 5

what are the chronic causes of an emergency headache?

Answer 5

raised ICP (tumours), temporal/giant cell arteritis, hypertension, pre eclampsia, phaemochromocytoma

Question 6

how do you take a history of someone with a headache?

Answer 6

full history of presenting complaint including SQITARS
past medical history
drug history - analgesics or side effects
family history - migraine with aura
social - stress, diet, hydration

Question 7

what vital signs would be relevant in someone experiencing a headache?

Answer 7

vital signs/obvs - raised ICP can cause bradycardia/hypotension
neurological exam - full peripheral and cranial
if faintness - CVS

Question 8

what are the red flag features of headaches?

Answer 8

systemic signs and disorders 
neurological symptoms
onset new or changed and patient over 50
onset in thunderclap presentation
papilloedema

Question 9

what are the features of a headache caused by a space occupying lesion?

Answer 9

gradual onset
progressive
neurological feature - visual disturbances
early morning headache, nausea and vomit, worse on cough/bend indicating raised ICP

Question 10

who is most likely to be affected by a migraine?

Answer 10

2x more females
most have attack before they are 30
severity decreases as age increases

Question 11

what are the features of a headache caused by a migraine?

Answer 11

unilateral (often frontal), onset sudden or gradual, throbbing/pulsating, moderate intensity, lasts between 4 and 72 hours with cyclical character, photophobia/phonophobia, sleep helps, medications such as triptans help, may have aura, nausea and vomit
can be triggered by foods such as cheese or chocolate, or lack of sleep or stress

Question 12

what is the possible pathophysiology of a migraine?

Answer 12

unknown - maybe due to vasodilation or ‘spreading depression’ in cortex but usually with FH

Question 13

who is most likely to be affected by a tension headache?

Answer 13

females
young
if over 50 - think malignancy

Question 14

what are the features of a tension headache?

Answer 14

bilateral frontal
can radiate to neck
squeezing/band like restriction, non pulsatile
mild-moderate, worse at end of day, chornic if more than 15x/month if less than episodic
aggrevated by stress, poor posture, lack of sleep
give analgesics, maybe sx of mild nausea

Question 15

what is the pathophysiology of tension headaches?

Answer 15

tension in muscles of head and neck such as occipitofrontalis
no family history

Question 16

who is most likely to be affected in medication overuse headache?

Answer 16

3rd most common type
females
30/40 year olds

Question 17

what are the clinical features of medication overuse headaches?

Answer 17

present on at least 15 days per month
no improvement with over the counter medication
patients using analgesics on at least 10 days per month who usually take it for a headache in the first place
variety of symptoms
can co exist with depression and sleep disturbance

Question 18

what is the management of medication overuse headaches?

Answer 18

discontinue medication

Question 19

what is the pathophysiology of a medication overuse headache?

Answer 19

upregulation of pain receptors in meninges

Question 20

who is most likely to be affected in a cluster headache?

Answer 20

males

20-40 yr olds

Question 21

what are the clinical features of cluster headaches?

Answer 21

around/behind one eye
no radiation
sharp and penetrating
very severe and constant intensity
rapid onset
attacks last 15 min to 3 hours and occur 1/2x/day, usually at night
clusters of attacks - 2-12 weeks and remision between can last 3 months to 3 years
aggrevated by head injury, alcohol, smoking
relieved by simple analgesics
red watery eye, nasal congestion, ptosis (due to decreased sympathetic activity)
can be triggered by alcohol, hisatmine, GTN, heat, exercise, solvent inhalation, lack of sleep

Question 22

who is most likely to be affected by trigeminal neuralgia?

Answer 22

50/60, increasing with age

females more

Question 23

what are the features of trigeminal neuralgia?

Answer 23

unilateral, radiates to eyes, lips, nose and scalp
sharp and stabbing, electric shock feeling
severe, sudden onset, lasts a few secs/mins
light touch to face, eating, cold wind, vibrations
difficulty to alleviate
can have numbness and tingling before attack

Question 24

what is the pathophysiology of trigeminal neuralgia?

Answer 24

compression of trigeminal nerve by vascular formation or by tumpurs, MS or skull base anomalies
more common in those with a history of chronic pain

Question 25

how can one investigate headaches?

Answer 25

CT
headache diary
other imaging

Question 26

how can cluster headaches be treated?

Answer 26

high flow oxygen