Headache

Question 1

What are the ‘primary’ headaches?

Answer 1

Migraine
Tension
Cluster

Question 2

Red Flags for headache:

Answer 2

Sudden
Traumatic
Exertional
Maximal at onset
Meningism

Anticoagulated

Age >50 at onset
Pregnant/ PP
Immunosuppressed
Malignancy

Change in usual pattern

Abnormal vitals or neuro exam

These indicate SECONDARY headache and should be IMAGED

Question 3

DDx causes of headache:

Answer 3

PRIMARY
- Tension
- Migraine
- Cluster

INTRACRANIAL
- Infective: meningitis
- SOL
- Vascular: SAH, CVST
- ICP: BIH, obstructive hydroceph, post-dural/dural leak

FACIAL
- Trigeminal neuralgia
- Paroxysmal hemicranias
- Giant cell arteritis
- Acute glaucoma
- Shingles
- Sinusitis
- Dental pain
- TMJ

SYSTEMIC
- Tox (CO)
- DCI
- Viraemia
- Withdrawal

etc.

Question 4

Medication options for MIGRAINE:

Answer 4

Strongest to weakest evidence

ANTIDOPAMINERGICS (dystonic reaction, hypoTN)
PROCHLORPERAZINE (Stemetil)
- 10mg PO/ 12.5mg IM/ 12.5mg in 1L
CHLORPROMAZINE (Largactil)
- 25mg in 1L
DROPERIDOL
- 2.5 - 5mg IV/ IM
Less effective: Metoclopramide

TRIPTANS (CI: IHD, uncontrolled HTN, SSRI (SS), pregnancy
SUMATRIPTAN
- 6mg IM/ 20mg IN/ 50-100mg PO

NSAIDS (pregnancy)
ASPIRIN
- 900mg
KETOROLAC
- 30mg IM/IV

STEROIDS
Dexamethasone 10mg IV –> reduces early recurrence

..No opioids!

Question 5

Management of CLUSTER HEADACHE

Answer 5

High flow 100% O2
Triptan

Avoid triggers
Prophylaxis:
–> Verapamil, lithium

Question 6

Features and Management of TRIGEMINAL NEURALGIA

Answer 6

‘Lightening’ or ‘poker’ pain paroxysms
Triggered by light touch, breeze
Middle age +

Frequently due to nerve compression –> MRI for this reason
Shingles

CARBAMAZEPINE 200-400mg/day PO divided
2: Further anticonvulsants, nerve block, OT.

Question 7

When are triptans contraindicated:

Answer 7

IHD
Uncontrolled HTN
SSRI/MAOI (serotonin syndrome)

Pregnancy