Clinical Lecture: Headaches

Question 1

What is the acronym used to describe the symptoms in a life-threatening headache?

Answer 1

SNOOP4
S - Systemic symptoms e.g. rigors, fever, rash, myalgia, weight loss, comorbid systemic disease e.g. HIV, malignancy, pregnancy etc.

N - Neurogenic signs/symtoms

O - Onset (sudden) - first he ache, thunderclap or worst headache

O - Older age

P 4: Previous Headache (Pattern change, Progressive etc.), Postural, Precipitated by Valsala maneuverer, Pulsatile tinnitus and Pregnancy

Question 2

What should we look for in a headache examination?

Answer 2

• Look for signs of systemic signs and symptoms of systemic disease- fever, rash, neck stiffness (these three suggest infection) blood pressure, organomegaly
  
  • Fundal changes (papilledema - swelling of the optic nerve to suggest increase pressure)
  • Cranial nerve signs/Horner’s syndrome (anhidrosis is often difficult to see as most of the times it is incomplete)
  • Long tract signs - sensory changes?
  • Focal abnormalities

Question 3

Give secondary headache syndromes.

Answer 3

• Subarachnoid haemorrage
• Intra-cerebral haemorrhage/stroke
• Meningoencephalitis
• Intracranial thrombosis
• Giant cell arteritis
• Tumour with increased ICP
• Cervicogenic headache
• Idiopathic intracranial hypertension

Question 4

Diagnose the following case:

58 year old man brought to AE
Awoken with severe, sudden onset (<1 minute) headache
Back of head, severity 10/10 reaching max intensity in seconds
Vomiting and confused (GCS 14/15) on arrival
Clinically apyrexial, refusing fundoscopy and globally hyper-reflexic
Ocular movements appear impaired
No PMH

What is the diagnosis? Name the headache?? Primary or Secondary??

Answer 4

Thunderclap headache - this is a secondary cause of headache. Investigation shows ed a bleed. Management includes pain management and surgical input.

Question 5

What is the general diagnosis for the following case:

54 year old female
Diabetic
72 hours evolving generalised headache and nausea
Left ear pain for 3 days prior to start of headache
Received antibiotic ear drops from GP
Presents
Obtunded, pyrexial, hyperreflexia in right arm and leg with right extensor plantar.
Intubated and taken to ITU

Answer 5

• SNOOP criteria suggests secondary - she has systemic signs, older etc.
  - Pyrexia - infection? Ear infection that could have travelled to the brain
  She has papilledema suggesting increased pressure in the brain

Investigations shows step pneumonia in CSF and blood cultures. We can drain abscesses and use a craniotomy. Treatment is also broad spec. IV antibiotics. Can give steroids in patients with step. Pneumonia meningitis.

Question 6

Give causes of increased intracranial pressure.

Answer 6

• Mass
• Brain swelling (Hypertensive encephalopathy)
• Increased venous pressure
• CSF outflow obstruction (hydrocephalus)
• Increased CSF production (meningitis/SAH)

This leads to:
	- Symptoms
		• Headache (worse on lying or awakening)
		• Vomiting
		• Seizures
	- Signs
		• Papilledema
		• lateralising signs

Question 7

70 year old female
General malaise and left temporal headache for 2 weeks
Radiates into jaw and worse when eating
Tender temporal area and scalp feels sensitive
Can’t sleep on left side
This morning visual disturbance
Top half of visual completely obscured for several minutes then seemed to resolve

Diagnosis??

Answer 7

Diagnosis: Temporal Arteritis - A type fo vasculitis in which the temporal arteries become inflamed.

Question 8

25 year old female
Child: Abdominal pain, Visual symptoms-flashing lights, Motion sickness..
Three month history of episodic headache (1/week)
unilateral temporal/occipital/ throbbing
Nausea and dizziness
Preceded by black dots moving across the visual field
Lasting up to 24 hours
Takes the COCP
Two episodes associated with left hemi-sensory disturbance resolving over several hours

Diagnosis??

Answer 8

Migraine

- By definition the headache lasts over 4 hours
- Consistent with the complaint of sensory paraesthesia 
- Migraine is seen in 10% of the population - more common in female than males
- May get prodrome symptoms - pre-monitory symptoms. 
- 30% have aura - typically visual lasting up to 60 minutes 
- Unilateral headache
- Nausea/photophobia/dizziness/sensitivity to smells 
- Triggers: sleep deprivation/hunger/stress/oestrogen (this could be a consequence of the migraine or premonitory symptom  rather than a trigger)

There are many subtypes: basilar (cranial neuropathies/cerebellar signs), hemiplegic (get strokes, weakness, this is very rare), Acephalgic migraine (this is the aura but no headache)

Question 9

What receptors can we block in the treatment fo migraines?

Answer 9

CGRP and triptans

Question 10

33 year old IT consultant
Presents to A&E at 2 am with severe disabling onset unilateral right orbital pain
Describes someone sticking a knife in eye
On admission; agitated and tachycardic
Clinically streaming red eye with eyelid droop and runny nose

Smoker and consume 28 units alcohol/week

Diagnosis?

Answer 10

Cluster headaches - these headaches tend to be quite disabling and short lived. They show a circadian and circannual pattern.

Cluster headaches are more common in men. They tend to present with agitation.

	Management is Tripans as there is also evidence of release of CGRP and serotonin. They respond to high flow oxygen (superior salivatory nucleus involved is susceptible to oxygen). Neurostimulation such as gammacore which is a vagal nerve stimulation.

Question 11

How do we treat migraines?

Answer 11

• Brain Imaging
• Conserrvative measurements - e.g. avoid caffeine, vapid tyramine foods (e.g chocolate, cheese and red wine), sleep hygiene and regular meals

Question 12

What can we use in the prevention (at the beginning) in the treatment of migraines/

Answer 12

• Prednisolone
• GON Blocks - Greater occipital nerve blocks
• Verapamil
• Indomethacin (NSAID0