Headache

Question 1

What is a primary headache and secondary headache

Answer 1

Primary: Headache with no underlying medical cause (90% of headaches)
Secondary: identifiable structural or biochemical cause

Question 2

What are types of primary headache (3)

Answer 2

Tension type headache
Migraine (most common)
Cluster headache

Question 3

What are causes of secondary headaches (4)

Answer 3

Tumour
Meningitis
Sub-arachnoid haemorrhage
Medication overuse headache (migraine)

Question 4

What is the management of primary headache (4)

Answer 4

Modifiable lifestyle triggers (e.g. sleep, dehydration, stress - important in migraine)
Abortive treatment (stopping headache that’s already started)
Transitional treatment (important in cluster headache - series of headaches over months)
Preventative treatment (reduce amount of triggers)

Question 5

What is the aim preventative treatment

Answer 5

To reduce the threshold (sensitivity) for developing headache e.g. if only have 1 trigger to develop a headache going to have more headaches than if you have 3 triggers

Question 6

Give examples of how the features of secondary headaches indicate what the diagnosis is (thunderclap + postural)

Answer 6

Thunderclap headache associated with subarachnoid haemorrhage
Postural headache in low pressure headache (headache when upright which resolves when lying flat)

Question 7

What is the investigation of primary headaches

Answer 7

For most patients investigation not required…

Look for an underlying secondary cause triggering the primary headache
MRI more sensitive than CT but more likely to show incidental findings (complicates management and lead to further unnecessary investigation)

Question 8

What is the investigation in secondary headaches

Answer 8

Specific investigations can help confirm diagnosis and guide treatment (e.g. CT and CT angiogram in SAH)

Question 9

What is a tension-type headache

Answer 9

Most frequent primary headache

Mild, bilateral headache which is often pressing or tightening in quality - no associated features and not aggravated by physical activity

Not disabling and rarely presents to doctors

Question 10

What is the treatment for tension-type headaches (acute and preventative)

Answer 10

Acute: paracetamol, NSAIDs
Preventative: tricyclic antidepressants (amitriptyline)

Question 11

What is a migraine

Answer 11

Most frequent disabling primary headache

Chronic disorder with episodic attacks, leads to complex changes in the brain

Question 12

What are the symptoms during a migraine attack (4)

Answer 12

Headache
Nausea
Photophobia
Functional disability (more you move around the worse it gets - desire to lie down in a dark room)

Question 13

What are the symptoms in-between migraine attacks (1)

Answer 13

Enduring pre-disposition to future attacks —> anticipatory anxiety

Question 14

What are the criteria for chronic migraines

Answer 14

Headache on more than 15 days per month, of which more than 8 days have to be a migraine for more than 3 months

Question 15

How do migraines lead to medication overuse migraines

Answer 15

Associated with the anticipatory anxiety
Think headache is gonna start so take medication for it —> desensitisation of the system leading to medication overuse headaches

Question 16

How are medication overuse headaches treated (2 strategies)

Answer 16

Preventative: Limit acute treatment to 2 days per week

Abrupt withdrawal: headaches may become worse for 2-4weeks, need to wait for 2 months to determine whether treatment was successful or not

Question 17

What is the management strategy for migraines (3)

Answer 17

Consider:
Modifiable lifestyle triggers
Abortive treatment
Preventative treatment

Question 18

What is the acute treatment for migraines (2)

Answer 18

Aspirin or NSAIDs
Triptans (specific for migraines)
(Limit this to 10 days per month to avoid development of medication overuse headache)

Question 19

What is the aim of prophylactic treatment for migraines (what are the options (3))

Answer 19

Preventative treatment to reduce incidence
Propanalol
Anti-epileptics (valproate)
Botox

Question 20

What presentations of a headache are more likely to have a sinister cause (6)

Answer 20

Head injury (bleed)
First or worst
Sudden (thunderclap) onset
New daily persistent headache
Change in headache pattern or type
Returning patient

Question 21

Red flag features that should make you consider secondary headache (6)

Answer 21

New onset
Change in frequency and associated symptoms
Neck stiffness/fever (meningitis)
High pressure (e.g. worse lying down, wakening patient up, precipitated by physical exertion)
Low pressure
GCA (jaw claudication, prominent or beaded temporal arteries)

Question 22

What are the features of a thunderclap headache

Answer 22

High intensity headache reaching maximum intensity in less than 1 minute
Affects the whole head (worst occipitally)

(MUST exclude SAH)

Question 23

What is a SAH

Answer 23

Subarachnoid haemorrhage
Aneurysmal rupture and bleeding into subarachnoid space

Question 24

What are the complication of SAH (5)

Answer 24

Vasospasm
Hydrocephalus (blood in ventricular system)
Seizure
Infection
Re-bleeding

Question 25

What is the investigation for SAH

Answer 25

CT head ASAP
LP > 12hrs after headache onset
CT angiogram if SAH confirmed

Question 26

What is the treatment for SAH (4)

Answer 26

Early treatment of aneurysm (coiling of aneurysm = very effective)
Nimodipine (reduce vasospasm)
Treat complications
HHH therapy (hydration, hyperoxia, hypertension)

Question 27

When would meningitis and encephalitis be considered?

Answer 27

Any patient presenting with headache and fever

Question 28

What are the symptoms of meningitis (3)

Answer 28

Nausea +/- vomiting
photo/phono phobia
stiff neck

Question 29

what are the symptoms of encephalitis (3)

Answer 29

Altered mental state/consciousness
Focal symptoms/signs
Seizures