Headache, migraine and blackouts

Question 1

Headache - acute single episode

Answer 1

With meningism (meningitis, encephalitis or subarachnoid haemorrhage), head injury, venous sinus thrombosis, sinusitis or acute glaucoma.

Question 2

Headache - with meningism

Answer 2

If the headache is acute, severe, felt over most of the head and accompanied by meningeal irritation you must exclude:

• Meningitis – fever, photophobia, stiff neck, purpuric rash or coma.
• Encephalitis – fever, odd behaviour, seizures or decreased consciousness.
• Subarachnoid haemorrhage – thunderclap headache, often occipital, stiff neck, focal neurological signs or decreased consciousness.

Admit immediately for an urgent head CT and if negative a lumbar puncture to look for infection or blood in the CSF.

Question 3

Headache - head injury

Answer 3

Headache is common at the site of trauma but may be more generalised. It can last around 2 weeks and is often resistant to analgesia.

Perform a head CT to exclude subdural or extradural haemorrhage if drowsiness, lucid interval or focal neurological signs.

Question 4

Headache - venous sinus thrombosis

Answer 4

A subacute or sudden onset headache with papilloedema.

Question 5

Headache - sinusitis

Answer 5

Causes dull, constant aching pain over the frontal or maxillary sinus with tender overlying skin and postnasal drip - pain should be worse on bending over.

It is commonly accompanied by coryza and the pain usually lasts between 1-2 weeks.

Question 6

Headache - acute glaucoma

Answer 6

Typically in elderly, long sighted patients. A constant, aching pain develops rapidly around one eye and radiated to the forehead.

Symptoms include markedly reduced vision, visual haloes, nausea and vomiting. Signs include a red congested eye, cloudy cornea, dilated and non-responsive pupil and decreased visual acuity.

Attacks may be precipitated by dilating eye drops, emotional upset or by sitting in the dark e.g. in the cinema. Refer urgently – if >1 hour delay in treatment is likely give 500mg IV acetazolamide over several minutes.

Question 7

Headache - recurrent acute attacks

Answer 7

Migraine, cluster headache, trigeminal neuralgia or recurrent (Mollaret’s) menigitis.

Question 8

Migraine - explanation

Answer 8

The old theory behind migraine was vascular – constriction during aura and dilation causing pain.

However MRI during attacks shows episodic cerebral oedema, dilation of intra-cerebral vessels and PET shows increased hypothalamic activity – may explain food cravings?

Triptans work by constricting cranial arteries and inhibiting the release of neurotransmitters involved in pain.

Question 9

Migraine - symptoms

Answer 9

Classically there is a visual or other aura lasting 15-30 minutes followed within 1 hour by a unilateral, throbbing headache.

Alternatively there can be an isolated aura with no headache or an episodic severe headache without aura, often premenstrual and usually unilateral with nausea, vomiting and photophobia or phonophobia. There may also be allodynia – all stimuli produce pain.

Question 10

Migraine - prodrome and aura

Answer 10

A prodrome – yawning, food cravings or changes in sleep, appetite or mood precede the headache by hour or days.

An aura – precedes the headache by minutes and may persist during it – can be visual (chaotic cascading, distorting, jumbling of lines, dots or zigzags, scotomata (a blind spot) or hemianopia) somatosensory (paraesthesia spreading from fingers to face), motor (dysarthria, ataxia, hemiparesis or opthalmoplegia) and speech (dysphasia or paraphasia – senseless word combinations).

Question 11

Migraine - diagnostic criteria if no aura

Answer 11

>5 headaches lasting 4-72 hours with either nausea, vomiting, photo or phonophobia and >2 of – unilateral, pulsating, interferes with life and worsened by routine activity.

Question 12

Migraine - triggers

Answer 12

Chocolate, and ChOCOlATE - cheese, oral contraceptives, caffeine (or its withdrawal), alcohol, anxiety, travel or exercise.

In 50% no trigger is found and in only a few does avoiding the trigger prevent all attacks.

