Chapter 1: Headache

Question 1

What are the sinister causes of headache?

Answer 1

VIVID

Vascular: subarachnoid haemorrhage (SAH), haematoma (subdural, extradural), cerebral venous sinus thrombosis, cerebellar infarct
Infection: meningitis, encephalitis
Vision threatening: temporal arteritis, acute glaucoma, cavernous sinus thrombosis, pituitary apoplexy, posterior leucoencephalopathy
Intracranial pressure (raised): space-occupying lesion (SOL; e.g. tumour, abscess, cyst), cerebral oedema (e.g. trauma, altitude), hydrocephalus, malignant hypertension, idiopathic intracranial hypertension
Dissection: carotid dissection

Question 2

When taking the headache Hx, what are the ‘red flags’?

Answer 2

• Decreased level of consciousness
• Sudden onset, worst headache ever
• Seizure or focal neurological deficit
• Reduced visual acuity
• Persistent headache, worse when lying down
• Progressive, persistent headache
• Constitutional symptoms: weight loss, night sweats, fever suggesting malignancy, chronic infection (e.g. TB) or chronic inflammation (e.g. temporal arteritis)
• Past medical history: malignancy -> mets to brain, HIV or other immunosuppression (transplant pts) resulting in higher risk of intracranial infection (toxoplasmosis, abscess, TB)

Question 3

Why are you worried about decreased level of consciousness?

Answer 3

SAH must be excluded!
Hx of head injury could suggest subdural haematoma (fluctuating consciousness) or extradural haematoma (altered consciousness following a lucid interval).
Meningitis and encephalitis can also affect consciousness

Question 4

Why are you worried about sudden onset, worst headache ever?

Answer 4

SAH must be excluded! Blood in the CSF irritates the meninges.
A very severe headache of almost instantaneous onset is characteristic of SAH
‘being hit on the back of the head with a bat.’

Question 5

Why are you worried about seizure or focal neurological deficit?

Answer 5

e.g. limb weakness, speech difficulties

Suggests intracranial pathology, but a migrainous aura can give neurological signs

Question 6

Why are you worried about reduced visual acuity?

Answer 6

-Temporal arteritis is more common in older pts
Also ask about jaw claudication (pain in jaw with chewing) and scalp tenderness
-Carotid or vertebral artery dissection
-Transient blindness (amaurosis fugax) is usually due to TIA, but rarely with a headache

Question 7

Why are you worried about persistent headache, worse when lying down?

Answer 7

With early morning nausea (lying down flat overnight) -> raised ICP
Can also occur when pt bend over
Headaches worse when standing up suggests reduced ICP and are common after a lumbar puncture (LP) - this is not sinister!

Question 8

Why are you worried about progressive, persistent headache?

Answer 8

Could be an expanding SOL (e.g. tumour, abscess, cyst, haematoma)

Question 9

What are you looking for in the basic observation of a pt with a headache?

Answer 9

• Altered consciousness, esp. GCS score
• BP and pulse for malignant hypertension
• Temperature: fever suggests intracranial infection

Question 10

What focal neurological signs are you looking for in the patients with a headache?

Answer 10

• Focal limb deficit
• 3rd nerve palsy
• 6th nerve palsy
• 12th nerve palsy
• Horner’s syndrome

Question 11

What is the sig. of focal limb deficit?

Answer 11

Increases the likelyhood of intracranial pathology

Question 12

What is the sig. of 3rd nerve palsy?

Answer 12

Ptosis (droopy eyelid) + mydriasis (dilated pupil) + eye deviation (down and out)
-SAH due to a ruptured aneurysm of the posterior communicating artery (PCOM)

Question 13

What is the sig. of 6th nerve palsy?

Answer 13

Convergent squint +- failure to abduct the eye laterally

• Nerve compression either by a mass or indirectly by increased ICP
• 6th nerve has the longest intracranial course

Question 14

What is the sig. of 12th nerve palsy?

Answer 14

Tongue deviation

-Carotid artery dissection

Question 15

What is the sig. of Horner’s syndrome?

Answer 15

Triad of partial ptosis + miosis (constricted pupil) + anhydrosis (dry skin around the orbit)
These result from interruption of the ipsilateral sympathetic pathway
-Suspect carotid artery dissection (ask about neck pain) or cavernous sinus lesion

Question 16

What can you look for in the eye inspection?

Answer 16

• Exopthlamos: cavernous sinus thrombosis
• Cloudy cornea, fixed dilated /oval pupil: acute glaucoma
• Optic disc appearance on fundoscopy: papiloedema, indicating raised ICP

Question 17

What does reduced visual acuity suggest in the pt with headache?
Scalp tenderness?
Stiff neck or photophobia?

Answer 17

• Suggests acute glaucoma or temporal arteritis
• Temporal arteritis
• Meningism due to infection or SAH

Question 18

Temporal arteritis is also known as?

