Headache and Facial Pain

Question 1

Headache classification

Answer 1

-Primary headache syndromes
=Migraine
=Tension-type (episodic)
=Trigeminal autonomic cephalgias (TACs, cluster headaches)
=Benign Cough/Exertional Headache
=Benign Orgasmic Cephalgia
=Ice-pick headache

-Secondary (due to other problem)
-Acute
=Meningitis
=Encephalitis
=SAH
=Head injury
=Sinusitis
=Glaucoma (acute angle-closure)
=Tropical illness (Malaria)

-Chronic
=Chronically raised IC
=Paget’s disease
=Psychological

Question 2

Presentation of Tension-type headache

Answer 2

-Typical Pattern:
=Generally bilateral
=Often Tightness/pressure; band-like headache (non-pulsating)
=Often worse end of day, may be related to stress
=None of the systemic or neurological symptoms associated with migraine (can co-exist)
=Lower intensity than migraine (mild to moderate)
=Can be related to stress but not aggravated by routine physical activity

Question 3

Presentation of TACs (cluster headache)

Answer 3

-Men (3:1), smokers, alcohol trigger, nocturnal sleep
-Unilateral headaches with accompanying autonomic features
=Severe pain (typically around the orbit, intense sharp, stabbing pain occurring 1-2 times a day with episodes lasting 15mins-2hours)
=Red/watering eye
=Drooping/ swelling eyelid
=Constriction of pupil
=Blocked/runny nose= all usually ipsilateral to pain
=Agitation and restlessness during attack

-Clusters typically last 4-12 weeks

Question 4

Time factors

Answer 4

-Migraine
=Several hours; variable frequency

-Tension-type
=Several hours; variable frequency

-Trigeminal Neuralgia
=Seconds-minutes, triggered

-Cluster headache
=15-60+ mins, several times a day, typically ‘cluster’

Question 5

Epidemiology of Migraine

Answer 5

A very common disorder, average population prevalence: ~12%
-F:M 2-3:1
-Often occurring in families
-Heritability element ~65%
-A major cause of disability

Question 6

Age group for migraine

Answer 6

-Affects all age groups
=20-45 age group

-Onset often around puberty
=children are affected, and late-set migraines occur

Question 7

Primary headache syndrome symptoms

Answer 7

-Headache
-Systemic symptoms
-Neurological disturbances

Question 8

Describe a migraine headache

Answer 8

-Typically throbbing or pounding , recurrent
-Classically unilateral (can be bilateral)
-Severity variable (mild to very bad)
-Typically made worse by movement (stay still/ lie down): Aggravated by, or causes avoidance of, routine activities of daily living. Patients often describe ‘going to bed’.
In women may be associated with menstruation

Question 9

Systemic symptoms of migraine

Answer 9

-Nausea and vomiting
-Photo/phono/osmo- phobia
-Sweating/ polyuria
-Poor concentration/ mood change
-Abdominal pain (usually in children)
-Malaise/ tiredness

Question 10

Neurological disturbances of migraine

Answer 10

-Visual
=Blurring, scotomata, fortification spectra, coloured blobs

-Somatosensory
=Classically spreading tingling/ numbness arm/ face

-Vertigo

-Dysphasia
=Usually expressive

Question 11

Types of migraine

Answer 11

-Common migraine (without aura)- 80%
-Classical migraine (with aura)- 20%

Question 12

Pattern of migraine

Answer 12

-Intermittent attacks
-Variable frequency
-Variable duration (few hours-2+ days)
-Chronic migraine is recognized
=Very frequent/Persistent over long periods

Question 13

Triggers for migraine attacks

Answer 13

-Stress/ relief from stress
-Bright loud/ loud noises/ strong smells
-Sleep disturbances/ sleep pattern changes
-Atmospheric pressure/ weather changes
-Coffee/ alcohol/ dietary items
-Hormonal factors (menstrual cycle, pregnancy, OCP, menopause)

Question 14

Diagnosis of migraine

Answer 14

International Headache Society Criteria

A: At least 5 attacks fulfilling criteria B-D
B: Headache attacks lasting 4-72hrs
C: At least 2: unilateral, pulsating, moderate to severe intensity, aggravation by routine physical activity
During: nausea and/or vomiting/ photophobia and phonophobia
E: Not attributed to another disorder

Question 15

Treatment of acute migraine attacks

Answer 15

-Lie in bed in darkened room
-Simple analgesia (NSAID/ paracetamol)
-Triptans (oral)
-Anti-emetic (metoclopramide)
-Consider triggers

Question 16

Prophylactic treatment of migraine

Answer 16

Generally indicated only if frequent/ severe attacks
-Topiramate
-Sodium Valproate
-Beta blockers (propranolol)
-Others

Question 17

What is trigeminal neuralgia?