Question 13

Migraine - management - NSAIDs

Answer 13

e.g. 100mg ketoprofen or 900mg dispersible aspirin – less chance of medication misuse headache and similar efficacy to oral 5-HT agonists (e.g. triptans and ergot alkaloids).

Question 14

Migraine - management - triptans

Answer 14

Generally better tolerated than ergots – e.g. rizatriptan has been found to be better and cheaper than sumitriptan.

Triptans are contraindicated in ischaemia heart disease, coronary artery spasm, uncontrolled hypertension and recent lithium, SSRI or ergot use.

Rare side effects include – arrhythmias or angina ± MI even if no pre-existing risk factors.

Question 15

Migraine - management - ergotamine

Answer 15

Take 1mg PO as soon as the headache starts and repeat at 30 minutes – up to 3mg in as day and 6mg in a week. Alternatively can be given as a suppository – 2mg ergotamine and 100mg caffeine up to twice in 24 hours.

Contraindications – OCP, peripheral vascular disease, ischaemic heart disease, pregnancy, breast feeding, hemiplegia migraine, Raynaud’s, liver or renal impairment or hypertension.

Side effects – vascular damage and gangrene.

Question 16

Migraine - prophylaxis

Answer 16

Required if >2 attacks per month. If 1 drug has no effect within 3 months try another:

• 1st line – 40-120mg propranolol BD, 25-50mg topiramate BD or 25-75mg amitriptyline nocte.
• 2nd line – valproate, pizotifen (causes weight gain), gabapentin, pregabalin or NSAIDs.

Question 17

Migraine, stroke and the COC pill

Answer 17

The incidence of migraine and pill related ischaemic stroke is 8 in 100,000 if aged 20 and 80 in 100,000 if aged 40 years.

Those with migraine with aura are known to be at particular risk and the COC is contraindicated in this group (no problem with progesterone only pill or non-hormonal contraception). In patients with migraine without aura only low dose COCs should be used.

Risk is further increased by smoking, age >35 years, hypertension, BMI >30, diabetes, hyperlipidaemia or family history or arteriopathy when aged <45 years.

Question 18

Headache - cluster headache

Answer 18

The male to female ratio is 5:1 and onset is at any age. One theory is that it is caused by superficial temporal artery smooth muscle hyper-reactivity to serotonin.

• Symptoms – rapid onset severe pain around one eye which may become watery and bloodshot with lid swelling, lacrimation, facial flushing, rhinorrhoea, miosis ± ptosis. Pain is always unilateral and commonly affects the same eye. It lasts between 15-160 minutes, can occur 1-2 times per day, is often nocturnal and clusters last 4-12 weeks.
• Management – acute – 100% oxygen via a rebreathe mask and 6mg sumitriptan SC at the onset of the attack. Preventatives – 1st line are verapamil or topiramate.

Question 19

Headaches - trigeminal neuralgia

Answer 19

A unilateral intense stabbing pain lasting seconds in the trigeminal nerve distribution (commonly mandibular or maxillary). It typically effects Asian women, >50 years old.

• Triggers - include washing affected area, shaving, eating, talking or dental prostheses.
• Secondary causes – compression of the trigeminal nerve root by anomalous or aneurysmal intracranial vessels or a tumour, chronic meningeal inflammation, MS, zoster or skull base malformation. MRI is required exclude secondary causes (in 14%).
• Management – give 100mg carbamazepine PO BD. If drugs fail surgery may be necessary – may be directed at the peripheral nerve or the trigeminal nerve root.

Question 20

Headache - Mollaret’s meningitis

Answer 20

Recurrent meningitis – suspect if fever and meningism with every headache.

Question 21

Headache of subacute onset

Answer 21

Giant cell arteritis – exclude in all >50 year olds with a headache that has lasted more than a few weeks. Signs include tender, thickened, pulseless temporal arteries, jaw claudication and ESR >40 mm/h. Prompt diagnosis and steroid treatment will prevent blindness.

Question 22

Headache - chronic headaches

Answer 22

Tension headache, raised intracranial pressure or medication overuse headache.

