Headaches

Question 1

What is the one-year-prevalence of headaches?

Answer 1

50%

Question 2

How are headaches classified?

Answer 2

• Primary
• Secondary

Question 3

What are primary headaches?

Answer 3

• Migraine
• Tension-type headache
• Trigeminal autonomic cephalalgias
  
  • Cluster headache

Question 4

What is the main way to differentiate between primary headaches?

Answer 4

• Short-lasting headaches
  
  • Cluster headache
• Long-lasting headaches
  
  • Migraine
  • Tension-type headache

Question 5

What are secondary headaches?

Answer 5

Headache is spercipitated by another condition / disorder - local os systemic

Serious causes of secondary headache are uncommon

Question 6

What are the red flags of secondary headaches (4)?

Answer 6

• Age
  
  • New onset or different headaches in a person >50yrs
• Onset
  
  • Sudden, abrupt onset of a severe headache (thunderclap headache)
• Systemic symptoms
  
  • Fever, neck stiffness, rash, weight loss
• Neurological signs
  
  • Confusion, impaired consciousness, focal neurology, swollen optic discs

Question 7

What is the clinical approach to headaches to distinguish between primary & secondary god?

Answer 7

Question 8

What are the characteristics of migraines (episodic or chronic disorder) (SOCRATES)?

Answer 8

• Site:
  
  • Unilateral location
• Onset:
  
  • Auras (sometimes)
• Character:
  
  • Pulsating quality
• Radiation:
  
  • Unilateral location
• Associated symptoms:
  
  • Nausea and/or Vomiting
  • Photophobia and/or Phonophobia
• Time:
  
  • Last hours and sometimes days
• Exacerbating / Relieving factors:
  
  • Aggravation by routine physical activity
• Severity:
  
  • Moderate or severe pain intensity

Question 9

What are auras in migraines?

Answer 9

• Complex array of symptoms reflecting focal cortical or brainstem dysfunction
• Gradual evolution: 5-30minutes (< 60minutes)
• Usually before headache

Question 10

What are the 5 phases of migraines?

Answer 10

• Premonitory:
  
  • Yawning
  • Polyuria
  • Mood change
  • Irritable
  • Light sensitive
  • Neck pain
  • Concentration difficulty
• Aura:
  
  • Visual
  • Sensory (numbness/paraesthesia)
  • Weakness
  • Speech arrest
• Headache:
  
  • Head and body pain
  • Nausea
  • Photophobia
• Resolution:
  
  • Rest and sleep
• Recovery:
  
  • Mood disturbed
  • Food intolerance
  • Feeling hungover
  • Can take up to 48 hours

Question 11

How are migraines managed?

Answer 11

Question 12

What lifestyle changes should take place to prevent further migraines (4)?

Answer 12

• Avoid diet triggers
• Good sleep
• Good exercise
• Mindfulness

Question 13

What is the acute management of migraines (4)?

Answer 13

• Paracetamol
• NSAIDs (high dose & soluble)
• Prokinetics (anti-emetics)
• Triptans (5-HT1B/1D/1F receptor agonists)

Question 14

What are the characteristics of tension type headaches (SOCRATES)?

Answer 14

• Site:
  
  • Bilateral location
• Onset:
  
  • No auras
• Character:
  
  • Tight muscles around head and neck, as though head is in a vice
• Radiation:
  
  • Tight muscles around head and neck, as though head is in a vice
• Associated symptoms:
  
  • No nausea and/or Vomiting
  • No photophobia and/or Phonophobia
• Time:
  
  • Lasts 30mins (but can be hours long)
• Exacerbating / Relieving factors:
  
  • Not aggravation by movement
• Severity:
  
  • Mild or moderate pain intensity

Question 15

How are tension-type headaches managed (2)?

Answer 15

• Reassurance may suffice in the majority of patients
• Individual attacks can be treated with simple analgesics such as Aspirin or Paracetamol
• Preventative medications rarely required

Question 16

What are the characteristics of cluster headaches (SOCRATES)?

Answer 16

• Site:
  
  • Unilateral location
• Onset:
  
  • 1-3 attacks per day (up to 8)
  • Usually occur daily for 2-3 months
• Character:
  
  • Severe pain in one side of your head, often felt around your eye
• Radiation:
  
  • Around the eye
• Associated symptoms (at least one):
  
  • Conjunctival redness and/or lacrimation
  • Nasal congestion and/or rhinorrhoea
  • Eyelid oedema
  • Forehead and facial sweating
  • Miosis and/or ptosis
• Time:
  
  • Last 15-180 minutes if untreated
• Exacerbating / Relieving factors:
  
  • A sense of restlessness or agitation
• Severity:
  
  • Severe pain intensity

Question 17

What is the acute managemnt of cluster headaches (2)?

Answer 17

• Triptan: Nasal or subcutaneous route
• High flow oxygen
  
  • Oxygen inhibits neuronal activation in the trigeminocervical complex

Question 18

How are cluster headaches prevented (2)?

Answer 18

• Verapamil (Calcium channel inhibitor)
  
  • Get an ECG first!
• Greater occipital nerve block