Headache differentials and treatment

Question 1

What are the three most common headaches?

Answer 1

Migraine, tension headache and medication overuse headache

Question 2

What is migraine aura?

Answer 2

Visual auras - flashing lights, zigzag lines and fortification spectra
Hemianopia
sensory parasthesia
Hemiparesis
Opthalmoparesis

Question 3

What are the characteristics of migraine with vs migraine without aura?

Answer 3

Without aura they typically last longer, spread bilaterally and are more frequent

Question 4

What are the associated features with migraine?

Answer 4

Sweating, nausea, vomiting, photophobia.

Throbbing unilateral pain that is worse on activity

Question 5

What is the first thing to be addressed in management of migraine?

Answer 5

Removal of any triggers e.g. chocolate, cheese, alcohol

Question 6

What are the acute and prophylactic treatments of migraine?

Answer 6

Acute - pain relief, NSAIDS, anti-emetics (metoclopramide), triptans (5-HT antagonists)
Prophylactic - When they are severe >4 a month: beta blockers, anti-epileptic drugs, tricyclic antidepressants

Question 7

how do tension type headaches present?

Answer 7

Bilateral pressure that can be episodic or continous
Can cause hyperventilation and come alongside anxiety
hyperventilation can present as dizzy spells and palpatations

Question 8

How are tension headaches managed?

Answer 8

Stress management and reassurance, this may involve lifestyle changes and analgesia
Prophylaxis can include TCAs and SSRIs
Can be reffered to psychiatrics as headache may be stemming from other causes

Question 9

How is a diagnosis of medication induced headache made?

Answer 9

If the headache attenuates after 3 months since drug withdrawl

Question 10

What are the characteristics of cluster headaches?

Answer 10

Often occur 4-5 times a day and last 30-60 mins, often more at night. This can go on for 3-4 weeks and then can be asymptomatic for a couple of years before the next cluster.
Typically orbital pain associated with eye watering, redness, unilaternal nasal discharge

Question 11

What are the investigations and treatment for cluster headache?

Answer 11

Investigations involve MRI to look for pituitary lesions that may irritate the trigeminal nerve
Treatment includes sumitriptan and oxygen
Prophylaxis is verapamil and prednisolone

Question 12

What is temporal arteritis and how does it present?

Answer 12

Inflammation of the external carotid arteries leads to headache, scalp tenderness and jaw claudication

Question 13

What are the investigations and treatment for temporal arteritis?

Answer 13

Can look at erythrocyte sedimentation rate (ESR) and temporal artery biopsy can also be performed
Treatment involves a high dose of predisolone to have an initial effect then it is gradually titrated down

Question 14

What are the clinical findings for idiopathic intercranial hypertension?

Answer 14

non specific chronic headache, visual obscurations and temporary blindness
Will be papilloedema on fundoscopy

Question 15

How should idiopathic intracranial hypertension be diagnosed?

Answer 15

Lumbar puncture indicates raised intracranial pressure, MRI and CT should be done to rule out venous sinus thrombosis and tumour

Question 16

How is idiopathic intracranial hypertension managed?

Answer 16

Should be managed by neuro-opthamology, monitor visual fields to make sure vision is not impaired. Any prescipitating agents should be removed and weight loss recommended. Acetazolamide and diuretics can be used. Lumbo-peritoneal shunting can be done surgically

Question 17

How is trigeminal neuralgia managed?

Answer 17

With oral gabapentin and carbamezapine, it can also be treated with injection of alcohol at the formaen magnum but runs risk of nerve damage

Question 18

Where do tumour normally cause headaches?

Answer 18

In the right fronto-temporal region, causes focal symptoms on one side of the body