Answer 17

-A facial pain condition
-Typically begins after age of 50
-Females>Men
-Incidence 1:8000 people/year

Question 18

Typical clinical picture of Trigeminal Neuralgia

Answer 18

-Brief (seconds-minutes) episodes
-Shooting/ lancinating pain unilateral

-Triggered
=Washing/ shaving/ cleaning teeth/ talking/ eating/ cold wind/ touching face

Question 19

Causes of trigeminal neuralgia

Answer 19

-May be no apparent cause
-Arterial compression/ compression of trigeminal roots by tumour
-Other disease (MS)

Question 20

Treatment of trigeminal neuralgia

Answer 20

-Medical:
=Carbamazepine
=Other drugs

-Surgical:
=Microvascular Decompression

-Other:
=Trigeminal Destructive Techniques

Question 21

Causes of physical activation of pain receptors

Answer 21

-In blood vessels
-Meninges

=Displacement/ stretching by mass lesions/ RICP/ Irritation by inflammation/ blood products

Question 22

Causes of secondary headaches

Answer 22

-Vascular
=Subarachnoid haemorrhage
=Intracerebral haemorrhage
=Intracranial venous thrombosis
=Giant Cell Arteritis

-Infection
=Meningitis
=Encephalitis

-RICP
=Intracranial tumour
=Idiopathic intracranial hypertension

Question 23

Headache timeline and urgent considerations

Answer 23

-New, acute headache
=Intracranial infection and haemorrhage

-Recent, subacute headache
=Raised ICP
=GCA (giant cell arteritis)

-Longer-standing, chronic headache
=Primary Headache Syndrome

Question 24

History of headache and facial pain

Answer 24

-General context: age, sex
-When, what, where
=How long? Had it before?
=Mode of onset: sudden (intracranial haemorrhage), subacute, gradual
=Intermittent (frequency and duration- migraine) vs constant (variable/ increasing/ decreasing)

Question 25

Other history taking aspects

Answer 25

-Severity
=How to measure- how it interferes with life
=How useful

-Other symptoms
=Nausea/ vomiting/ photo-phonophobia/ neurological/ fever/ malaise

-Exacerbating/ relieving factors
=Relationship to activity
=Drugs
=Jaw claudication/ scalp tenderness
=Triggered by touch, cold

Question 26

Examination for headache and facial pain

Answer 26

-Intermittent/ chronic headache
=Often unhelpful

-Acute/ subacute
=Temperature
=Conscious level
=Neurological deficits
=Rash
=Signs of meningeal irritation
=Signs of RICP
=Cranial artery tenderness

Question 27

Investigations of possible serious underlying cause

Answer 27

-Blood tests
-Cranial imaging
-CSF examination
-Temporal artery biopsy (GCA)

Question 28

Diagnosis of cluster headaches

Answer 28

At least five attacks of severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15–180 minutes (untreated), and the headache is associated with a sense of restlessness or agitation and/or at least one of the autonomic symptoms.
=Clusters lasting several weeks (4-12) typically once a year
=More common in men (3:1) and smokers
=Alcohol may trigger attack/ relation to nocturnal sleep
=Neuroimaging for underlying brain lesions- MRI with gadolinium contrast

Question 29

Management of cluster headaches

Answer 29

-Acute= 100% oxygen, subcutaneous triptan
-Prophylaxis= verapamil, tapering dose of prednisolone, discuss triggers

Question 30

Diagnosis of tension-type headaches

Answer 30

Definition: Recurrent episodes of headache lasting from 30 minutes to 7 days which are not associated with nausea or vomiting.

-Infrequent episodic — less than 1 day of headache per month (usually self-limiting).

-Frequent episodic — at least 10 episodes of headache occurring on fewer than 15 days per month on average, for more than 3 months.

-Chronic tension-type headache defined as tension headache occurring on 15 or more days per month.

Question 31

Management of tension-type headaches

Answer 31

-Acute treatment: aspirin, paracetamol or an NSAID are first line
-Prophylaxis: up to 10 sessions of acupuncture over 5-8 weeks/ low-dose amitriptyline

Question 32

Definition of medication overuse headache

Answer 32

-Headache occurring on 15 or more days per month in a person with a pre-existing primary headache disorder, which develops as a consequence of regular overuse of one or more drugs that can be taken for acute and/or symptomatic treatment of headache, for more than 3 months.
-Ergotamines, triptans, opioids, or combination analgesics are taken on 10 days or more per month. Patients using opioids and triptans are at most risk
-Simple analgesics are taken on 15 days or more per month.

Question 33

Management of medication overuse headache

Answer 33

-Simple analgesics and triptans should be withdrawn abruptly (may initially worsen headaches) 1 month
-Opioid analgesics should be gradually withdrawn
-Withdrawal symptoms such as vomiting, hypotension, tachycardia, restlessness, sleep disturbances and anxiety may occur when medication is stopped

Question 34

Presentation of subarachnoid haemorrhage

Answer 34

-Sudden-onset thunderclap headache, severe, occipital, peaking in intensity 1-5 minutes
-Maybe history of less-severe ‘sentinel’ headache in weeks prior
-Nausea and vomiting
-Meningism
-Coma
-Seizures

Question 35

Diagnosis of subarachnoid haemorrhage

Answer 35

-Non-contrast CT head= hyperdense/ bright on CT
-If CT done more than 6 hours after symptom onset and is normal= LP
-CT angiography to identify cause

Acute: Symptoms usually develop within 48 hours of injury, characterised by rapid neurological deterioration
Subacute: Symptoms manifest within days to weeks post-injury, with a more gradual progression.
Chronic: Common in the elderly, developing over weeks to months. Patients may not recall a specific head injury.

