Headache

Question 1

What are key aspects of headache history taking?

Answer 1

1. Temporal profile (age onset, time to max intensity, frequency and/or pattern, time of day, duration)
2. Characteristic features (location, unilateral/bilateral, quality of pain, severity)
3. Associations before during & after: nausea, light sensitivity, noise sensitivity, autonomic features, loss of consciousness, hemisensory / hemiplegic symptoms, visual aura
4. Aggravating / precipitating factors: trauma, recent medical illness, triggers i.e. certain diet or sleep deprivaiton, activity, recent prescriptions / OTC, postural symptoms
5. Relieving factors: pharm and non-pharm (lying flat)
6. Drug history: hormonal contraception, HRT, herbal remidies
7. Psychosocial history
8. FH (e.g. migraine FH ~ 50% increase in migraine)

Question 2

What are examples of primary headaches

Answer 2

Migraine
Tension
Cluster
Paroxysmal hemicrania
SUNCT (shortlasting unilateral neuralgiform headache attacks with conjunctival injection and tearing...)

Primary thunderclap headache
Primary cough headache
Primary exertional headache
Hypnic headache (alarm clock headache)
Hemicrania continua

Question 3

What can cause a thunderclap headache

sudden onset, peak intensity within 1 minute

Answer 3

• Subarachnoid haemorrhage
• Cerebral venous sinus thrombosis
• Meningitis
• Cervical artery dissection

• Pituitary apoplexy

• Reversible cerebral vasoconstriction syndrome (de novo, drug induced, or systemic illness)
• Benign coital cephalgia (likely to be linked with reversible cerebral vasoconstriction syndrome)

• Concussion / head injury

Question 4

Who do migraines affect?

Answer 4

Typically benign recurring syndrome, female > male

Onset in teens, seldom begin after 40

Question 5

What are typical features of a migraine?

Answer 5

Throbbing, moderate-severe intensity
Unilateral (60%)
Frequency highly variable, usually 1-2 month

Nausea, vomiting, photophobia and phonophobia
Worse on head movement
Like quiet dark room
Can have visual, sensory, motor or speech disturbance
50% Family History

Question 6

What are the 2 main types of migraine?

Answer 6

Migraine with aura (classical migraine): 35%

Migraine without aura (common migraine): 65%

Question 7

What are provocating triggers for migraine?

Answer 7

Alcohol (red wine), chocolate, cheese, menses, hunger, missing a meal, lack of sleep, stress, period after stress, anxiety, worry, depression, OC pills, HRT, perfumes, glare, light flashes, physical exertion, head trauma, citrus, cured meats

Question 8

List some migraine auras

Answer 8

Visual: photopsia (light flashes), scintillating scotomas, fortification spectra, visual hallucinations

Sensory: numbness or paraesthesia of limbs / face

Motor or speech - less common

Question 9

What is a hemiplegic migraine?

Answer 9

Recurrent episodes of hemiparesis or hemiplegia during the aura phase of migraine headache, with recovery usually in 30-60 minutes, rarely can last up to days or weeks

Condition can be inherited as an autosomal dominant trait (familial hemiplegic migraine - FHM: very rare!)

Question 10

What is a basilar migraine?

Answer 10

Associated vertigo, dysarthria, diplopia, tinnitus, ataxia, visual field defects, bilateral distal or perioral paraesthesia, confusional state.

Neurological symptoms usually persist for 20-30mins, generally followed by throbbing occipital headache

Question 11

How are acute migraine attacks treated?

Answer 11

Triptans: 5-HT1B & 5-HT1D agonists (Sumatriptan, Zomitriptan, Rizatriptan, Almotriptan)

NSAIDs / aspirin / paracetamol +/- antiemetic (domperidone, metoclopramide)

Avoid opioids!

Question 12

What drugs are used for migraine prophylaxis?

Answer 12

Propanolol
Topiramate
Amitryptyline, nortiptyline
Riboflavin
Candesartan

Question 13

What is a cluster headache?

Answer 13

M:F 5:1 (male predominance)

15-180 min duration, occur in clusters lasting days to weeks separated by long attack free intervals

Always unilateral, intense, non-throbbing, mainly periorbital: pacing and restless (ask if suicidal with pain)

Autonomic features >1 i.e. nasal stuffiness, rhinorrhoea, redness of eye, eyelid/facial oedema

Can have partial Horner’s syndrome with ptosis and meiosis on side of pain

Question 14

How are cluster headaches treated?

Answer 14

High flow O2 15-20 mins, s/c or i/n triptans, prednisolone

Prophylaxis: verapamil, lithium, topiramate

Question 15

What is a tension type headache?

How are they managed?

Answer 15

Bilateral, dull, persistent, featureless
Mild-mod intensity, can last 30 mins - several days/weeks

Episodic or chronic and no aggravation with physical activity. Chronic if frequency is 15 days/month.

Acute: as required aspirin or paracetamol
Chronic: accupuncture or amitryptilline

Question 16

What is paroxysmal hemicrania?

Management?

