Headache

Question 1

How can headaches be classified?

Answer 1

Primary: Headaches not associated with an underlying condition for example migraine, tension-type headache, and cluster headache Secondary: Headaches which occur as a result of underlying local or systemic pathology for example due to trauma, intracerebral infection, vascular disorders, medication overuse or neoplasm

Question 2

What clinical examination/investigations should be done for headache?

Answer 2

Vital signs - BP and temperature Fundoscopy - rule out increased ICP Central and peripheral nervous system examination Extracranial structures i.e neck and temporal arteries

Question 3

What is the classification system for tension-type headaches?

Answer 3

International Classification of Headache disorders: Infrequent episodic tension-type headache — less than one day of headache per month.

Frequent episodic tension-type headache — at least 10 episodes of headache occurring on average 1–14 days per month for more than 3 months.

Chronic tension-type headache — 15 or more days of headache per month for 3 or more months

Question 4

What is the management for episodic tension-type headaches?

Answer 4

Analgesia i.e paracetamol/aspirin/NSAIDs

Question 5

What sort of preventative treatment may be considered for chronic tension-type headache?

Answer 5

Acupunture (10 sessions over 5 - 8 weeks)

Low dose amitryptiline (off label use)

Question 6

What features indicate a severe cause of headache, which warrant referral to secondary care?

Answer 6

New severe or unexpected headache - SAH, vertebral artery dissection, intracranial haemorrhage

Progressive or persistent headache or headache that has changed dramatically

Associated features: neck stiffness, photophobia, seizures, impaired consciousness, fever, papilloedema

Contacts with similar presentation: carbon monoxide poisoning

Precipitating factors: trauma

Comorbidities i.e immunosuppression, malignancy

Current or recent pregnancy - pre-eclampsia

Question 7

What are the SSx of migraine?

Answer 7

Unilateral headache, throbbing

Photophobia

Nause and vomiting

May or may not have aura (zigzag lines, scotoma, pins and needles etc)

Question 8

How to identify causes of migraine in an individual? What test?

Answer 8

Headache diary

Question 9

What treatment should be given in acute migraine attack?

Answer 9

Oral triptan i.e sumatriptan (serotonin agonist) + NSAID/paracetamol

Consider anti-emetics

• If <18 years, give nasal triptan. Do not offer Aspirin for risk of Reye’s syndrome*
• Do not issue preventative Tx for children with migraine in primary care –> refer to secondary care*

Question 10

When and what preventative therapy should be given for migraines?

Answer 10

Propanolol/Topiramate/Amitryptiline (do not give propanolol or topiramate if breastfeeding or pregnant)

Consider lifestyle advice i.e relaxation therapy/acupuncture

Question 11

When should I refer a person with migraine to secondary care?

Answer 11

Urgent referral:

• Suspect serious cause of headache
• Status migrainosus

Normal referral:

• A complication of migraine has developed.
• Atypical symptoms ( motor weakness or poor balance) are present.
• The diagnosis is uncertain.
• Optimal treatment in primary care does not adequately control the symptoms (medication overuse headache should be considered).