Answer 18

Giant Cell Arteritis (GCA)

Question 19

Pathophysiology of temporal arteritis

Answer 19

-Typically appears in pts with over 50 yo
-Formation of immune, inflammatory granulomas in the tunica media of medium/large size arteries
-The inflammation or thrombosis or spasm may block the lumen of the affect arteries
-Mandibular branch of the external carotid artery -> jaw claudication
-Superficial temporal branch of the external carotid artery -> headache and scalp tenderness
-Posterior ciliary artery -> visual disturbance:
retina ischaemia -> blurring, visual field loss
optic motor muscles -> double vision (diplopia)

Question 20

Why concerns you about temporal arteritis?

Answer 20

With visual loss in one eye the other eye is at risk without prompt treatment

• Ophthalmological emergency
• Refer to on-call ophthalmologist ASAP!

Question 21

What are the first-line investigation for pt with temporal arteritis?

Answer 21

• ESR

- CRP

Question 22

What’s the first-line management for temporal arteritis?

Answer 22

-High-dose corticosteroids

*More time consuming Ix done after this.
e.g. temporal artery biopsy: to confirm dx
but even the biopsy may not show the granulomas

Question 23

What is the guideline for diagnosing temporal arteritis?

Answer 23

American College of Rheumatology guideline
3 of the following 5
-Age of onset of symptoms > 50
-New headache
-ESR > 50 mm/h
-Clinically abnormal temporal artery (tender or non-pulsatile)
-Biopsy of temporal artery showing mononuclear cell infiltration or granuloma

Question 24

What are the non-sinister causes of headache?

Answer 24

• Tension-type headache
• Migraine
• Sinusitis
• Medication overuse headache
• Temporomandibular joint (TMJ) dysfunction syndrome (TMJ syndrome)
• Trigeminal neuralgia
• Cluster headache

Question 25

What additional qs would you ask after the pain Hx? And why?

Answer 25

-Suffer from different types of headaches?
Pts with migraine are also vulnerable to medication overuse headache

-Any triggers?
Stress and fatigue for tension-type headache
Certain food (e.g. cheese, caffeine) for migraine
Alcohol for cluster headaches

-How disabling are the headaches?
Migraines are very disabling around a day
Cluster headaches are severely painful + disabling, often occurs at night

-‘Aura’ before the headache?
1/3 of migraine sufferers report auras as a feature of migraines

Question 26

Features of tension-type headaches

Answer 26

• Often bi-frontal pain
• Described as pressure or tightness around the head like a tightening band
• Lasts no more than few hours
• Not very disabling
• Stress and fatigue as triggers

Question 27

Features of migraine

Answer 27

• More common in women than men
• Unilateral
• 1/3 associated with aura (migraine with aura = classical migraine)
• Migraine without aura = common migraine
• Described as throbbing or pulsatile
• Increased sensitivity to light, sound, smell
• Could feel nauseous
• Lasts between 4 - 72 hours

*Some people suffer from aura without migraines
This is a differential for TIAs and epilepsy

Question 28

Features of sinusitis

Answer 28

• Usually comes with facial pain + coryzal symptoms
• Described as tight, like tension-type
• Exacerbated by movement
• Lasts several days, time course consistent with infection

Question 29

Features of medication overuse headache

Answer 29

• Often seen in pts using migraine meds and analgesics
• This headache resembles either migraine or tension-type
• Most pts will be taking a large quantities of analgesic meds
• Treatment: withdrawal from analgesic use
• Often results in a period of exacerbation before improvement

Question 30

Features of TMJ syndrome

Answer 30

• Common in age 20 - 40
• 4 times more prevalent in women
• Headache + dull ache in the muscles of mastication + radiation to jaw and/or ear
• A ‘click’ or grinding noise when they move their jaw

Question 31

Features of trigeminal neuralgia

Answer 31

• Rare
• Occurring more in women
• Age of onset 60 -70
• Unilateral stabbing sharp facial pain involving one or more divisions of the trigeminal nerve
• Pain only lasts seconds but several or even hundreds of episodes a day
• Triggered by eating, laughing, talking, touching the affected area
• Can develop a long-lasting background pain

Question 32

Features of cluster headache

Answer 32

• Predominantly affecting men
• Headaches occur in ‘clusters’ for about 6-12 weeks every 1-2 years
• Attacks tend to occur at exactly the same time every day or night
• The pain is focused over one eye
• Intense pain causes pts to wake up at night
• Pts even contemplates suicide
• Red, watery eye, rhinorrhoea, Horner’s syndrome suggested by the pt noticing droopy eyelid (ptosis) during attacks

Question 33

Treatment for migraine

Answer 33

• Triptans (5HT1-agonists): sumatriptan
• Analgesics: aspirin (NSAID), paracetamol
• Antiemetics: metoclopramide

Question 34

What physical examinations would you do? And why?

Answer 34

• Blood pressure: to exclude malignant hypertension
• Head and neck examination: muscle tenderness, stiffness, limited movement could occasionally mimic tension-type. If present, such findings may need treatment in order to relieve the headache
• Neurological examination: presence of focal neurological signs should ALERT you to intracranial pathology
• Fundoscopy: to exclude raised ICP