Answer 16

Severe unilateral orbital, supraorbital or temporal pain:
2-30 minutes. Ipsilateral autonomic features e.g. conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, eyelid oedema, forehead/facial swelling, miosis and/or ptosis

Treat with indomethacin

Question 17

What is SUNCT?

Answer 17

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing

Severe unilateral orbital, supraorbital or temporal stabbing or pulsating pain: 5-240 seconds. Ipsilateral conjunctival injection and lacrimation. Can occur from 3-200 times/day

Question 18

What is hemicrania continua?

Management?

Answer 18

Moderately intense daily and continuous unilateral pain - without side shift without pain free periods and with exacerbations of severe pain

Similar autonomic features to paroxysmal hemicrania.

Treat with indomethacin

Question 19

What can cause secondary headaches?

Answer 19

1. Head trauma
2. Vascular disorders: SAH, intracerebral haemorrhage, arterial HTN, ischaemic stroke, arteritis, venous sinus thrombosis, AVM
3. Meningitis
4. High CSF pressure (idiopathic intracranial hypertension IHH)
5. Low CSF pressure / volume (post LP, spontaneous intracranial hypertension)
6. Intracranial neoplasms
7. Metabolic disorders (hypoxia, hypercapnia, hypoglycaemia)
8. Headache with substance use/withdrawal (MOH)
9. Headache/facial pain with disorder of facial/cranial structures
10. Cranial neuralgias (trigeminal neuralgia, occipital neuralgia, post herpetic neuralgia)
11. Temporal arteritis
12. Systemic illness e.g. infectious mononucleosis, SLE, inflammatory bowel disease
13. Acute angle glaucoma

Question 20

What is MOH?

Answer 20

Medication overuse headache

Caused by opioids/triptans >10 days a month or NSAID/aspirin/paracetamol >15 days a month

Aim to slowly withdraw medication, staying within maximum recommended dose

Question 21

What can cause facial pain?

Answer 21

Trigeminal neuralgia
Post herpetic neuralgia
TMG pain (Costen’s syndrome)
Dental pain (worse at night, tooth tenderness)

Atypical facial pain (mainly females, cheek/maxillary areas, continuous and intolerable pain, no definite cause found, associated with anxiety or depressive states and may respond to antidepressant / anti-anxiety medications)

Structural lesion of trigeminal nerve

Question 22

What is trigeminal neuralgia?

How is it managed?

Answer 22

Paroxysmal, severe lancinating unilateral pain
Usually mandibular and maxillary divisions
Triggered by sensory stimulation of face: cold breeze, chewing, speaking
- no sensory or motor deficits

Treatment: carbamazepine, lamotrigine
Microvascular decompression if refractory to medication

Question 23

What is postherpetic neuralgia?

How is it managed?

Answer 23

Follows facial shingles

Somewhat responsive to tricyclics and SSRIs

Question 24

What is idiopathic intracranial hypertension?

Answer 24

Headache (raised ICP features - worse lying down, morning & manoevres like coughing, bending, straining) with papilloedema and enlarged blind spots

Blurred vision, visual obscuration (also worse on waking, bending or standing up after bending), or visual field defects. Pulsatile tinnitus (also postural).

Question 25

What are risk factors for idiopathic intracranial hypertension?

Answer 25

High BMI, female, pregnancy, tetracycline use, OC pill, hypervitaminosis A.

Question 26

How is idiopathic intracranial hypertension investigated? How is it managed?

Answer 26

Brain imaging and venography to exclude venous sinus thrombosis

Diagnosis by CSF measurement: opening pressure CSF OP >25cmH20

Treatment: weight loss, lumbar punctures to drain CSF fluid, carbonic anhydrase inhibtior (e.g. acetazolamide) or loop diuretics (e.g. furosemide). In rare cases: shunt surgery or cerebral venous sinus stenting.

Question 27

What is temporal arteritis?

Answer 27

Unilateral or bilateral headache in temporal region - seen in either gender over 50 years

Throbbing quality then persistent aching for weeks or months. Temporal artery thickened and tender. Can be associated with polymyalgia rheumatica.

Other features; loss of vision, jaw claudication, fever, weight loss, increased ESR

Question 28

How is temporal arteritis diagnosed?

How is it managed?

Answer 28

Temporal artery biopsy

High prednisolone - 1mg/kg

Question 29

What is SAH? Diagnosis and management?

Answer 29

Usually bilateral and occipital, sudden onset, instantly peaking ‘worst headache of my life’ with or without altered consciousness / focal signs and symptoms, severe headache is usually short lived

associated meningeal signs, nausea, vomiting

Diagnosis by neuroimaging, lumbar puncture (evidence of xanthochromia in CSF) and cerebral angiodema

Coiling of aneurysms

Question 30

What is venous sinus thrombosis?

Ix / Tx?

Answer 30

Severe headache with nausea vomiting +/- seizures and focal neurological signs, recent history of ear/sinus infection, dehydration or recent immobility - often found to have papilloedema

Ix: CT venogram or MR venogram

Tx: any underlying infection plus anticoagulation