Question 36

Management of subarachnoid haemorrhage

Answer 36

-Pain relief
-Enteral nimodipine for ruptured aneurysm
-Endovascular coiling
-Neurosurgical clipping

Question 37

Presentation of subdural haemorrhage

Answer 37

Neurological Symptoms:
Altered Mental Status: Ranging from mild confusion to deep coma. Fluctuations in the level of consciousness are common.
Focal Neurological Deficits: Weakness on one side of the body, aphasia, or visual field defects, depending on the haematoma’s location.
Headache: Often localised to one side, worsening over time.
Seizures: May occur, particularly in acute or expanding hematomas.
Recent head trauma, Patients frequently exhibit a lucid interval followed by a gradual decline in consciousness. This pattern is particularly common in chronic SDH. Other hallmark features include headache, confusion, and lethargy.

Physical Examination Findings:
Papilloedema: Indicates raised intracranial pressure.
Pupil Changes: Unilateral dilated pupil, especially on the side of the haematoma, indicating compression of the third cranial nerve.
Gait Abnormalities: Including ataxia or weakness in one leg.
Hemiparesis or Hemiplegia: Reflecting the mass effect and midline shift.

Behavioural and Cognitive Changes:
Memory Loss: Especially in chronic SDH.
Personality Changes: Irritability, apathy, or depression.
Cognitive Impairment: Difficulty with attention, problem-solving, and other executive functions.

Other Associated Features:
Nausea and Vomiting: Secondary to increased intracranial pressure.
Drowsiness: Progressing to stupor and coma in severe cases.
Signs of Increased Intracranial Pressure: Such as bradycardia, hypertension, and respiratory irregularities (Cushing’s triad).

Question 38

Investigation of subdural haemorrhage

Answer 38

-CT: crescentic collection not limited by suture lines
=They will appear hyperdense (bright) in comparison to the brain (acute) vs chronic hypodense. Large acute subdural haematomas will push on the brain (‘mass effect’) and cause midline shift or herniation.

=Rupture of the small bridging veins within the subdural space rupture and cause slow bleeding. Elderly and alcoholic patients are particularly at risk of subdural haematomas since they have brain atrophy and therefore fragile or taut bridging veins.
=Confsuion, reduced consciousness, neurological deficit

Question 39

Management of subdural haemorrhage

Answer 39

-Small or incidental acute subdurals can be observed conservatively. Surgical options include monitoring of intracranial pressure and decompressive craniectomy.

If the chronic subdural is an incidental finding or if it is small in size with no associated neurological deficit then it can be managed conservatively with the hope that it will dissolve with time. If the patient is confused, has an associated neurological deficit or has severe imaging findings then surgical decompression with burr holes is required.

Question 40

Presentation of temporal arteritis

Answer 40

-Typically, patient > 60 years old
-Usually rapid onset (e.g. < 1 month)
-Headache (mostly temporal)
-Jaw claudication
-Anterior ischemic optic neuropathy (occlusion of the posterior ciliary artery- a branch of the ophthalmic artery- so ischaemia of optic nerve head. Blurred margins and swollen pale disc on fundoscopy)
-Amaurosis fugax (temporary visual loss)
-Permanent visual loss
-Diplopia (involvement of any part of the oculomotor system- cranial nerves)
-Tender, palpable temporal artery (thickening and nodularity)
-Around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
-Lethargy
-Depression
-Low-grade fever
-Anorexia
-Night sweats

Question 41

Investigation of temporal arteritis

Answer 41

-Vision testing- Fundoscopy typically shows a swollen pale disc and blurred margins.
-Raised inflammatory marker (ESR>50, CRP elevated),
-Temporal artery biopsy (skip lesions may be present) or ultrasound
-Creatine kinase and EMG normal.

Question 42

Management of temporal arteritis

Answer 42

-Urgent high-dose glucocorticoids before the temporal artery biopsy
-If there is no visual loss then high-dose prednisolone is used
-If there is evolving visual loss IV methylprednisolone is usually given prior to starting high-dose prednisolone
-Urgent ophthalmology review
-Bone protection with bisphosphonates is required as long, tapering course of steroids is required
-Low-dose aspirin

Question 43

Headache red flags

Answer 43

-Compromised immunity, caused, for example, by HIV or immunosuppressive drugs
-Age under 20 years and a history of malignancy
-A history of malignancy known to metastasis to the brain
-Vomiting without other obvious cause
-Worsening headache with fever
-Sudden-onset headache reaching maximum intensity within 5 minutes - ‘thunderclap’
-New-onset neurological deficit
-New-onset cognitive dysfunction
-Change in personality
-Impaired level of consciousness
-Recent (typically within the past 3 months) head trauma
-Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise
-Orthostatic headache (headache that changes with posture)
-Symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
-A substantial change in the characteristics of their headache