Headache Presentations ☺️

Question 1

What are the red flag symptoms you don’t want to miss

-what could they indicate?

Answer 1

Sudden onset (within 5mins), worst pain ever - SAH

New onset in 50+ - SOL, temporal arteritis

Long progressively worsening pain - SOL, SDH

Atypical aura or on COCP (1hr+, weakness, neuro) - CVA

New neuro deficit - CVA, SOL, cranial bleed

Papilloedema - malignant HTN, SOL

Confusion, fever, seizure, low GCS - meningitis, encephalitis

Vomiting - SOL, CO poisoning

Visual changes - glaucoma, temporal arteritis

Pregnancy - preeclampsia

B symptoms - cancer

Question 2

How can you stratify between different causes of primary headaches

Answer 2

Blocked nose
-no => tension or TMJ

Yes => tissue tenderness, swelling
-no => sinusitis, migraines

Yes => cluster

Question 3

Presentation of tension headache

Answer 3

Recurrent episodes 30mins-7days
Mild/moderate
No impact on ADLs

Non pulsating bilateral pain, band around head
No other associated symptoms
-either photo/phonophobia

Question 4

Management of tension headache

• acute
• chronic
• preventative (lifestyle)
• preventative (chronic)

Answer 4

Acute - paracetamol/ibuprofen/aspirin
Chronic - 10 sessions acupuncture

Preventative - lifestyle

• Identify trigger - sleep, exercise, diet, caffeine, stress
• if medication overuse headache suspected => medication diary

Preventative - chronic
Low dose amitriptyline
-no response => NEURO and stop
-response => withdraw after 4-6months

Question 5

Presentation of migraines

Answer 5

Worse on movement
Photophobia, phonophobia
N+V

Unilateral, pulsing moderate/severe pain => ADLs affected

Sensory auras precede headache
-spreading, sequential progression

Question 6

Diagnosis of migraines

• with aura
• without aura

Answer 6

2 attacks with
-reversible aura with headache onset within 1hr

5 attacks+
-no aura, headaches last 4-72hrs

Question 7

Management of migraines

• acute medical
• when to refer
• preventative lifestyle
• preventative medical

Answer 7

FIRST LINE - ibuprofen/prarcetamol/aspirin
-can add PO sumatriptan at start of headache
-SC/IN if PO unsuitable
Antiemetic even if no N+V - metoclopramide

No improvement 72hrs after treatment => REFER to neuro

Preventative lifestyle -avoid triggers
-headache diaries
-stress, hydration, regular meals, sleep
Acupuncture and CBT

Preventative medical if frequent severe/ADLs impacted/acute not working
-Propanolol/topiramate (AVOID IN PREGNANCY, on contraception)/amitryptiline

Question 8

Presentation of cluster headaches

Answer 8

Acute onset for 1hr in clusters
Extremely severe pain around eye, temple
Sharp piercing unilateral => agitations, restless

Red watery eye
Drooping, swollen eyelid
Constricted pupil
Blocked, runny nose

Question 9

Management of cluster headaches

• referral
• acute

Answer 9

URGENT NEURO REFERAL

Acute
-high flow O2
-SC triptan
NO SIMPLE ANALGESIA

Question 10

Possible differentials

Answer 10

Vascular
-cranial bleeds

Idiopathic/iatrogenic

• medication overuse headaches => triptans, analgesics, opioids,
• cluster headache => severe unilateral burning around the eye, temple, agitation, restless

Trauma
-recent head/neck trauma => cerebral bleeds

Infective/inflammatory

• meningitis => confusion, neckstiffness, fever
• encephalitis, abscess
• sinusitis
• otitis media
• PHN

Neoplastic

• head neoplasms,
• SOL => in elderly

Degenerative
-TMJ headache from osteoarthirits => tight, painful jaw, clicking, linked to teeth grinding

Endocrine/environmental

• migraine => photophobia, aura, nausea, vomiting, unilateral
• preeclampsia => high BP, proteinuria, blurry vision, edema, N+V
• CO poisoning