9.2 Headache

Question 1

what are secondary headaches?

Answer 1

headaches that occur because of another condition

Question 2

what are some of the differential diagnosis of acute headache?

Answer 2

Vascular
• Haemorrhage - Subarachnoid, Subdural, Extradural
• Thrombosis - Venous sinus thrombosis

Infective/inflammatory
- Meningitis, Encephalitis, Abscess, Temporal arteritis

Ophthalmic - Glaucoma

Situational (exacerbating factors)
- Cough, Exertion, coitus

Question 3

what are some of the differential diagnosis of chronic headaches?

Answer 3

• Migraine
• Cluster headaches
• Drug side effects - Analgesics, Caffeine (particularly withdrawal), Vasodilators
• Tension headaches
• Trigeminal neuralgia (difficult to classify but probably secondary due to a vascular anomaly)
• Raised intracranial pressure (e.g. tumours)
• Temporal / giant cell arteritis
• Systemic - Hypertension, Pre-eclampsia, Phaemochromocytoma – rare

Question 4

what taking a history for headaches, what should we be asking about?

Answer 4

Full history of presenting complaint using SOCRATES/SQITARS
What might be causing /triggering the headache?
PMH of headache?
Drug history - Analgesics, Side effects causing headache (e.g. vasodilators)
FH - E.g. migraine with aura has some heritability
social history - Stress, Diet (some foods can trigger migraine), Hydration

Question 5

what do we look for on examination of a patient with headaches?

Answer 5

Vital signs / obs - E.g. raised ICP can cause bradycardia / hypotension. Hypertension itself can cause headache
Neurological examination - Full peripheral and cranial nerve
Other relevant systems as guided by history (e.g. if associated feelings of faintness then examine CVS)

Question 6

what are the red flag features of headaches?

Answer 6

Systemic signs and disorders (e.g. of meningitis or
hypertension)
Neurological symptoms
Onset new or changed and patient >50 yo (can be suggestive of malignancy e.g. brain metastases)
Onset in thunderclap presentation (suggests vascular cause such as SAH)
Papilloedema (suggests raised ICP

Question 7

what are the symptoms associated with a headache that is being caused by a space occupying lesion?

Answer 7

Gradual onset 
Progressive 
Associated neurological features E.g. visual disturbance or focal signs Additional features of raised ICP
- Early morning headache
- Nausea and vomiting
- Worse on coughing and bending

Question 8

what population is most at risk of developing migraines?

Answer 8

females
under 30 (most have first attack when young)

Question 9

what are the clinical features of a migraine?

Answer 9

unilateral and often frontal
onset can be sudden or gradual
quality is throbbing or pulsing
moderate intensity
lasts between 4 to 72 hours , possibly cyclical character
photophobia and phonophobia - bright lights and loud noises are aggravating factors
relieving factors are sleep and medications such as triptans
may have aura and nausea and vomiting

Question 10

what is a migraine aura?

Answer 10

Migraine aura symptoms include temporary visual or other disturbances that usually strike before other migraine symptoms — such as intense head pain, nausea, and sensitivity to light and sound. Migraine aura usually occurs within an hour before head pain begins and generally lasts less than 60 minutes.30 M

Question 11

what are triggers for migraines?

Answer 11

Certain foods - Cheese, Chocolate
Lack of sleep
Stress

Question 12

what is the pathophysiology of a migraine?

Answer 12

Unclear, but a number of ideas have been put forward from vasodilatation to ‘spreading depression’ in the cerebral cortex
Often clear family history

Question 13

what is the epidemiology of tension headaches?

Answer 13

most common primary headache
more common in females
more common in younger patients
first onset in over 50s is unusual and should possibly be thinking of malignancy

Question 14

what are the clinical features of a tension headache?

Answer 14

bilateral frontal
can radiate to the neck
quality is squeezing, band like constriction
non-pulsatile
intensity is mild to moderate
worse at the end of the day as stress builds up
worsen when stressed, poor posture and lack of sleep
simple analgesics can help
sometimes some mild nausea

Question 15

what are chronic tension headaches?

Answer 15

tension headaches that occur more than 15 times a month

Question 16

what are episodic tension headaches?

Answer 16

tension headaches that occur less than 15 times a month

Question 17

what is the pathophysiology of tension headaches?

Answer 17

Maybe tension in muscles of head and neck (e.g. occipito-frontalis)
Usually no family history

Question 18

what is the epidemiology of medication overuse headache?