Question 23

Headache - tension headache

Answer 23

The usual cause of bilateral, non-pulsatile headache ± scalp muscle tenderness but without vomiting or sensitivity to head movement. Stress relief e.g. massage or antidepressants may have more benefit for the patient than a neurologist.

Question 24

Headache - raised ICP

Answer 24

Typically worse on waking, when lying down, bending forward or coughing. Other signs include vomiting, papilloedema, seizures, focal neurological signs or personality changes.

Perform imaging to exclude a space occupying lesion and consider idiopathic intracranial hypertension. (Lumbar puncture is contraindicated until after imaging).

Question 25

Headache - medication overuse headache

Answer 25

Often caused by mixed analgesics especially those containing paracetamol, codeine, opiates, ergotamine or triptans. This is a common reason for episodic headache becoming chronic daily headaches.

Analgesia must be withdrawn – aspirin or naproxen may help with rebound headaches.

Advise patients not to use over the counter analgesia for more than 6 days per month.

Question 26

Blackout - differential diagnosis

Answer 26

Vasovagal syncope, situational syncope, carotid sinus syncope, epilepsy, Stokes-Adams attacks, drop attacks, hypoglycaemia, orthostatic hypotension, anxiety, choking or factitious blackouts.

Question 27

Blackout - vasovagal syncope

Answer 27

Due to reflex bradycardia and peripheral vasodilation provoked by pain, emotion, fear or standing up for too long.

Onset is over seconds and is often preceded by pre-syncope - nausea, pallor, sweating and closing in of visual fields. It cannot occur when lying down!

The patient falls to the ground and is unconscious for around 2 minutes. Brief clonic jerking of the limbs may also occur = reflex anoxic convulsions but there is no stiffening of the limbs, incontinence or tongue biting.

Question 28

Blackouts - situational syncope

Answer 28

The symptoms are the same as in vasovagal syncope but are related to situations e.g. cough syncope, effort syncope or micturation syncope (mostly effects men during the night).

Question 29

Blackouts - carotid sinus syncope

Answer 29

Carotid baroreceptors are hypersensitive and cause excessive reflex bradycardia and peripheral vasodilation on minimal stimulation e.g. head turning or during shaving.

Question 30

Blackouts - epilepsy

Answer 30

Attacks vary with type of seizure but certain features are more suggestive of epilepsy – attacks when asleep or lying down, aura, identifiable triggers e.g. television, altered breathing, cyanosis, typical tonic clonic movements, urinary incontinence, tongue biting (ask about a sore tongue), prolonged post-ictal drowsiness, confusion, amnesia and transient focal paralysis (Todd’s palsy).

Question 31

Blackouts - Stokes-Adams attacks

Answer 31

Transient arrhythmias e.g. bradycardia due to complete heart block cause decreased cardiac output and loss of consciousness. The patient falls to the ground often with no warning except palpitations - they are pale with a slow or absent pulse.

Recovery is in seconds – the patient flushes, the pulse increases and consciousness is regained. Myoclonic jerks may occur if the attack is prolonged – reflex anoxic convulsion. Attacks may happen in any posture, several times a day.

Question 32

Blackouts - drop attacks

Answer 32

Sudden weakness in the legs causes the patient to fall to the ground – usually an older women. There is no warning, no loss of consciousness and no confusion afterwards. The condition is benign and usually resolves spontaneously after a number of attacks.

Question 33

Blackouts - other causes

Answer 33

• Hypoglycaemia – tremor, hunger and perspiration before loss of consciousness in a diabetic.
• Orthostatic hypotension – LOC on standing from lying – inadequate vasomotor reflexes.
• Anxiety – hyperventilation, tremor, sweating, tachycardia, paraesthesia, light head but no LOC.
• Choking – if food blocks the larynx patients may collapse, become cyanosed and can’t speak.

Question 34

Blackouts - examination and investigation

Answer 34

• Examination – cardiovascular, neurological and measure the blood pressure both lying and standing.
• Investigations – ECG, 24 hour ECG, Us and Es, FBC, glucose, tilt table test, EEG, echo or head CT/MRI.