Chronic daily headache

Question 1

A 36 year old woman has been experiencing almost daily headaches for the past three months. She is otherwise asymptomatic. How would you assess and manage her?

Answer 1

Impression
patient presents with chronic daily headache (>15 days per month for >4 hrs). Could be due to a number of aetiologies. In particular, need to rule out red flag DDx including SOL, IIH, GCA. The most common cause for headache is tension headache (others are cluster, migrainous).

• Rule out pregnancy and pre-ecclampsia

Goals

• conduct thorough H/E/I to identify aetiology of presentation (tension vs cluster vs migraine)
• rule out red flag differentials
• manage woman appropriately with acute and ongoing preventative

Question 2

Chronic headache - History

Answer 2

History

• sx: pain history, triggers (stress, work), relieving factors, timing/frequency, assoc. features (aura, etc)
• REDF: morning headaches, N/V, vision changes, worse on bending over, neurological deficits
• Past psychiatric history
• Medications
• SNAP

Question 3

Chronic headache - Examination

Answer 3

Examination

• General observation + vitals
• Neurological examination + Fundoscopy

Question 4

Chronic headache - Investigations

Answer 4

Investigations
Chronic daily headache is a clinical diagnosis. Investigations would be conducted to rule out red flag differentials on the basis of clinical suspicion:

Bedside: Vitals
Bloods: nil
Imaging: CTB +/- MRI brain (SOL, raised ICP)

Question 5

Chronic headache - Management

Answer 5

Management
Depends on the type of headache (tension, migraine, cluster).

Non-pharmacological

• avoid triggers
• keep headache diary
• CBT: relaxation techniques, coping skills
• lifestyle modifications, correction of posture, limit caffeine intake

Pharmacological therapy
Acute treatment
- tension: non-opioid analgesia
- cluster: then sub-cut sumitriptan (5HT agonist) +/- high flow oxygen
- migraine: non-opioid analgesia + anti-emetic, triptans (use for less than 10 days to limit risk for medication overuse headache)

Preventative/ongoing treatment

• cluster: sodium valproate, verapamil, gabapentin
• tension: TCA, mirtazepine
• migraine: TCA, CBT