Answer 18

3rd most common type of headache
20% of headaches are due to medication overuse
30-40 years old
Females > males

Question 19

what are the clinical features of medication overuse headaches?

Answer 19

Present on at least 15 days per month
No improvement after OTC medication (e.g. paracetamol)
Using analgesics on at least 10 days per month
Taking analgesia for headache in the first place
Can get a variety of symptoms Often co-exists with depression and sleep disturbance

Question 20

what is the management of medication overuse headache?

Answer 20

Discontinuation of medication (following this will get worse before getting better)

Question 21

what is the pathophysiology of medication overuse headache?

Answer 21

related to upregulation of pain receptors in the meninges

Question 22

what is the epidemiology of cluster headaches?

Answer 22

1/1000 people
Males > females
Usual onset 20-40 years old

Question 23

what are the clinical features of cluster headaches?

Answer 23

around or behind one eye
no radiation
quality is sharp and penetration
intensity is severe and constant
rapid onset
attacks last 15mins to 3 hours and occur 1-2 times a day
usually occur at night
clusters of attacks last 2 to 12 weeks
remissions between clusters can last 3 months to 3 years
aggravating factors are head injury, alcohol and smoking
simple analgesics can help
associated with decreased sympathetic activity
- red, watery eye
- nasal congestion
- ptosis

Question 24

what are some of the triggers for cluster headaches?

Answer 24

Alcohol
Histamine (hayfever)
GTN
Heat
Exercise
Solvent inhalation
Lack of sleep

Question 25

what is the incidence of trigeminal neuralgia?

Answer 25

Peak incidence 50-60, increasing with age
25/100,000 UK population
Females > males

Question 26

what are the clinical features of trigeminal neuralgia?

Answer 26

unilateral, often over one eye
radiates to eyes, lips, nose and scalp (CN V)
quality is sharp and stabbing
electric shock feeling
intensity is severe
sudden onset
lasts a few seconds to 2 minutes
aggravating factors include a light touch to the face, eating, cold wind, vibration
can have numbness or tingling proceeding an attack

Question 27

what is the pathophysiology of trigeminal neuralgia?

Answer 27

Most cases caused by compression of trigeminal nerve by a vascular malformation
A few cases can be found to be caused by tumours, MS or skull base anomalies
More common in those with a history of chronic pain (central sensitisation?)

Question 28

what investigations are used in headaches?

Answer 28

Clearly, dependent on cause (e.g. if subarachnoid haemorrhage then investigate accordingly
Headache diary can be useful for chronic headaches
Imaging may be indicated if red flags
vital signs
neurological examination - cranial and peripheral nerve examination, Glasgow-come scale)

Question 29

what is the main treatment for migraines?

Answer 29

triptans

Question 30

what is the treatment of cluster headaches?

Answer 30

simple analgesia

high flow oxygen

Question 31

when do headaches need to be referred?

Answer 31

Suspicion of a tumour 
Suspicion of raised ICP 
Recent onset seizures 
Previous cancer  
Unexplained focal deficit 
Unexplained cognitive /personality changes

Question 32

what are the majority of headaches caused by?

Answer 32

majority are benign due to primary headache disorder - usually tension headaches.

Question 33

give some examples of primary headache disorders

Answer 33

tension headache
migraine
cluster headache

Question 34

give some examples of secondary headaches due to another condition?

Answer 34

trigeminal neuralgia 
space occupying lesion
tumour 
haemorrhage 
meningitis 
medication overuse 
medication related
hypertension
pre-eclampsia

Question 35

what headaches might be sight threatening?

Answer 35

giant cell (temporal) arteritis 
acute glaucoma

Question 36

describe the headache caused due to a space occupying lesion?

Answer 36

gradual, progressive
mild in severity 
worse in the mornings
early-morning on waking 
worsened with posture, couch, valsalva manoeuvre, straining 
simple analgesics may be effective in early stage 
focal neurological signs
nausea and vomiting 
visual symptoms

Question 37

what is temporal arteritis?

Answer 37

vasculitis of large and medium sized arteries of the head, often branched of the external carotid artery.

Question 38

what is the epidemiology of temporal arteritis?

Answer 38

more common in females

>50 years, most common in over 75yrs

Question 39

when should temporal arteritis be considered?

Answer 39

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

Question 40

what artery is commonly involved in temporal arteritis?

Answer 40

superficial temporal

Question 41

why is temporal arteritis a medical emergency?

Answer 41

Risk of irreversible loss of vision due to involvement of blood vessels supplying CN II (optic)