Headache

Question 1

What are the different types of primary headache?

Answer 1

Migraine
Tension-type headache
Trigeminal autonomic cephalalgias:
- Cluster Headache

Question 2

What are secondary headaches?

Answer 2

Headaches precipitated by another condition/disorder - can be local or systemic

Question 3

What types of headaches are long-lasting headaches?

Answer 3

Duration >4 hours
- Migraine
- Tension-type headache

Question 4

What types of headaches are short-lasting headaches?

Answer 4

Duration <4 hours
- Trigeminal autonomic cephalalgias - Cluster headache

Question 5

What other type of headache can fall under long-lasting headache?

Answer 5

Medication overuse headache
Headache from pain relief overuse

Question 6

Outline the clinical approach to headaches

Answer 6

History and examination:
Red flag present?
- If no, go down primary headache route
- If yes, go down secondary headache route and carry out diagnostic tests

Question 7

What are four key red flags suggesting secondary headache?

Answer 7

Age: New onset or different headaches in a person >50 years
Onset: Sudden, abrupt onset of a severe headache (thunderclap headache)
Systemic symptoms: Fever, neck stiffness, rash, weight loss
Neurological signs: Confusion, impaired consciousness, focal neurology, swollen optic discs

Question 8

What are the characteristics of a migraine?

Answer 8

Episodic/chronic disorder
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by routine physical activity
Lasts hours and sometimes days

Question 9

What other symptoms are migraines often associated with?

Answer 9

Nausea and/or vomiting
Photophobia and/or phonophobia

Question 10

What is an aura?

Answer 10

Complex array of symptoms reflecting focal cortical or brainstem dysfunction
Both positive and negative symptoms - e.g. black spots (negative)

Question 11

When do auras usually occur and how long do they last for?

Answer 11

Usually before a headache
Gradual evolution: 5-30 mins (<60 minutes)

Question 12

What does this image show and what condition is it associated with?

Answer 12

Expanding ‘C’s
Migraine with aura

Question 13

What are the phases of a migraine?

Answer 13

Premonitory
Aura
Headache
Resolution
Recovery

Question 14

What may occur in the premonitory phase of a migraine?

Answer 14

Yawning
Polyuria
Mood changes
Irritability
Light sensitivity
Neck pain
Concentration difficulty

Question 15

What may occur in the aura phase of a migraine?

Answer 15

Visual changes
Sensory aura - numbness, paraesthesia
Weakness
Speech arrest

Question 16

What may occur in the headache phase of a migraine?

Answer 16

Head and body pain
Nausea
Photophobia

Question 17

What happens in the resolution phase of a migraine?

Answer 17

Rest and sleep

Question 18

What happens in the recovery phase of a migraine?

Answer 18

Mood disturbed
Food intolerance
Feeling hungover
Can take up to 48 hours

Question 19

Describe lifestyle management of migraines

Answer 19

• Avoid triggers - e.g. certain foods - cheese, red wine
• Diet, sleep, exercise - having a regular schedule may help prevent migraines
• Mindfulness

Question 20

What are the two types of pharmacological therapy for migraines?

Answer 20

Acute/abortive
Long term preventative

Question 21

Give examples of acute/abortive management of migraines

Answer 21

Paracetamol
NSAIDs (high dose & soluble)
Prokinetics (typically anti-emetics) - Increases gut motility during migraines - can provide relief
Triptans (5-HT (serotonin) receptor agonists)

Question 22

When is long term preventative management of migraines considered and how is it administered?

Answer 22

Migraines >/= 5 days/month
“Low and slow” approach with doses until optimal dose is reached

Question 23

How do patients typically describe tension type headaches?

Answer 23

Tight muscles around the head and neck, as though head is in a vice

Question 24

Describe the features of a tension type headache

Answer 24

Tends to last around 30 mins but can be longer
Bilateral
Mild/moderate
Not aggravated by movement

Question 25

What features are typically absent in a tension type headache?

Answer 25

Nausea/vomiting
Photophobia/phonophobia

Question 26

What are the treatments for tension type headaches?

Answer 26

Reassurance may suffice with majority of patients
Can be treated with analgesics, e.g. aspirin or paracetamol
Preventative measures rarely required

Question 27

Describe the nature and frequency of cluster headaches

Answer 27

Severe unilateral pain (never bilateral)
Lasts 15-180 minutes if untreated
1-3 attacks per day (up to 8) and usually daily for 2-3 months at a time

Question 28

What other symptoms are cluster headaches associated with?

Answer 28

At least one of the following ipsilaterally:
- Conjunctival redness and/or lacrimation
- Nasal congestion and/or rhinorrhoea
- Eyelid oedema
Forehead and facial sweating
Miosis and/or ptosis
Restlessness/agitation
Not associated with a brain lesion on MRI

Question 29

What are the acute treatments for cluster headaches?

Answer 29

Triptans - nasal or subcutaneous
High flow oxygen - oxygen inhibits neural activation in trigeminocervical complex

Question 30

What are the preventative treatments for cluster headaches?

Answer 30

Verapamil (calcium channel inhibitor)
- Must get an ECG first - contraindicated in patients with heart block etc
Greater occipital nerve block

Question 31

Compare the different types of headache

Answer 31