Headache: a clinical approach

Question 1

What are primary headaches?

Answer 1

sometimes referred to as tension headaches or migraines

Question 2

What is trigeminal neuralgia?

Answer 2

primary headache syndrome = agony and disabling

trigeminal nerve becomes demyelinated

Question 3

What are tension type headaches?

Answer 3

usually last weeks-months
tight band there all the time but you can continue to do your normal things

they tend to be associated with stiffness in the neck but it is important to check they don’t have papilloedema

Question 4

What factors need to be considered for tension type headaches and what are the treatments?

Answer 4

1) medication overuse? - detox
2) cervicogenic headache (wear and tear in the cervical neck) - physiotherapy
3) need glasses
4) consider migraine - tricyclic antidepressants and SSRIs

Question 5

What are the rules for migraines?

Answer 5

episodic
better when lying down
associated features

Question 6

What are the 4 stages of acute migraine?

Answer 6

1) prodrome - hours
2) aura (20%)- minutes to hours
3) headache + associated features = hours to days
4) postdrome - usually 1-2 days

Question 7

What are the common non-headache manifestations of chronic migraine?

Answer 7

chronic fatigue, autonomic symptoms, myokymia, neck pain, back pain, sensory disturbances, restless legs, reflex syncope, stimulus sensitivity, migraine related dysequilibrium, stuttering

Question 8

How are migraines managed?

Answer 8

1) lifestyle - detox, no caffeine, look for triggers
2) rescue treatment - NSAIDs and antiemetica
3) triptans
4) prophylaxis - beta blockers, topiramate, candesartan (teratogenic), TCAs, SNRIs
5) BOTOX
6) referral - flunarizine, methysergide, dihydroergotamine, pizotifen, valporate
7) erenumab, fremanexuumab = very very expensive

Question 9

What are cluster headaches?

Answer 9

comes and goes, period of 3-4 weeks everyday and then period of nothing, there is a kind of hormonal element to them
they can wake you up and there is a diurnal pattern to them
hemicranial and it is always on the same side of the head and they do switch over they don’t switch back
droopy eye, miosis, conjunctivial reddeing, and tears on the same side of head
tend to last about 30 mins to several hours

Question 10

What is the severity of primary headache syndromes?

Answer 10

worst = SUNCT
paroxysmal hemicrania
cluster headache
hemicrania continus

Question 11

What are the rules for trigeminal autonomic cephalalgias?

Answer 11

1) strictly side-locked
2) autonomic activation
3) agitiation

Question 12

What are the treatments for trigeminal autonomic cephalalgias?

Answer 12

1) rescue - fast acting triptan e.g. sub cut sumitriptan, nasal zolmitripta
2) break the cluster - oral prednisolone 60mg OD reduce by 10mg every 3 days
3) prophylaxis - depends on duration
4) indometacin
5) needs MRI

Question 13

What prophylactic treatments are used for:

• SUNCT
• Paroxysmal hemicrania
• cluster headaches
• hemicrania continua

Answer 13

SUNCT= lamotrigine (rash)
paroxysmal hemicrania = indometacin (kidney injury, ulcer)
cluster headache = verapamil (heart block - can be delayed)
hemicrania continua = indometacin

Question 14

What are the rules for trigeminal neuralgia?

Answer 14

demyelinated axon - steady flow of sodium into the cell - can be caused in MS

1) one branch of trigeminal nerve
2) stabbing pain
3) triggered (cold wind, eating/drinking, touch sensitive)
4) need to detox to get clear picture

Question 15

What are the treatments for trigeminal neuralgia?

Answer 15

1) carbamazepine
2) maximum carbamazepine - refer to neurosurgery
3) oxycarbamazepine
4) another AED
need an MRI

Question 16

What are examples of secondary headaches?

Answer 16

raised ICP
thunderclap headache
vascular problems
sinusitis

Question 17

How can raised intracranial pressure arise?

Answer 17

increased arterial blood pressure = malignant hypertension, pre-eclampsia, hypercapnia

increased CSF pressure = obstruction to flow(mass, meningitis), failure of re-absorption, overproduction

increased brain pressure - space occupying lesion (blood, cancer, infection)

increased venous blood pressure - cerebral venous sinus thrombosis

meningeal inflammation - infection, autoimmune, cancer

Question 18

What red flags are there for secondary headaches?

Answer 18

1) papilloedema
2) seizures, focal neurological signs, cancer of HIV
3) visual disturbances
4) postural change (worse on lying down)
5) pregnancy
6) nausea and vomiting
7) previous history of vasculitis
8) diabetes - old man with temp and new onset hearing loss
9) getting progressively worse
10) morning headache or waking from sleep

Question 19

What are thunderclap headaches?

Answer 19

first presentation of thunderclap headaches = hospital = very sudden onset, gets as bad as its going to be in minutes

• rarely subarachnoid haemorrhage
• sometimes meningitis, CVST or pituitary apoplexy
• sometimes CSF leak
• mostly migraine

Question 20

What happens in hospital if you have a thunderclap headache?

Answer 20

need a CT within first 6 hours - sensitivity is almost 100%

if CT is negative do a lumbar puncture

Question 21

What are the symptoms of a carotid artery dissection?

Answer 21

neck pain, facial pain and horner’s syndrome - risk of anterior circulation stroke

Question 22

What are the symptoms of a vertebral artery dissection?

Answer 22

neck pain, sudden onset, vertigo or ataxia= risk of posterior circulation stroke

Question 23

What are the rules for temporal arteritis?

Answer 23

1) extremely rare below 60

2) ESR and/or CRP raised

Question 24

How is temporal arteritis managed?

Answer 24

1) refer immediately to rheumatology
2) steroids
3) US of temporal artery and biopsy within a week