Headache

Question 1

Wat are teh differentials for headaches

Answer 1

Chronic
• Migraine
• Cluster headaches
• Drugs: Analgesics, Caffeine, Vasodilators (i.e. side effects of other drugs)
• Tension headaches
• Neuralgia (trigeminal) 
• ICP ↑: tumours
• Giant cell arteritis
• Systemic: HTN (pheochromocytoma, pre- eclampsia),

Acute
• Vascular: Haemorrhage: SAH, intracranial bleed, sinus venous thrombosis • Infection/Inflammation: Meningitis, Encephalitis, Abscess
• Ophthalmic: Acute glaucoma
• Situational: cough, exertion, coitus

Question 2

What are primary headaches

Answer 2

Primary
• Due to the headache condition itself, not due to another cause
• E.g. migraine, tension, cluster

Question 3

What are secondary headaches

Answer 3

Secondary
• Headache that is present because of another condition
• E.g. headache in meningitis/sinusitis/SAH
• Medication overuse is in this category

Question 4

What is the important thing to know about the headach

Answer 4

• How worried you are about the cause of the headache?
• What you are going to do next? • Investigations?
• Start some treatment?
• Send to specialist?
• Send straight to A+E?

Question 5

Desxribe the history for headache

Answer 5

History
• HPC: SOCRATES/ SQITARS
• Causal factors/ triggers
• PMHx: problems related to headaches i.e. previous history
• DHx: analgesia/ drugs that give headache as a side effect
• FHx
• SHx: stress, eating, dehydration • Red Flags

Question 6

Describe the examination for each abe

Answer 6

• Observations
• Neuro (peripheral and cranial)
• Any related system depending on what you are worried about
Sepsis??

Question 7

When does a patient need to do to a+e for a headache

Answer 7

Ss

Question 8

What ae the red flag symptoms of headache

Answer 8

Asking about red flags.

Snoop

Question 9

Descrbe SOL headache

Answer 9

• Gradual onset
• Progressive
• Associated neurology
• Change in vision
• Features of increased ICP
• Early morning headache
• N+V
• Worse on coughing or bending

Question 10

Describe the epidemiology of migraines

Answer 10

Epidemiology
2% general population have chronic migraines Females > males (6% males, 18% females) 80% have had first attack by 30
Severity tends to decrease as age increases

Question 11

Describe the history for migraine

Answer 11

S – Unilateral, often frontal
Q – Sudden or gradual onset, Throbbing/
  pulsating
I – Moderate
T – Between 4 and 72 hours. May be cyclical A – Photo/phonophobia
R – Sleep make better, medication
S - +/- aura, N+V

Triggers: Food, sleep, stress Often has FHx
?Cause – vascular dysfunction vs neuronal dysfunctio

Question 12

Descirb ethe epidemiology of ensign headache

Answer 12

Epidemiology
Most common type of headache Females >males
Young > old
First onset > 50 unusual

Question 13

Describe history of tension headache

Answer 13

S – Bilateral, frontal (vertex-bitemporal)
Q – Squeezing, non-pulsatile
I – Less severe (mild-moderate) (10 min to 48 h)
T – Worse at the end of the day. ? Less than 15 times per month (episodically v chronic
A – stress, poor posture, lack of sleep R – ? To neck
S – mild nausea
No FHx
Usually responsive to OTC medication

Question 14

Describe teh epidemiology of medication overuse headache

Answer 14

Epidemiology
3rd most common type of headache 1-2% UK population
20% population who have headaches 30-40 years old
Females>males

Question 15

What is a education overuse headache

Answer 15

• Defined as headache present on at least 15 days per month
• Does not improve after OTC medication
• Regular overuse greater than 3 months of one of the following:
• Triptans or opioids (codeine) on at least 10 days of the month
• Paracetamol, aspirin or NSAIDs on at least 15 days of the month
• Resolves completely after 2 months following discontinuation of medication
• Initially may get worse before it gets better - Explain to patient then it will get worse before it gets better. Reboud headache initially which is worse. Goes away after 2 months

Question 16

Describe the mechanisms or medication overuse headache

Answer 16

• Headache mechanism is thought to be an increase in headache pain receptors - (only if taking mecocation for a headache in the first place, not for another reason)
• Mixed symptoms
• Often co-existing with depression/ sleep disturbance
• Difficult to manage
• Might get withdrawal

Question 17

Descrbe the epidemiology of cluster headache

Answer 17

Epidemiology
1/1000 people Males>females
Usually begins 20-40 years old

Question 18

Describe the presentation of a cluster headache

Answer 18

Cant get away. Agitated. Extremely severe. Increase in sympathetic overdrive. Red watery eye, one run, congestion, wearing, partial ptosis
S – Around/behind one eye
Q – sharp, penetrating
I –Very severe and constant intensity
T – Rapid onset. Attacks last 15min–3hrs, 1-2x/day, mostly nocturnal.
• Clusters last 2-12wks, remission lasts 3mo-3yrs
• Can be chronic vs. episodic
A – head injury, alcohol, cigarette smoking R – No radiation
S – Red, watery eye, nasal congestion
Triggers: Alcohol, histamine, GTN, heat, exercise, solvents, lack of sleep

Question 19

Describe teh epidemiology of trigeminal neuralgsi

Answer 19

Epidemiology

Peak incidence 50-60 Prevalence increases with age ~25/100,000 UK population Females > males

Question 20

Descrbe the presentation of trigeminal neuralgia

Answer 20

90-95% caused by compression of CNV by loop of artery or vein
5% attributed to tumours, MS, skull base abnormalities or AV malformations
S – unilateral, often over the eye
Q – stabbing, sharp, “electric shock”
I – severe
T – sudden onset, lasts a few seconds to 2 minutes
A – light touch to face, eating, cold wind, vibrations
R – radiates to eyes, lips, nose and scalp
Preceding symptoms: tingling, numbness
More common with PHx chronic pain

Question 21

What are the investigations to do next

Answer 21

• Investigations?
Headache diary - how did it feel, timing, what they were doing
Imaging- CT/ MRI

Question 22

Describe the treatment for some headaches

Answer 22

Simple analgesia Migraine: Triptans

Cluster headaches: High flow oxygen

Question 23

Decsribe ethe referrer always criteria for headaches for urgent referrall

Answer 23

Refer urgently patients with:
• Symptoms related to the CNS in whom a brain tumour is suspected, including:
• progressive neurological deficit • new-onset seizures
• headaches
• mental changes
• cranial nerve palsy
• unilateral sensorineural deafness
• Headaches of recent onset accompanied by features suggestive of raised intracranial pressure, for example:
• vomiting
• drowsiness
• posture-related headache
• pulse-synchronous tinnitus
• or by other focal or non-focal neurological symptoms, for example blackout, change in personality or memory
• Suspected recent-onset seizures (refer to neurologist)
• Refer urgently patients previously diagnosed with any cancer who develop any of new onset neurological symptoms

Question 24

When should uget refuel be considered with progression of…..

Answer 24

Consider urgent referral (to an appropriate specialist) in patients with rapid progression of:
• subacutefocalneurologicaldeficit
• unexplainedcognitiveimpairment, behavioural disturbance or slowness, or a combination of these
• personalitychangesconfirmedbyawitness and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour
• Considernon-urgentreferralordiscussion with specialist for:
• unexplained headaches of recent onset:
• present for at least 1 month
• not accompanied by features suggestive of raised intracranial pressure.